Gearing up for the worst for the mentally impaired

When disaster strikes, a plan in place is imperative

Planning for a disaster is always important and necessary, and probably even more so when the disaster affects the mentally impaired in a hospital setting.

The authors of a commentary that appears in Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science,1 suggest that more attention should be devoted to triaging and managing those individuals identified as having mental disorders if a disaster were to arise. Ensuring the needs of these individuals are met during a disaster are vital aspects of preparedness planning, say ethical experts.

"When we think about planning for individuals with non-physical impairments, there is a range of differences and needs, from behavioral issues, to cognitive, to emotional issues," says Kathy Kinlaw, MDiv, associate director and program director, health, science and ethics, for the Emory University Center for Ethics; bioethics associate in pediatrics, Emory School of Medicine, and executive director of the Healthcare Ethics Consortium of Georgia, Emory Hospital, all in Atlanta. In some ways, disaster planning incorporates and is similar for all populations across a community, but there are planning concerns that are of particular importance in mental health services, she adds.

Disaster plans readily address support for mental health needs faced by all who are impacted by a crisis, Kinlaw says. "There are fewer plans which incorporate specific ways to support those who are dealing with mental health concerns prior to the crisis," she says.

Amy Davis, MS, LPC, business analyst in clinical information systems at Ridgeview Institute in Smyrna, GA, agrees with the commentary. "As a psychiatric hospital, we approach disaster planning with our specific patient population in mind," she says. Davis notes that whether the disaster is natural or man-made, the focus of the planning revolves around the safety of patients in the facility, assisting other hospitals in the region in caring for psychiatric patients, and providing crisis counseling and support to members of the community who are in need.

Kinlaw says, "When individuals with mental health/behavioral health concerns are in need of healthcare interventions during a crisis, there may be increased challenges around consent to treatment."

Kinlaw notes that healthcare professionals dealing with a disaster should not assume that any particular individual is incapable of decision making. "For example, many individuals with psychiatric diagnoses are quite capable of making decisions about the specific healthcare treatment decision he or she is facing. In a crisis the pressure to make decisions rapidly and the lack of people resources to assess decision-making capacity could place patient rights at risk, especially for those who are less able to advocate for themselves," says Kinlaw.

Disaster plans should include additional training for all hospital staff who might be asked to assist in the care of individuals with chronic or serious mental illness, According to Kinlaw. "Training in psychological first aid should be available, along with a clear triage plan for individuals who need additional intervention," she says. In the planning stage, family members (or other surrogates) of these patients should be made aware that the hospital might not be able to continue routine treatment and that family involvement might be important during a crisis.

While it is important to ensure the safety of all patients during a disaster, concern for patient safety might be heightened depending on the nature of the underlying condition or illness. "Given the broad range of mental health issues, it is difficult to make uniform, and perhaps stereotyping, recommendations about evacuation," says Kinlaw. If the crisis leads to increased stress or anxiety with escalation of underlying conditions, special efforts might be needed to help patients cope with symptoms and participate as calmly as possible in the evacuation.

Kinlaw says that residents of institutions might face additional challenges. "In a crisis such as pandemic influenza in which 'social distancing' is instituted, visitors may not be allowed. Some residents or inpatients who anticipate regular visits from family or friends may have difficulty understanding or dealing with the change in routine." Suggestions on how staff should address this potential problem might simply involve being upfront with patients about what is going on.

According to the commentary, individuals with new symptoms or pre-existing mental disorders are more vulnerable to adverse outcomes during and after disasters. Davis says that your disaster plan needs to include plans to decompress your psychiatric units in order to handle the influx of patient needing emergency medical treatment. Your disaster planners should talk to psychiatric hospitals in your area, before disaster actually strikes.

"Our disaster planning [at Ridgeview] involves assisting acute care hospitals with decompressing their psychiatric units in order to help them accommodate more medical emergencies," says Davis.

During communitywide exercises and drills, Ridgeview often participates by simulating an influx of psychiatric patients transferred to the facility quickly from other area hospitals, says Davis. Your facility could include transfer of psychiatric patients in your disaster drills to be prepared for this scenario. Disaster plans should provide crisis counseling to members of the community who have to deal with the emotional effects of the adversity.

As with most pre-emptive planning, ethical issues must be addressed. Because a disaster is never expected or likely, even it can be difficult to ensure that ethics remain at a high standard. "Some ethical issues that might arise during a disaster might involve patient rights," Davis says. "For example, before giving medication to a child or adolescent, we have to obtain the parent or guardian's permission. In a disaster, with phone lines down, it might be impossible to contact a parent/guardian when a child/adolescent is in need of a medication." In situations such as this, the next steps would be at the discretion of the healthcare provider.

Many of these mentally impaired individuals represent historically vulnerable groups, and crisis plans need to be careful not to exacerbate existing disparities in care, Kinlaw says. "For individuals who are unable to assess risk in a crisis or react in ways to protect their own interests, surrogate decision-makers may be needed," she says. "To the degree possible, individuals with mental health/behavioral health concerns should be included in planning and decision making, and a shared model for decision making created."

Ridgeview staff continues to practice for potential disasters, Davis says, "Using full scale drills as well as table-top discussion have been very helpful," she says. "Each exercise shows us areas we can improve on and ideas for how we can better prepare our staff and help our patients."

According to Davis, when participating in full scale drills, Ridgeview has benefitted immensely from involving other hospitals from the region and other agencies including public health and local emergency management agencies. "It has been really interesting to see how other facilities work during drills, and by participating in the exercises together and discussing the exercise afterward, we have learned a lot by listening to the experience of other hospitals," Davis says.

Many non-psychiatric hospitals that have set up crisis counseling services for patients and families who were disaster survivors, she says. "Services such as these would be helpful for psychiatric patients as well, in the aftermath of a disaster," says Davis.

Reference

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

Sources

For additional information, contact

  • Amy Davis, MS, LPC, Business Analyst, Clinical Information Systems, Ridgeview Institute, Smyrna, GA. E-mail: adavis@ridgeviewinstitute.com.
  • Kathy Kinlaw, MDiv, Associate Director and Program Director, Health, Science and Ethics for the Emory University Center for Ethics; Bioethics Associate in Pediatrics, Emory School of Medicine; and Executive Director of the Healthcare Ethics Consortium of Georgia; Emory Hospital, all in Atlanta. E-mail: kkinlaw@emory.edu.