Tough call: Providing mass care with scarce resources
Tough call: Providing mass care with scarce resources
Who gets the vent, who goes to palliative care?
In the aftermath of a disaster or terrorist attack, with supplies scarce and lives in the balance, hard choices may have to be made about who can be saved and who must be designated solely for pain relief and comfort care.
Such thorny issues – not often openly discussed at public forums – were addressed in a recent webcast discussion as part of the release of the federal Agency for Healthcare Research and Quality (AHRQ) report: "Providing Mass Medical Care with Scarce Resources: A Community Planning Guide."
For example, how should decisions be made in allocating a limited but potentially life-saving resource like ventilators?
"That's the most extreme situation, and very difficult to deal with," said John L. Hick, MD, an emergency department physician at Hennepin County Medical Center in Minneapolis, MN. "But in that case what we would want to do is assign experienced clinical staff. For instance it might be senior critical care and infectious disease physician team [that] takes a look at the objective evidence. Say we clearly think this patient who needs this resource has a better prognosis than the other patient that either needs or is using a resource and make a recommendation to the administrative person. And we sort of termed it a 'bed Czar' that has administrative authority to make those changes, saying these would be the recommendations from a clinical standpoint as we think this is the best use of the resources available."
Decisions may not be well accepted
Discussing such scenarios before they arise is critical, but that may not make the decisions that much easier, he warned. "It is really difficult to implement those kinds of decisions," Hick said. "We need to have a conversation about that transition of care. When you decide you are not going to allocate resources to a person there is [the issue] of palliative care. About where would that person be cared for, at the hospital or home. There are tremendous behavior health issues for the providers, patients, and families. There are security issues that need to be addressed and administrative issues. The administrators of the facilities need to understand that they are taking responsibility for decisions that will be made within these frameworks that will not be well accepted by the folks that don't get the resources. And yet it is really incumbent on us to have a structured, fair process to allocate these."
The AHRQ guide is designed to provide community planners and their partners at the institutional, state and federal levels with information that will help their efforts to plan for and respond to a mass casualty event (MCE). The planning guide examines MCE response and preparedness challenges across a wide range of health care settings and provides recommendations for planners in specific areas. The guide also discusses ethical and legal considerations related to MCE planning in pre-hospital, hospital, acute-care, and alternative-care sites. Planning for palliative care, or the aggressive management of symptoms and relief of suffering, also is covered.
Allocating scarce resources key
"The reason for today's conversation is clear and compelling," said Cindy DiBiasi, moderator of the AHRQ program. "In the event of a catastrophic, public health or terrorism related event such as an influenza pandemic or the detonation of a nuclear device, there are likely to be tens of thousands of victims whose needs will overwhelm the resources of a community's health care system. In such a dire scenario it will be necessary to allocate scarce resources in a manner different from usual circumstances yet appropriate to the situation. Making optimal decisions concerning the allocation of scarce resources could make a difference in the degree to which health care systems continue to function and in saving countless lives."
Still, the situation will be "overwhelming on a number of levels," but disaster planners can begin with the assumption that tough decisions will have to be made because there will be no other options, Hick said. "We are talking about a situation here where we have an overwhelming demand for limited resources and there is nothing we can do to get by," he said. "[For example], we can't hand-bag people, we don't have enough antitoxin. It is not something they can substitute for."
It is critical that individual states clarify what liability protections providers have in such situations, he added. Indeed, a larger umbrella of incident management must guide all aspects of a disaster response, he noted.
"If you are not using a comprehensive incident management system you are going to fall flat on your face," he said. "Incident management is key to making sure you are making the best use of the resources that you have. And it needs to be integrated. You need to have the incident management system at the facility integrating with the regional construct, with the state and the feds so that you are able to pass available resources around [and] allocate them fairly [in order] to do the best job you have with the resources available."
'You don't want to make this up'
If clinical care is to be compromised by lack of resources, all stakeholders must be on the same page, he emphasized. "You want to make sure that you have a plan in place, that you have looked at your administrative changes that you are going to make," Hick said. "You have looked at the roles and responsibilities within the institution and decided whose going to take on what and how — how will you make this happen because you don't want to be making this up when the situation hits. So your incident management structure would recognize there is a situation, and they would basically convene a group of people that should have been preorganized — a clinical care committee."
Such a group may include medical executives, nursing, respiratory care, nursing administration, pediatrics and infectious diseases, he said. "You need to bring the right stakeholders to the table to agree on, based on the situation we are in, what is the best possible care we can offer today to our patients," he said. "What is the ethical basis we are going to be doing that upon, and that should be set ahead of time, and what are the decision tools we might have to use for this specific situation."
Research is under way to develop better decision tools, methods to assess patients and balance prognosis against resources. "The problem with making a good decision tool for pandemic influenza [for example], is we have no idea how the virus will behave once it is out into the human population," he said. "But we can look at the balance of critical care literature and make some general recommendations about who will likely benefit from mechanical ventilation and who will not. Or for those folks who have already received the mechanical ventilation, if things like oxygenation index are not improving or other markers are becoming worse, that's probably a good indication you are not making good progress. So there are a few decision tools in the works and I would look for those to be coming out within the next six to 12 months."
Communication and media relations will be critical if a hospital changes "the paradigm of care," he emphasized. "So for instance, if you have adequate stocks of Tamiflu and patients need to get into screening or treatment facilities that have been set up at the earliest onset of symptoms [in order to] get that antiviral medication, that's got to be communicated," he said. "If you don't have any antivirals or vaccines to offer, they shouldn't go to their providers until they are deathly ill. So there is a tremendous range of messages you need to get out. And if the media are not in partnership with you, you are going to have great trouble communicating that, and your health system will pay for it."
Even in such battlefield triage situations, there should be some mechanism for real-time appeal or reassessment of the decision. "Any just system will provide some mechanism for appeal," Hick said. "If there is a change in the clinical condition or other information that the family or the bedside provider thinks needs to be considered, there needs to be a small time window for that to occur, during which time you might be doing temporary measures [for] a patient who is waiting for the ventilator. It needs to be very rapid turn around, but you need accountability for reasonableness of decision making and part of that incorporates an appeals process."
[Editor's note: The AHRQ planning guide is available on web at http://www.ahrq.gov/research/mce/]
In the aftermath of a disaster or terrorist attack, with supplies scarce and lives in the balance, hard choices may have to be made about who can be saved and who must be designated solely for pain relief and comfort care.Subscribe Now for Access
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