As the spread of the delta variant continues unabated in much of the U.S., public health leaders have approved health care rationing in Idaho and parts of Alaska and Montana.

At least five more states—Georgia, Kentucky, Mississippi, Arkansas and Texas—are nearing capacity with more than 90% of their intensive care unit beds full, according to data from the U.S. Department of Health and Human Services.

The move to ration healthcare comes amid a spike in the number of unvaccinated COVID-19 patients requiring hospitalization. Crisis standards of care allow health care providers to give scarce resources, like ventilators, to the patients most likely to survive.

But determining who gets what is no easy feat.

WHAT ARE ‘CRISIS STANDARDS OF CARE?’

Crisis standards of care give legal and ethical guidelines to health care providers when they have too many patients and not enough resources to care for them all. Essentially, they spell out exactly how health care should be rationed in order to save the most lives possible during a disaster.

Some health care rationing steps have become commonplace during the pandemic, with hospitals postponing elective surgeries and some physicians switching to online visits rather than seeing patients in person. But more serious steps—such as deciding which patients must be treated in a normal hospital room or intensive care unit bed, and which patients can be cared for in a hospital lobby or classroom—have been rare.

At the extreme end of the spectrum, crisis standards of care generally use scoring systems to determine which patients get ventilators or other life-saving medical interventions and which ones are treated with pain medicine and other palliative care until they recover or die.

WHAT’S THE SCORING SYSTEM, AND WHAT ARE ‘TIE-BREAKERS’?

States may use a combination of factors to come up with patient “priority scores.” Idaho’s and Montana ‘s system both consider how well a patient’s major organ systems are functioning. Patients with indications of liver or kidney damage, poor oxygen and blood clotting levels and an inability to respond to pain because they are in a coma have higher scores.

Both states also score people based on saving the highest number of “life-years,” so if a person has cancer or another illness that is likely to impact their future survival, they get a higher score.

The lower a patient’s score, the more likely they are to survive, moving them toward the front of the line for ventilators or other resources.

The plans also have “tie-breakers” that come into play if there aren’t enough resources for all of the folks at the front of the line. Youth is the biggest tie-breaker, with children getting top priority.

In Idaho, pregnant women who are at least 28 weeks along with viable pregnancies come next. Both states also give consideration to younger adults ahead of older adults, and Idaho’s fourth tie-breaker is if the patient performs a task that is vital to the public health crisis response. The final tie-breaker is a lottery system.

If someone at the front of the line is given a ventilator and doesn’t show improvement within a set period of time, Idaho says they should be taken off so someone else can have a chance.

On Thursday, shortly after Idaho enacted crisis standards of care statewide, Dr. Steven Nemerson with Saint Alphonsus Regional Medical Center in Boise said that to his knowledge, no patient in the state had been removed from life support in order to provide the equipment to someone else. But he warned it would happen.

“It’s bad today. It’s going to get much worse,” Nemerson said. “I’m scared for all of us.”

DOES VACCINATION STATUS MATTER?

No.

In both Idaho and Montana, the crisis standards of care don’t consider whether a person has been vaccinated against COVID-19. Likewise, patients aren’t denied care if they are injured in a car accident because they failed to wear a seatbelt or drove while intoxicated.

“Vaccination status is not relevant to us when it comes to taking care of patients. We simply do what they need us to do within the constraints and the resources that we have,” said Dr. Shelly Harkins, chief medical officer at St. Peters hospitals in Helena.

WHAT ELSE CHANGES WHEN A HOSPITAL IS OPERATING UNDER CRISIS STANDARDS OF CARE?

Nearly everything.

People will likely wait longer for care, not just in hospitals but at urgent care centers that will likely be dealing with more patients as well. Nurses will care for more patients than they normally would. Instead of hospital beds, some people might be placed on stretchers and cots. Patients will likely be sent home from the hospital as soon as possible, relying on friends, family and prescriptions for in-home medical equipment during their recovery.

And in some cases, physicians may not attempt to save a patient’s life at all. Idaho’s crisis standards of care plan calls for a “Universal Do Not Resuscitate Order” for all adults once the state has reached the point where there aren’t enough ventilators to go around.

That means if a patient experiences cardiac arrest—where the heart stops suddenly—there will be no chest compressions, no attempts to shock the heart back into a normal rhythm, no chance at hooking them up to life support. That’s partly because resuscitation requires a bunch of hospital staffers, a lot of time, and is frequently unsuccessful. It’s also because if the patient has COVID-19, the process of attempting to revive sends aerosolized virus particles into the air, putting staffers at risk.

Montana’s plan is a bit different, in that it allows individual doctors to decide whether or not to resuscitate patients on a case-by-case basis.

HOW DOES THIS IMPACT HEALTH CARE WORKERS?

Talk to a health care provider in Idaho, and you’re likely to hear the phrase “moral injury,” a term that means the emotional trauma that health care providers experience when they lose a patient or are faced with being unable to provide life-saving treatment. Ideally, crisis standard of care plans reduce moral injury, but they are far from perfect.

Dr. Matthew Wynia, a University of Colorado professor of medicine and health ethics expert, said state authorities should be responsible for establishing strategies needed to make triage decision fairly, so doctors and nurses aren’t left making those calls on their own at a patient’s bedside.

That means making sure that transfer systems are in place and working well so that one hospital isn’t making tragic decisions because they are out of a resource that is available at another facility, he said.

When facing critical shortages of staff or equipment, “You really can’t say (to patients or their families), ‘Would you like to go to the ER?’ You have to go to the patient and say, ‘We can’t do it,’ which is an incredibly hard situation,” Wynia said.

“There’s no way to look at this and say this is OK. It’s not OK,” he said. But it’s necessary if hospitals are running out of resources, “which is happening right now,” Wynia said.

WHAT CAN BE DONE TO GET BACK TO NORMAL?

Health experts say getting vaccinated is the best way to protect against needing hospitalization because of coronavirus. Idaho’s hospital crisis is caused primarily by a massive increase in the number of coronavirus patients needing hospital care, Idaho Department of Health and Welfare Director Dave Jeppesen said Thursday.

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