Triage during a mass disaster: The usual rules don’t apply
Triage during a mass disaster: The usual rules don’t apply
Hard choices must be made, but establish ethical criteria ahead of time
A catastrophic disaster, either natural or manmade, that not only results in widespread casualties but also wipes out medical resources can force health care providers to abandon typical delivery of care and shift to a kind of battlefield medicine, where the sickest patients may not be treated so that care can be delivered to more.
That’s the kind of decisions physicians were forced to make when they were trapped in hospitals in New Orleans after Hurricane Katrina with very sick, frail patients, no electricity, and few medical supplies.
"Doctors and nurses who stayed behind were scrambling to find drugs for their critically ill patients," says Joseph L. Cappiello, vice president for accreditation field operations at the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), the nation’s major hospital accrediting body, who toured New Orleans in the wake of Hurricane Katrina. "[Health care providers in New Orleans] had to make choices that we ordinarily don’t make in America, to help those with the greatest chance of survival."
Triage in a typical U.S. hospital on an average, non-disasterous day typically consists of identifying the sickest or most critically injured patients and getting them appropriate care as quickly as possible, perhaps temporarily bypassing patients who are less sick or injured.
That kind of triage has to fall by the wayside to some extent when casualties are many and supplies and physicians are few, according to bioethicist John Moskop, PhD, professor of medical humanities and director of the Bioethics Center of University Health Systems of Eastern Carolina in Greenville, NC.
"There’s a whole spectrum of situations that involve what we call triage, and it goes from the sort of routine triage that would happen in any busy emergency department, where we determine how quickly patients need to be treated, whether they can wait or have an urgent need for treatment. At the other end of the spectrum," he explains, "would be a massive disaster, [such as] a nuclear attack, in which many people say triage would be useless, because so many resources would have been destroyed and so many thousands of serious injuries that you couldn’t do anything."
But in between are disaster scenarios ranging from multivehicle car crashes that tax hospital emergency departments, plane crashes with hundreds of casualties, battlefield triage during war, or natural disasters like the tsunami that hit Sri Lanka or the hurricanes that hit the Gulf Coast in late summer.
"Each one is different; each has different criteria and difficulties for the triage officers, and there are underlying moral criteria involved. These are not typical situations, so there are some departures and some differences from the choices we might make outside a disaster situation," Moskop says.
Outside a disaster situation, when a patient presents to an emergency department with serious injuries, the medical staff does what it can to save him or her. In a large-scale disaster, that person might not be treated — and might die — since diverting the resources and manpower and time necessary to treat him or her might cost the lives or functionality of several more patients who could have been helped in the meantime and who might be more apt to survive.
"It’s not an easy thing for people to do, because we don’t want to feel like we’re leaving someone to die," says Moskop. "One way to defend it would be to say This is an extraordinary circumstance, and look at the number we can save, and we’re going to save as many people as possible.’ And if that means setting another [less salvageable patient] aside, that’s justifiable in these situations."
Cappiello, in comments made to the media during and after his visit to New Orleans after Hurricane Katrina, recounted harrowing details of how doctors and nurses felt compelled to ignore the fundamentals of their training and make triage-style choices to aid some patients at the expense of others.
Howard R. Epstein, MD, medical director of care management and palliative care at Regions Hospital in St. Paul, MN, has studied the ethics of triage, and says disasters such as the recent hurricanes, bioterrorist attacks, and the Sept. 11, 2001, terrorist attacks have caused physicians to give thought to situations many never thought they would experience.
He says large-scale disasters creating multitudes of casualties require physicians to treat patients based on the concept of medical utility rather than how they treat patients under normal circumstances.
Epstein says hospitalists and emergency medicine physicians who train for disasters should not concern themselves just with the medical aspects of such a frightful scenario.
"We must also prepare ourselves for the real and significant ethical and moral dilemmas we will encounter," when and if they are forced to deliver care primarily to those who benefit most from the fewest resources, he cautions.
Jeffrey Orledge, MD, is an emergency medicine physician at the Medical College of Georgia in Augusta, and is a member of the Georgia-4 Disaster Medical Assistance team that went to Louisiana to assist after Hurricane Katrina. He says even though he has trained in and taught lifesaving and mass casualty triage, and was part of the 9/11 medical response to New York, the situation demanded he adapt to what he found.
"I was doing triage the first day at the [New Orleans International] airport, and even though I teach BDLS/ADLS and have done the MASS triage station and helped teach that station, I still had to change because of the circumstances," he says. "There were tough questions — chest pain in a patient with a history of cardiac disease having the same type of chest pain, who after one nitro is pain-free, is he a red or green patient?"
In some ways, Orledge says, his decisions may have been easier than those made by hospital-based physicians in a disaster, because what he could offer patients was limited.
"At least we were part of a DMAT team, and we truly did not have enough resources there to do what is normally done, which is everything for everybody,’" he says. "That made it easier for me, because we knew our limited resources. I think it would be more difficult in a hospital setting."
"We need to have a conversation about what we would do if, like the doctors at Charity [Hospital in New Orleans], we are put into a situational ethics situation and have to decide what’s right and wrong," says Epstein. "We need to give doctors and hospitals more of an ethical framework, to say that when we impose our hospital’s disaster alert, what our medical response is going to be and what our ethical response is going to be."
By and large, Epstein says, physicians are not prepared to make those decisions without some authority from their states or communities that gives them permission to "change the paradigm."
No room for patient autonomy
A prize cornerstone of American health care, patient autonomy, by necessity, falls victim to the pursuit of the greater good when disasters strike, Epstein and Moskop point out.
"Patient autonomy kind of disappears in a triage situation," Moskop says. "That’s another way our moral priorities shift."
Epstein says that in a disaster, doing what’s best for the individual patient is supplanted by "society’s competing interest."
"We are used to our paradigm, but what we’re talking about is giving up patient autonomy and saying society has a competing interest," he says. "In a disaster with mass casualties, the balance shifts from individual autonomy to the greater good."
Key to making that shift, Epstein says, is hammering out a framework long before disasters strike, so that the medical staff, support staff, and the community know what health care will look like in a disaster.
"You need to have community support ahead of time, because you don’t have the luxury of time to get everyone around a table [during a mass casualty incident]," he says. "You need to prepare in advance and have a plan that’s transparent to the community, because if you’re going to say I’m going to treat this person and not your grandmother,’ you need to have already had that discussion and know, as a community, how you’re going to handle it."
Moskop says physicians have to realize that even with a plan and set criteria in hand, the disaster and its scope will dictate many of the decisions that must be made.
"Each triage officer has to make tough judgments, such as whether or not a person’s injuries justify priority for lifesaving intervention or should be passed over to give the time and resources to someone with a better chance at survival," he says.
Criteria have been developed for triaging patients in a disaster, in an effort to make as many decisions as routine as possible. Those are somewhat successful, Moskop continues, but don’t remove all discretion and responsibility from the person making triage decisions.
"And in a situation like Katrina, other choices, like who to transport or not, don’t come into play because you’re stuck, at least temporarily, with limited resources — the hospitals were not functioning well, were low on supplies, no electricity," he says. "Physicians had to make do with what they had, and there’s no way you can plan in that kind of detail."
But ethical issues probably should not arise during the application of disaster triage criteria, Moskop says; ideally, at that point, the physician should be trained and know the criteria, and thus be able to apply them "and not stew over the ethical issues."
"The ethical issues are more in how to design the criteria and deciding who do we give priority to," he explains.
This can include deciding priority — which can mean giving first priority to immediate lifesaving, second priority to those needing urgent but not lifesaving care, then those with minor injuries, and last, those who are so severely injured that they stand little chance of survival. That last group of patients, many say bluntly, may have to be considered a waste of scarce resources.
"Not everyone agrees with that," Moskop points out. "Some people say you should try to give everyone an equal chance to survive, and then, even if most of them die, you can say, At least they had the chance.’ But I think the majority reject that, and say that in extraordinary circumstances, you have to adopt a different moral perspective given the huge need that we have and the limited resources we have to address that need."
There is another priority advocated by some, taken from the military medicine practice of treating those lightly wounded in battle first, so they can return to the fight. In the case of a disaster in which medical personnel are among those injured, Moskop says an argument can be made to treat them first, so they can then assist in treating the rest of the sick and injured.
Epstein says that even physicians trained in disaster response and mass casualty triage can feel the effects of their decisions long after the disaster has passed.
"We’re used to making the best decisions for our own patients and being the best advocates for those patients, regardless of what’s going on, but in a triage situation like that, you have to treat those who have the most chance of survival," he says. "I don’t think most health care providers are equipped emotionally and ethically, when they’re put in a difficult situation, to avoid having ramifications down the road.
"I mean, how much more can you play God than when you say, I’m not going to feed this patient so I can feed that one,’ or I am taking the ventilator off this patient so that I can put it on that patient’?"
Part of an institution’s plan for coping with disasters should be provisions for debriefing and psychological counseling, he says.
"Especially if they inflict death on people who haven’t asked them to do that," he says. "How do you make that decision at the point of care? There has to be some support [for the practitioner]."
Despite the daunting example provided by Hurricane Katrina and its effects on hospitals in New Orleans, Epstein says he has heard very little discussion among his colleagues at Regions Hospital about how they might respond if put in a similar situation.
"We have medical triage, but there’s no way [in place] to make decisions in any fashion other than what we have now, which is the sickest get help first," he says.
Additional reading
Epstein, H. Bioterrorism: Ethical issues for hospitalists. The Hospitalist 2002; 6:24-27. Available on-line at www.hospitalmedicine.org (accessed 9/24/05).
Sources
- John Moskop, PhD, professor of medical humanities and director of The Bioethics Center, The Brody School of Medicine at East Carolina University, Greenville, NC 27858. Phone: (252) 744-2361.
- Howard R. Epstein, MD, medical director, care management & palliative care, Regions Hospital, 640 Jackson St., St. Paul, MN. Phone: (651) 254-3456.
- Jeffrey Orledge, MD, emergency medicine physician, Medical College of Georgia, 1120 15th Street, Augusta, GA 30912. Phone: (706) 721-0211.
- Joseph L. Cappiello, vice president for accreditation field operations, Joint Commission on Accreditation of Healthcare Organizations (JCAHO), One Renaissance Blvd., Oakbrook Terrace, IL 60181. Phone: (630) 792-5757. E-mail: [email protected].
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