Study Examines Rationing by Age During the COVID-19 Pandemic

doctor and female patient, masks, COVID19
Doctor checking and inquired Asian elderly woman patient wearing a face mask in hospital for protect infection and kill Novel Corona virus Covid-19 virus.
How have different parts of the US incorporated rationing by age into their pandemic preparedness plans?

Ongoing disagreement persists regarding whether and how age should figure into the rationing of intensive care resources during a health crisis such as the current COVID-19 pandemic. Findings of a study examining how different states in the US have handled the issue of age-related rationing were recently published in the journal Chest.

Concern over potential COVID-19–related shortages caused many states to update or rapidly develop Crisis Standards of Care (CSCs) and other pandemic preparedness plans intended to ration resources, particularly ventilators. Recognizing this, researchers sought to examine how US states may have incorporated standards for rationing by age and/or life-years into their pandemic preparedness plans. Toward that end, investigators identified the most recent versions of CSC documents and official state pandemic preparedness plans that included triaging guidance in each of the 50 states and Washington, DC. Research was conducted between April and June 2020, via online search as well as email and telephone queries targeting individuals in a position to know state standards for rationing healthcare resources.  

Investigators then independently categorized all plans with guidelines that had been operationalized regarding age and life-years. Category A plans were those that considered only an individual’s likelihood of survival in the short term (ie, for 1 year or less) when triaging that individual for critical care resources. Category B plans took into consideration an individual’s next expected 1 to 5 life-years. Category C plans accounted for an individual’s total anticipated number of life-years. Category D plans used the “fair innings” principle, in which specific age cutoffs for the utilization of resources were created. Category O (other) plans did not provide any specific guidance, instead offering general ethical frameworks for hospitals to follow.

A total of 35 published, state-endorsed pandemic preparedness plans were identified, which were dated between 2007 and 2020. Overall, 7 pandemic preparedness plans were grouped into category A, 7 into category B, 13 into category C, 1 into category D, and 7 into category O. All of the protocols examined by investigators were official CSCs, with the majority having been written in 2020. Among the various plans, 11 (Connecticut, Indiana, Iowa, Kansas, Louisiana, Michigan, Mississippi, New Mexico, New York, Oregon, and Virginia) predated the pandemic, having been written between 2007 and 2019. Among the 21 states that considered age/life-years to some extent in their plans (ie, the sum of categories B, C, and D), 17 states used it as a primary consideration and 4 as a secondary consideration.

The investigators ultimately found that “Guidance with respect to rationing by age and/or life-years varied widely,” further noting that “Terminology was often vague, and many plans evolved in response to pushback,” which included the filing of civil rights complaints by “marginalized groups such as the elderly and disabled.”

Researchers concluded that “a more comprehensive and inclusive vetting process is needed to avoid policy mistakes and the unjust exclusion of certain groups.”

Disclosure: None of the study author have declared affiliations with biotech, pharmaceutical, and/or device companies.


Scire E, Jeong KY, Gaurke M, Prusak B, Sulmasy DP. Rationing with respect to age during a pandemic: a comparative analysis of state pandemic preparedness plans. Chest. Published online September 7, 2021. doi:10.1016/j.chest.2021.08.070