The Care of Patients Under Crisis Standards of Care

Originally approved October 2021

The Covid-19 pandemic led to a renewal of the discussion and development of Crisis Standards of Care (CSC) protocols throughout the United States.1 CSCs are implemented when a crisis results in a substantial change in the level of care that can be delivered.2 As resource scarcity increases, the typical availability of “space, stuff, and staff” becomes limited, necessitating a transition of focus from individual patient-centered care to public health–based obligations to the community.3 CSC guidelines aim to provide direction for navigating this conflict, typically through a focus on maximizing lives saved and/or life years saved. CSC policies provide concrete guidance for clinicians and institutions facing difficult decisions about who should receive scarce resources.3

In response to the  2009 H1N1 pandemic, the National Academies of Medicine (formerly the Institute of Medicine) released guidance for establishing CSC protocols for implementation during disaster events.2 These recommendations are based on the ethical principles of fairness, duty to care, duty to steward resources, transparency, consistency, proportionality, and accountability.2 In the intervening decade, several states established CSC guidelines, though there is variation in the manner in which these guidelines have been operationalized.4

During the COVID-19 pandemic, several versions of CSC were developed by states to provide guidelines with subsequent implementation by healthcare systems.5,6

As the frontline in current and future disasters, emergency medicine physicians, particularly those with an expertise in disaster medicine, should:

  • Be involved in design, trial and implementation of CSC guidelines at the federal, state, and local level. CSC design should include standards of equity and transparency.7
  • Support state legislatures and Congress who must provide liability protections and support services (physical and mental) for clinicians who are engaged in implementation of CSC guidelines.6, 8
  • Serve as critical advisors to hospitals, health care systems and governmental agencies that should track the initiation of CSC and review their implementation to document maximum benefit and equity within an impacted community.



  1. Hick JL, Hanfling D, Wynia MK, Pavia AT. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. Washington, DC; NAM Perspectives. Discussion paper. National Academy of Medicine. Washington, DC. 2020. 10.31478/202003b.
  2. Altevogt BM, Stroud C, Hanson SL, Hanfling D, Gostin LO, eds. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Institute of Medicine (US) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Washington (DC): National Academies Press (US); 2009. 10.17226/12749.
  3. Berlinger N, Wynia M, Powell T, et al. Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19) Guidelines for Institutional Ethics Services Responding to Managing Uncertainty, Safeguarding Communities, Guiding Practice. Vol 2.; 2020. The Hastings Center.
  4. D Romney, H Fox, S Carlson, D Bachmann, D O’Mathuna, N Kman. Allocation of Scarce Resources in a Pandemic: A Systematic Review of US State Crisis Standards of Care Documents. Disaster Med Public Health Prep. 2020;***:1-7. 1017/dmp.2020.101.32295662
  6. Milliken, Aimee, Martha Jurchak, Nicholas Sadovnikoff, William B. Feldman, Sejal B. Shah, Mark Galluzzo, Judith Krempin, and Eric Goralnick. “Addressing challenges associated with operationalizing a crisis standards of care protocol for the Covid-19 pandemic.” NEJM Catalyst Innovations in Care Delivery1, no.4 (2020).
  8. Koch, Valerie Gutmann. “Crisis Standards of Care and State Liability Shields.” San Diego L. Rev.57 (2020):973.


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