Shiloh
Editor, Senior Moderator
Source: http://www.tahoedailytribune.com/article/20080620/COMMUNITY/644795471/1060/NEWS&parentprofile=-1
Making ethical decisions in a public-health emergency
Jason Eberhart-Phillips
Today, most Americans take it for granted that in a medical emergency, the local health-care system will respond with the best possible treatments, including the world's most advanced medical technology.
We just assume that whatever doctors require to save lives always will be available in ample supply when acute hospital care is called for, whether that is oxygen, IV fluids, medications or life-support machines.
But what will happen to patients caught in a major disaster, such as an earthquake, a flood or a nationwide flu pandemic? How will the limited supply of hospital beds, services and supplies be allocated in such an overwhelming public-health emergency?
These are questions that California public-health officials, critical-care specialists and hospital administrators now are pondering as they anticipate the tremendous needs for medical care that will arise in extreme emergencies. No one here wants a rerun of the health-care calamities that followed Hurricane Katrina in New Orleans three years ago.
How can we be ready? That's what a statewide workgroup that I am part of now is examining. We are thinking about how the usual standards of medical care given in hospitals today would have to change under catastrophic circumstances, and how the new standards could be applied fairly, transparently and ethically.
When the number of critically ill patients exceeds the capacity of trained hospital staff to care for them, how will it be decided who gets intensive care and who doesn't? When the demand for vital equipment such as mechanical ventilators - the machines that breathe for patients unable to breathe for themselves - exceeds the supply, how will doctors determine which patients receive scarce hospital resources and which ones don't?
Questions like these don't have easy answers, but it is certainly better to think through such matters before a disaster strikes than to wait until mass casualties begin to arrive at the hospital door in the midst of a crisis. Having no plan for such emergencies will invite inequities in care and public disdain.
Details of the new "crisis standards of care" are yet to be developed, but certain guiding principles are taking shape. These include:
-- The Duty to Care: No patient needing medical care will be abandoned. When interventions that would save lives under ordinary circumstances are not available, no patient will be left without some level of care. This may require easing some of the licensing restrictions that govern who can provide medical services, so that basic forms of care can be given to all.
-- The Duty to Triage: In mass casualty events, the needs of the whole population will trump those of individual patients. Instead of treating the sickest or the most critically injured first, the focus in a crisis will be to maximize the number of lives saved. A patient's likelihood of survival will be a more critical factor in deciding to provide intensive care than severity of need. Perceptions of a patient's social worth or ability to pay will have no place in deciding what care is provided.
-- The Duty to Inform: The ways that decisions will get made about allocating scarce health-care resources in a disaster must be clear and understood by the public. As guidelines that relax the usual standards for health-care delivery are developed, every effort should be made to inform the community and seek public comment. That's the reason I am writing this column.
If you have some views on this challenging topic, please let me know.
- Jason Eberhart-Phillips, M.D., is the El Dorado County health officer. He can be reached at jeberhart-phillips@edcgov.us.
Making ethical decisions in a public-health emergency
Jason Eberhart-Phillips
Today, most Americans take it for granted that in a medical emergency, the local health-care system will respond with the best possible treatments, including the world's most advanced medical technology.
We just assume that whatever doctors require to save lives always will be available in ample supply when acute hospital care is called for, whether that is oxygen, IV fluids, medications or life-support machines.
But what will happen to patients caught in a major disaster, such as an earthquake, a flood or a nationwide flu pandemic? How will the limited supply of hospital beds, services and supplies be allocated in such an overwhelming public-health emergency?
These are questions that California public-health officials, critical-care specialists and hospital administrators now are pondering as they anticipate the tremendous needs for medical care that will arise in extreme emergencies. No one here wants a rerun of the health-care calamities that followed Hurricane Katrina in New Orleans three years ago.
How can we be ready? That's what a statewide workgroup that I am part of now is examining. We are thinking about how the usual standards of medical care given in hospitals today would have to change under catastrophic circumstances, and how the new standards could be applied fairly, transparently and ethically.
When the number of critically ill patients exceeds the capacity of trained hospital staff to care for them, how will it be decided who gets intensive care and who doesn't? When the demand for vital equipment such as mechanical ventilators - the machines that breathe for patients unable to breathe for themselves - exceeds the supply, how will doctors determine which patients receive scarce hospital resources and which ones don't?
Questions like these don't have easy answers, but it is certainly better to think through such matters before a disaster strikes than to wait until mass casualties begin to arrive at the hospital door in the midst of a crisis. Having no plan for such emergencies will invite inequities in care and public disdain.
Details of the new "crisis standards of care" are yet to be developed, but certain guiding principles are taking shape. These include:
-- The Duty to Care: No patient needing medical care will be abandoned. When interventions that would save lives under ordinary circumstances are not available, no patient will be left without some level of care. This may require easing some of the licensing restrictions that govern who can provide medical services, so that basic forms of care can be given to all.
-- The Duty to Triage: In mass casualty events, the needs of the whole population will trump those of individual patients. Instead of treating the sickest or the most critically injured first, the focus in a crisis will be to maximize the number of lives saved. A patient's likelihood of survival will be a more critical factor in deciding to provide intensive care than severity of need. Perceptions of a patient's social worth or ability to pay will have no place in deciding what care is provided.
-- The Duty to Inform: The ways that decisions will get made about allocating scarce health-care resources in a disaster must be clear and understood by the public. As guidelines that relax the usual standards for health-care delivery are developed, every effort should be made to inform the community and seek public comment. That's the reason I am writing this column.
If you have some views on this challenging topic, please let me know.
- Jason Eberhart-Phillips, M.D., is the El Dorado County health officer. He can be reached at jeberhart-phillips@edcgov.us.