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editorial
. 2020 May 22;158(4):1332–1334. doi: 10.1016/j.chest.2020.05.526

Table 1.

Priority Scores and Chronic Comorbidity Points

Variable Major Chronic Conditions Severe Chronic Conditions
Model policy (Pennsylvaniaa, Oklahoma) Examples of major comorbidities:
  • •

    Moderate dementia

  • •

    Malignancy with <10-year expected survival

  • •

    NYHA Class III heart failure

  • •

    Moderately severe chronic lung disease (COPD, IPF)

  • •

    End-stage renal disease, age <75 y

  • •

    Severe, inoperable multivessel coronary artery disease; cirrhosis with history of decompensation

 Examples of severely life limiting comorbidities:
  • •

    Severe dementia

  • •

    Metastatic cancer receiving only palliative treatments

  • •

    NYHA Class IV heart failure with frailty

  • •

    Severe chronic lung disease plus evidence of frailty

  • •

    Cirrhosis with MELD >20, ineligible for transplant; end-stage renal disease, age >75 y
2 “points”
Equivalent ethical weight to a SOFA difference of 4 to 10 points (25% to 60% reduction in short-term survival)		 4 “points”
Equivalent ethical weight to the maximum possible difference in SOFA scores (80% to 100% reduction in short-term survival)
Maryland Not used Examples of severely life limiting comorbidities:
  • •

    NYHA Class IV heart failure

  • •

    Severe chronic lung disease

  • •

    Primary pulmonary hypertension with NYHA Class III or IV heart failure

  • •

    Chronic liver disease with Child-Pugh score >7

  • •

    Severe trauma

  • •

    Advanced untreatable neuromuscular disease; metastatic malignant disease
3 “points”
Equivalent ethical weight to a SOFA score difference of 7 to 14 (50% to 70% reduction in short-term survival)
New York No points for chronic conditions. Assign priority based on SOFA score. …
University of Chicago Proposal Assign priority based on SOFA score. Acceptable to use severely life-limiting conditions with <5% one-year survival (confirmed by expert consultation) and age to break ties within patients with similar short-term survival. If uncertainty about prognosis exists, do NOT use medical history in allocation. Ethically, the first consideration is saving lives, and this principle is NOT weighed equally with life-years gained. …

We give examples of how such a comorbidity might be affected by the allocation rules in 3 adjacent states, followed by our proposed approach. The ethical equivalence calculations are performed based on the SOFA score categories and a published SOFA calibration study.

IPF = idiopathic pulmonary fibrosis; MELD = model end stage liver disease; NYHA = New York Heart Association; SOFA = sequential organ failure assessment.

a

In April 2020, Pennsylvania removed its example list of chronic comorbidities due to concern raised by disability rights advocates. However, comorbidities are still considered in the policy, and this influential policy with this list was adopted in other states and in many local hospitals throughout the United States.