Task force suggests health care rationing in catastrophes
Care focus is on whole, not individual
"If a mass casualty critical care event were to occur tomorrow, many people with clinical conditions that are survivable under usual health care system conditions may have to forgo life-sustaining interventions owing to deficiencies in supply or staffing."1
In a nation whose Founding Fathers emphasized the freedom and autonomy of the individual to form the basis for the United States as we know it today, those words could create alarm in some.
But in the "Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26-27, 2007," that group chose to weight its suggested protocols on mortality vs., for example, life years saved in the event of a mass casualty event.
The task force met in Chicago in January 2007 following extensive literature searches with MEDLINE, OVID and Google databases from January 1966 to November 2006, as well as other types of publication searches. The group later communicated electronically and in conference calls after forming writing committees when it initially convened to develop the manuscript.
The result almost a year later (the manuscript was submitted and accepted for publication in March 2008), in a 67-page document that offers specific suggestions in four documents titled, respectively: "Definitive Care for the Critically Ill During a Disaster: Current Capability and Limitations" "Definitive Care for the Critically Ill During a Disaster: A Framework for Optimizing Critical Care Surge Capacity" "Definitive Care for the Critically Ill During a Disaster: Medical Resources for Surge Capacity" as well as "Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care."
"...No one had really taken the soup to nuts approach of what really are the likely events, what are the likely capabilities that are going to be brought to bear, and what are the situational contexts which will create certain limitations to be able to augment access," notes Lewis Rubinson, MD, PhD, of the Harborview Medical Center in Seattle, and one of four authors of the manuscript.
"How can we prepare ahead of time, so that this likelihood of having to decide between people never becomes a reality? Still, it would be irresponsible of us if we just bury our heads in the sand and don't take on a fair, just and objective means to allocate, knowing that we're trying to reduce the plausibility, but the plausibility will always exist," Rubinson tells Medical Ethics Advisor.
In addition to suggestions for rationing health care – albeit with a full consideration of the ethics associated with such decisions — is an "absolute frank statement that everyone will get dignified care," in the scenario that the task force envisioned, according to Rubinson.
"You may not get a ventilator if there are orders of magnitude of people all needing it, and you are much more sick than someone else, because they're more likely to benefit," he says.
As the executive summary points out, the "vast majority" of mass casualty events "do not generate overwhelming numbers of critically ill victims."
The suggestions, as the title indicates, are just that — not policies or guidelines, he says. The task force suggestions are meant to help state and local level planning, and the groups that are involved in this planning, since most health care emergency procedures are developed at these levels.
While most of the mainstream media attention on the suggestions focused on the rationing of health care that is specifically suggested, Rubinson said the group's ethical considerations began long before this point.
Ethical construct framed
"So, even before allocation takes place, there is a potential ethical construct that has to be newly created that leads, again, from individual focus to population focus," he says. "And for those specifics, we hesitate to recommend to each community to do their own specifics, because then every community is going to be doing something differently. The only way to truly do things fairly and justly is to have people following similar things."
For example, by following these suggestions, it would prevent smaller hospitals with fewer resources from bearing the brunt of the care during a mass catastrophe, and therefore placing their patients at higher risk than perhaps at other facilities.
With the rationing of health care comes obvious obligations for what could be considered fair treatment, even when the goal is to save those who may benefit most from receiving therapies or treatments under the circumstances.
Rubinson says that the suggestions are careful to specify the "triggers" that would lead to rationing of health care. For example, Suggestion 4.3A states, among other things, that "critical care will be rationed only after all efforts at augmentation have been exceeded."
"The task force assumes that [emergency medical critical care (EMCC)] has become exhausted and a Tier 6+ level has been attained or exceeded," Suggestion 4.2 states.
One aspect of the rationing of health care is that decisions will be made by the medical professionals, i.e., "Rationing of critical care will occur uniformly, be transparent, and abide by objective medical criteria."
Another suggestion, 4.3D, states that "Rationing should apply equally to withholding and withdrawing life-sustaining treatments based on the principle that withholding and withdrawing care are ethically equivalent."
Palliative care is also an essential part of the suggestions for rationing health care in an EMCC.
"…{For] anyone who practices critical care, palliative care and end-of-life care [are] a huge part of what we do, so it was just logical to have that as part of this strategy," Rubinson says.
Related to the rationing of health care, the suggestions actually spell out that "providers should be legally protected for providing care during the allocation of scarce resources in mass critical care when following accepted protocols."
In providing for this in policy, it would have to be done at the state level, he says.
"We wanted to give [stakeholders] specifics, so that ultimately, when they do want to implement this, they have something to take to their legislature, because no legislature is going to give them carte blanche . . .," Rubinson says. "Clearly, that's not a wise strategy, either, because we want to make sure that the public is protected as well as possible."
The goal of any legislation would be to provide "either immunity or indemnification from civil and criminal liability," Rubinson says.
Creating surge capacity
"Every hospital with an ICU should plan and prepare to provide EMCC and should do so in coordination with regional hospital planning efforts."
The suggestions specifically say that hospitals should plan to provide EMCC for a "total critically ill patient census at least triple usual ICU capacity." And, hospitals should plan to deliver this level of care for 10 days "without sufficient external assistance."
One has only to think of the ravages of Hurricane Katrina, or more recently in Myannmar, to think of the number of days that can pass before some type of aid or assistance outside the affected area may be available.
Hospitals also should plan to have EMCC include such things as IV fluid resuscitation, vasopressor administration, and antidote or antimicrobial administration for specific diseases.
In suggestion 3.3 in the document related to providing medical resources at surge capacity, one of the specifics is that rules should be developed "for medication restriction (eg, oseltamavir if in short supply during an influenza pandemic)," as well as guidelines for extending the shelf-life of medications.
The suggestions also address "staffing models" for operations during surge capacity, which include four specifics, including one that "systematic efforts to reduce care variability, procedure complications and errors of omission must be used when possible."
Conclusions reached
The task force hinged its efforts on EMCC to provide what it considers an "effective conceptual and operational framework" for responding in the best way possible to mass casualty events.
Focusing on the "good of the collective society," the task force decided that its goal was to provide a framework that may allow those responding in such events to "do the greatest good for the greatest number."
And finally, the task force again noted that the decisions that often are required during a natural or manmade catastrophe are "complex" and "fraught with ethical dilemmas that require thoughtful consideration well in advance of their use in an emergency."
In the event the public or other stakeholders object to rationing, regardless of the greater good of the task force's values, Rubinson said that providing the best health care to every person in certain catastrophes is "an impossible situation."
So, while the task force's goals are to reduce the likelihood of an individual needing health care being deprived of that care, Rubinson said, "I don't really think it's fair to say that it will never happen."
Reference
- Deveraux, A. et. al. Summary of Suggestions From the Task Force for Mass Critical Care Summit, January 26-27, 2007. Chest. 2008; 133: 1S-7.
Sources
For more information, contact:
- Lewis Rubinson, MD, PhD , Harborview Medical Center, Seattle, WA.
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