The state Department of Health posted on its website Wednesday an updated version of its health care rationing plan, which despite recent outcry from senior advocacy groups like AARP still uses age as a tiebreaker when evaluating certain treatments during a crisis.

Hawaii’s COVID-19 surge has not gotten bad enough to invoke its Crisis Standards of Care Triage Allocation Framework, which is a statewide effort to plan for worst-case scenarios in the event there are not enough medical resources for everyone.

The framework, which was developed last year by 21 Hawaii physicians representing health care systems across the state, was updated Wednesday and posted on the state Department of Health website at bit.ly/398XbXB.

DOH Director Dr. Elizabeth Char declined an interview with the Honolulu Star-Advertiser on Wednesday, but answered questions from legislators about the plan, which she described as a “living document” during an afternoon briefing before the House Committee on Pandemic & Disaster Preparedness.

Char’s remarks did not make clear what changes had been made since the plan was last revised in August 2020. However, the updated document still specifies that “Life-cycle considerations will also be used as a tiebreaker, if there are not enough resources to provide to all patients within a priority group, younger patients will be prioritized.”

“Evidence from multiple countries including the U.S. show that age (greater than 65 years old) is an indicator for poor prognosis in COVID-19 patients,” the framework said. “If the triage score is equal between two individuals, the Triage Officer/Review Committee should use the consideration that a patient (greater than 65 years old) who is also COVID-positive is less likely to benefit from the scarce resource.”

Keali’i Lopez, AARP Hawaii state director, thanked DOH for making the Crisis Standards of Care public, which “allows the public to be aware of the state’s plan to ration health care in an emergency.”

Char told legislators that the August 2020 version of the document previously had been posted on the HI-EMA website. However, DOH and the Healthcare Association of Hawaii told AARP Hawaii last week that the document could not be released because it was under revision. DOH told the Star-Advertiser that it could not be located.

Lopez said AARP Hawaii understands that the state will continue to review and update the Crisis Standards of Care framework, and strongly advocates that DOH review recent federal and ethical guidance about age discrimination.

“The problem we see with the current crisis standards of care is that age is a factor that doctors can consider when deciding if someone gets health care. It’s a tiebreaker. If two people have equally bad conditions, the state’s health care rationing plan allows younger people to be prioritized over older people solely based on age,” she said. “We think this is an age bias and age discrimination and it doesn’t belong in these crisis standards.”

Lopez said since August of last year when the state originally developed the plan, other states have modified their plans to remove age discrimination.

“The Office of Civil Rights in the Health and Human Services Administration has further directed states that using age as a factor in limiting health care violates federal age discrimination laws and the thinking of medical ethicists has evolved to recommend that states remove age and all biases from their plans,” she said.

Char told legislators that the plan does not discriminate based on age, which was “rejected as a primary triage criterion.”

She said using age 65 in a tiebreaker situation is only one specific exception.

“In the case of COVID, specifically, the research was showing that your prognosis for the older people that had severe COVID was not as good as the younger population that had severe COVID,” Char said.

Char said the document’s authors indicated that they vetted it with kupuna who had said, “if every other thing was equal”and “it was just for a tiebreaker” that they would actually rather give the ventilator to “to a younger person.”

State Rep. Tina Wildberger (D-South Maui) noted that vaccines were not discussed at all in the rationing care prioritization document, and said that she had received many calls or comments from constituents “that are concerned about unvaccinated people being a disproportional number of people taking up a lot of hospital capacity.”

Wildberger asked Char to address the medical ethics behind the framework’s decision making.

Char said, “As an emergency physician, I treat whoever comes into my ER, right, and if you crashed your car because you were intoxicated, I still take care of you.

“If you came in as a bad trauma patient because you did some things that weren’t too smart and you got into a bad altercation or something, I’m still gonna take care of you to the best of my ability. So that’s kind of where that lies. Whoever needs the care at that point, we, as physicians, that is our duty to try and treat that person at that point in time.”

Char sidestepped a question from Rep. Gene Ward (R-Hawaii Kai, Kalama Valley) about whether she supported using age as a tiebreaker in the framework.

“This is not my document. I did not write it,” she said. “This was our health care practitioners in our community with input from our community ethics folks, our community kupuna.”

Char said she hoped the document would never have to be used.

“Can you imagine what kind of moral injury would happen to that person having to make those kind of decisions. We absolutely do not want to play God,” she said. “And that’s what this document allows us to avoid having to do, that it’s not one person just making that decision and having to do something arbitrarily.”