State and local health agencies must develop protocols that guide physicians and other providers on how to allocate scarce resources during public health crises, such as terrorist attacks or pandemics, the Institute of Medicine said in a report sent late last month to HHS, which commissioned the study.
A key provision in those protocols should be stronger legal protection for clinicians, according to the IOM and public health experts, because the last thing that they should be worried about during a public health crisis is their legal liability for responding to extraordinary circumstances with extraordinary decisions.
The IOM stressed that medical ethics still apply during a disaster. Disaster circumstances, however, can justify actions, such as devoting resources preferentially to patients most likely to benefit, that wouldn't be ethical under normal circumstances.
Attempting to maintain regular standards of care during a crisis that swamps clinicians and strains resources “is likely to result in greater death, injury or illness,” the IOM says. Community members and clinicians must help draw up the protocols so that they can be seen as equitable and transparent.
“The goal is to do the most good for the most people,” says Kristi Koenig, M.D., a professor of emergency medicine at the University of California at Irvine's School of Medicine and a national spokeswoman on preparedness issues for the American College of Emergency Physicians.
“People have to understand that we can't save everyone in a catastrophic event,” Koenig says. The legal and regulatory questions have to be settled before a catastrophe, not after it, she says.
The Sept. 11 terrorist attacks spurred more disaster planning, and the experience of New Orleans in the aftermath of Hurricane Katrina in 2005 emphasized the point, Koenig says. A physician was arrested and accused of improperly administering lethal doses of morphine to four patients as the flood waters rose in New Orleans, but the grand jury declined to indict her.
Georges Benjamin, M.D., executive director of the American Public Health Association, says Hurricane Katrina showed that standards of care will change during a crisis, so local efforts have to be made to decide beforehand how to deal with these situations.
“The IOM was trying to create a national blueprint for how you do that,” Benjamin says. “It makes a lot of sense to me.”
The planning must be done on a regional basis, oftentimes across state lines, so that treatment in a given area is consistent between facilities, Koenig and Benjamin say. Besides coordinating resources, that means that states have to provide some measure of consistency in their legal frameworks, too, Benjamin adds.
Hospital administrators must have the systems in place to optimize their resources and must plan for absenteeism of employees who are victims of the catastrophe or have to care for relatives who are, Koenig says. The problems that occurred after the hurricane had more to do with a lack of coordination of resources than a lack of resources, she says.
Administrators also must plan to deliver palliative care for those who might in normal circumstances receive more intense life-saving services, Koenig says.
The ACEP is concerned that the trauma system is already stressed by the closure of emergency departments, Koenig adds.
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