An influential panel of experts on Thursday highlighted serious shortcomings in planning for a public health disaster and called for clear national guidelines for making ethical and medical decisions in crisis situations.
A 15-member committee convened by the Institute of Medicine said there was an “urgent and clear need” for consistent standards of care that would apply in disasters – especially on such thorny issues as knowing which patients should receive rare treatments or equipment and which should go without.
In its report, the committee said that a crushing disaster “will strain medical resources and could compromise the ability of healthcare professionals to adhere to normal treatment procedures and conventional standards of care.” The committee was not talking about day-to-day issues. Rather, he was referring to crises that come on without warning, like earthquakes and hurricanes, or those that get progressively worse, like a pandemic disease.
ProPublica reported yesterday that state and federal authorities are moving forward with plans that – during a severe flu outbreak – would hijack ventilators on some patients to ensure they would be available for patients who may need it. benefit more.
The committee – made up of doctors, lawyers and public health officials – acknowledged that such measures might be necessary, but repeatedly stressed that public input must be sought before such a plan is made. finalized.
Even decisions to deny treatment to patients must be based on ethics and research, according to the report. And some key research is lacking, particularly on how to prioritize care for children and the elderly.
Committee members strongly advised against reallocating resources based on a patient’s decision to sign a “do not resuscitate” order. The committee met just days after ProPublica and the New York Times Magazinereported that after Hurricane Katrina, patients ordered not to resuscitate at Memorial Medical Center in New Orleans were considered the lowest priority for evacuation – a decision that was not in the hospital emergency plan.
The article also pointed out that Memorial doctors, like most American doctors, had received little or no advice or training on how to operate in a disaster.
“Disaster planning must include advance ethical guidelines,” the committee report said. “Factors such as non-resuscitation status (DNR) have sometimes been factored into allocation patterns. However, DNR orders reflect individual preferences and foresight to establish advance directives more than a precise estimate. survival.As a result, DNR orders are not useful parameters for considering the allocation of scarce resources.
Dr Dan Hanfling, vice chairman, said that the “galvanizing point of the committee was the horror, the tragedy of Katrina”.
“We recognize that as a nation we can do better. We need to do better,” said Hanfling, special advisor for emergency preparedness and response at Inova Health System in Falls Church, Va.
The report comes as public health experts in recent months have planned – and feared – what could happen if the H1N1 flu epidemic spreads or becomes more deadly. So far, hospitals and other health facilities have been able to cope with cases without having to ration ventilators or drugs. But if the number of hospitalizations increases dramatically in many areas at once, that could change quickly.
Calls for better and deeper planning are not new. After the terrorist attacks of September 11, 2001 and the subsequent shipment of anthrax-contaminated packages, health officials and politicians spoke of the need to improve preparedness for a bioterrorist attack. And after Katrina in 2005, officials said they needed to be better prepared for natural disasters.
Despite this, the Institute of Medicine committee found that “many states are just beginning to meet this urgent need.”
Hanfling said communities with more advanced plans include those directly affected by the 9/11 attacks and disaster-prone areas such as Florida and California. “It’s a quilted patchwork of capabilities,” he said of the nation.
Because disasters can subject healthcare providers to tremendous physical and mental stress, Hanfling said there is a need to plan as much in advance as possible. “We have an obligation not to put our hands up and say, ‘Oh my God. I don’t know what I’m going to do … I’m just going to make it up as I go.’ “The most vulnerable people in society, he said,” will be even more vulnerable in the event of a disaster and we must be accountable to everyone. “
The nation is far from a comprehensive plan. Among the obstacles, according to the report, community groups and health professionals have not spoken enough about ethically justified actions during a crisis. Regional partnerships between hospitals and health professionals are incomplete and inconsistent. And inadequate liability protections exist for medical professionals who may have to put the needs of some patients ahead of others in crisis situations, according to the report.
The committee’s report revealed a troubling conundrum. On the one hand, panelists expressed support for using “evidence-based tools” rather than random or “first come, first served” approaches to allocate ventilators and other resources. At the same time, he expressed concerns about the quality of the tools available and the research used to rationalize this allocation.
“None of the current systems or guidelines were designed for pediatrics or other patients with special medical needs,” the report said, urging that the gap be closed by panels of experts. “The needs of other vulnerable populations must also be kept in mind to ensure the equity of the developed system,” the report continues, without providing details on how to do this.
In particular, the committee looked at the Sequential Organ Failure Assessment Score (SOFA), which helps physicians assess the functioning of major body systems through a relatively simple set of tests. States such as New York, Minnesota, Utah and Colorado use the SOFA score as a major criterion for removing certain patients from ventilators – and donating equipment to other patients – in the scenario of a severe pandemic of flu.
But the tool “was not intended as a prospective predictor of survival,” according to the report, and “the single-point differences on the SOFA scale are of unknown clinical importance in predicting outcomes.”
The committee felt that more research was needed to improve the tools available to guide decision-making, said a member, Dr Tia Powell, director of the Montefiore-Einstein Center for Bioethics in New York. SOFA, she said, “is the best there is, but it’s not optimal.”
Typically, physicians and hospitals use a patient-centered standard of care, in which they do what they think is best for each patient they treat. The shift to what the committee called “standards of crisis care” – focusing primarily on the best outcomes for a population – should only happen after all other measures have been exhausted, Powell said. These include pre-planning and then, in the event of a crisis, bringing in additional staff and equipment, and sending patients to places where more resources are available.
“It’s not something a hospital can decide to do because there are a lot of people in the emergency room on a Tuesday,” said Powell. “It must be a declared emergency with a severe impact on the ability to provide health care.”
When asked if anyone on the committee raised concerns about the ethics of taking vital resources, such as ventilators, from some patients and directing them to others, Powell said: ” it is certainly a very difficult question ”.
The committee, she said, tried to strike a balance between attempting to “save as many lives as possible” and the “need to care for and provide empathetic and ethical care to all patients, whom they are likely to survive or not “.
The report was produced quickly. Officials from the US Department of Health and Human Services only requested it last month. The committee held a four-day meeting, including a one-day public workshop, earlier this month.
In a planned second phase, the committee is tasked with soliciting comments from the public and health professionals and updating its recommendations. Reports from the institute, which is part of the Congress-accredited National Academy of Sciences, have great influence on Congress and federal agencies.