Disaster preparedness for mentally impaired

Planning for disaster response generally has overlooked the special needs of people who suffer from pre-existing and serious mental conditions, say bioethicists at Johns Hopkins University in Baltimore, MD. Survivors already diagnosed with schizophrenia, dementia, addictions, and bipolar disorder are vulnerable long before a disaster strikes, they point out.

More attention should be devoted to triaging and managing those already identified as having mental disorders, faculty from the Johns Hopkins Berman Institute of Bioethics, Baltimore, MD, say in a commentary appearing in a recent issue of the journal Biosecurity and Bioterrorism.1 This group must be given just as much consideration during the planning stage as is given those who will have physical injuries and more obvious anxiety-related reactions, such as post-traumatic stress disorder (PTSD).

"Disasters limit the availability of resources, and these groups are especially vulnerable because they cannot advocate for themselves," says Peter Rabins, MD, MPH, Richman family professor for Alzheimer's and related diseases at the Johns Hopkins University School of Medicine, Baltimore, MD. "But little attention has been given to the ethical challenges that arise when resources are limited, to the importance of identifying these ethical issues ahead of time, and for establishing mechanisms to address these moral dilemmas."

In the article, Rabins and Nancy Kass, ScD, the Berman Institute's deputy director for public health, say that many of the mentally ill are dependent on caretakers and aren't fully capable of making sound decisions on their own. Emergency planners are ethically obligated to ensure that immediate and adequate mental health services are provided alongside more traditional triage, the authors say. Rabins says, "Disaster-response managers and those on the front line are well aware that survivors may succumb to PTSD and other mental disorders." "But sudden devastation also puts people with both lifelong and acquired intellectual disabilities in grave danger as well."

Whether a disaster is natural, as in an earthquake, or is caused by man, as in war, the ethical obligation to treat those with mental disabilities in the aftermath is just as important as aiding those with flesh wounds, Rabins says. One study the authors cite found that 22% of Hurricane Katrina survivors who had pre-existing mental disorders faced limited or terminated treatment after the disaster.

Beyond patients with dementia and others who are mentally impaired, the authors say that this vulnerable group includes those who suffer from chronic pain and might be dependent on opiates, as well as substance abusers who receive treatment in the form of powerful sedatives classified as benzodiazepines. Withdrawal can be life-threatening, the authors note.

The authors acknowledge that drug and alcohol addicts often are seen as unworthy of focused attention during a state of emergency, with scarce resources, because their condition is widely perceived as "self-inflicted." But distinguishing between conditions that individuals have or don't have control over "is neither practical nor ethically justifiable, and in emergencies becomes wholly impractical," the authors assert.

Ethical challenges

The authors also recommend that planners focus on ethical challenges likely to arise when assisting the mentally disabled during and after a disaster. These challenges might be partially addressed by adopting a "crisis standard of care" consistent with guidelines from the Institute of Medicine, they say.

Special attention should be given to assisted-living and long-term care facilities that house many residents with significant cognitive impairment, such as dementia. If these people are forced to evacuate, they might not fully comprehend the crisis and might be at risk for extreme emotional distress. Hence, disaster-preparedness training for first-responders should include information about how to interact with such individuals in a way that respects their dignity, the authors say.

More broadly, criteria for priority setting and the allocation of scarce resources can be based on objective factors, such as the likelihood of response to intervention, the prevention of chronic health problems, and the impact on public safety, the authors explain.

Reference

  1. P Rabins, N Kass, L Rutkow, et al. Challenges for mental health services raised by disaster preparedness: mapping the ethical and therapeutic terrain. Biosec Bioterror 2011; 9:175-179.