The Most Good for the Most People:
Emergency Physicians Lead Push for Creating “Crisis Standards of Care” in Tough Political Climate
Article Outline
A long-standing need in US medicine—establishing standards for how care is delivered in crises—is being hampered by the need to engage the US public just when health care has become the most contentious topic around. If the effort were successful, promulgating agreed-on “crisis standards of care” could improve preparation for disasters and, as a side benefit, illuminate some of the decisionmaking made every day in overstressed emergency departments (EDs). But in the wake of a health care reform battle that began with former Alaska Governor Sarah Palin's claim of “death panels” and ended with bricks thrown through Congressional offices' windows, the chances of open debate on the issue—and the appetite for bringing it forward—both seem slim.1, 2
“A lot of people feel that, at this moment, public engagement on this issue is a very necessary thing,” said Darren P. Mareiniss, MD, JD, who is the Legal Medicine Fellow in the Department of Emergency Medicine at Johns Hopkins School of Medicine and author of an unpublished article on legal issues in crisis standards of care. Dr. Mareiniss, who presented on that topic at a Department of Homeland Security summit in March 2010, added, “But not everyone is clear on how to get that done.”
The impulse toward clearly delineated crisis standards dates back to the World Trade Center and anthrax-letter attacks of 2001 and to the fears of an avian flu pandemic stoked by that pathogen's movement across Asia and into Europe in 2004. It was first elucidated in a 2005 report issued by the Agency for Healthcare Research and Quality and the Office of the Assistant Secretary for Preparedness and Response of the Department of Health and Human Services.3 That report, which summarized the consensus of an August 2004 meeting of bioethicists, attorneys, health policy experts, and spokespersons for emergency medicine and health administration, warned that “[t]he goal of the health and medical response to a mass casualty event is to save as many lives as possible . … To achieve this goal, health and medical care will have to be delivered in a manner that differs from the standards of care that apply under normal circumstances. This issue is not addressed in a comprehensive manner in many preparedness plans.”
Katrina Makes Warning Come True
That hypothetical warning, published in April 2005, abruptly became real only months later, when hospitals in New Orleans lost both main and backup power to the floodwaters let into the city by levee breaks caused by Hurricane Katrina. The choices made by one set of health care workers as they evacuated critical care patients from Memorial Medical Center would subsequently trigger their arrests for second-degree murder, charges that were voided by a grand jury in 2007 under intense public pressure.4
At almost the same time as the grand jury's decision on the Katrina deaths, the New York State Department of Health published a draft version of its conclusions on a potential future mass casualty, a severe flu pandemic. According to federal projections, the state's Workgroup on Ventilator Allocation in an Influenza Pandemic predicted that in the peak of a severe pandemic, “35,000 patients—nearly 9 times current capacity—would require ICU care. Approximately 58,000 influenza patients would require ventilators … with 17,844 needing them in peak weeks. This is almost 3 times New York State's current ventilator capacity.”5
The draft document, “Allocation of Ventilators in an Influenza Pandemic,” was intended to stimulate public debate about triage, rationing, and liability protection for health care workers. But its implied corollary of potentially extubating critical patients with poor Sequential Organ Failure Assessment scores, to give their ventilators to others with better prognosis, proved so contentious in consultations with medical personnel and legal experts that the open public discussions envisioned by the state apparently have not been conducted, and the plan's Web site has not been updated.6
Paradoxically, public engagement went smoothly on a separate pandemic-related issue, vaccination priorities in times of scarcity. In 2006 to 2007, when avian influenza H5N1 was considered the most likely flu strain to trigger a pandemic, the nonprofit organization the Keystone Center conducted a nationwide series of public meetings to guide federal decisionmaking about vaccine allocation.7 In 2010, the center revived the process to gauge the public's reaction toward vaccine allocation in the nascent H1N1 pandemic, holding public meetings in July and August 2009 and meetings with public health stakeholder organizations in September. In its final report, though, the group warned that it is crucial to explore public attitudes toward controversial new measures because the parties disagreed so much about appropriate actions: “Stakeholders departed significantly from the citizens-at-large who attended the ten face-to-face meetings and from citizens-at-large and stakeholders participating in … online dialogues.”8
IOM Weighs In
A concerted push to establish crisis care standards has been made recently by the Institute of Medicine. The group's 2009 letter report “Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations” and accompanying 2010 “Crisis Standards of Care: Summary of a Workshop Series”9, 10 acknowledge that 8 states have begun work on consensus crisis protocols. But with most states and local governments (and health care facilities) yet to begin, the reports say that “there is an urgent and clear need for a single national guidance.”
Both reports emphasize how critical it is that the public be brought into any discussions of transforming care from its traditional focus on maximum benefit for the individual to a crisis-driven focus on the greatest good for the greatest number, at a potential cost to individuals. The workshop report underlines how complex that task will be, at one point listing 41 different stakeholders that should be invited into the discussion.
In March, Dr. Mareiniss's copanelist at the DHS Summit, Sally Phillips, RN, PhD, director of public health emergency preparedness research at the Agency for Healthcare Research and Quality, summed up efforts at public engagement on the issue: “We have done a miserable job.”
The delay in opening broad discussion of crisis standards of care is particularly frustrating to emergency medicine specialists who see establishing standards as not only an obligation for medicine generally but also a benefit to crowded EDs seeking to allocate beds and personnel while under stress.
“We are already not applying strict standards of care when we are overwhelmed, because strict standards of care assume that you are doing the very best you can for each and every patient, as if you had the appropriate time and resources to manage each to the very best they deserve,” said Gabor D. Kelen, MD, professor and chair of Hopkins' Department of Emergency Medicine and director of the university's Office of Critical Event Preparedness and Response. “[So] this has dual-use for emergency medicine. The concepts embedded in this are ones that we use every day.”
Hopkins is reaching out to its community to begin discussions, using decisionmaking in ICU care as the starting point.
“Getting real public input into the discussion of ethical principles underlying this is essential,” Dr. Kelen said. “But it's tricky. If we are not careful as to how we frame this, it could end up politicized in an ugly way.”
References
- . Statement on the current health care debate. August 7, 2009, 15:26 http://www.facebook.com/note.php?note_id=113851103434Accessed March 17, 2010
- Associated Press. Vandalism at 2 western NY Democratic offices. March 22, 2010.
- . Altered standards of care in mass casualty events (Department of Health and Human Services). April 2005 http://www.ahrq.gov/research/altstand/Accessed March 10, 2010
- . The deadly choices at Memorial. August 27 http://www.propublica.org/feature/the-deadly-choices-at-memorial-826Accessed March 20, 2010
- . Allocation of ventilators in an influenza pandemic: planning document. March 15, 2007 http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/docs/ventilator_guidance.pdfAccessed March 22, 2010
- . Allocation of ventilators in an influenza pandemic. http://www.health.state.ny.us/diseases/communicable/influenza/pandemic/ventilators/Accessed March 22, 2010
- . Public Engagement Project on vaccine prioritization for pandemic influenza. http://keystone.org/files/file/SPP/health/VaxPPreportdtrev_FINAL_3-25-2010.pdfAccessed March 31, 2010
- . The Public Engagement Project on the H1N1 pandemic influenza vaccination program. September 30, 2009 http://keystone.org/files/file/about/publications/Final-H1N1-Report-Sept-30-2009.pdfAccessed March 31, 2010
- Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: Institute of Medicine, National Academy of Sciences; 2010;http://books.nap.edu/openbook.php?record_id=12749Accessed March 10, 2010
- Crisis Standards of Care: Summary of a Workshop Series. Washington, DC: Institute of Medicine, National Academy of Sciences; 2010;http://www.nap.edu/openbook.php?record_id=12787Accessed March 12, 2010
Section editor: Truman J. Milling, Jr, MD
Funding and support: By Annals policy, all authors are required to disclose any and all commercial, financial, and other relationships in any way related to the subject of this article that might create any potential conflict of interest. The authors have stated that no such relationships exist. See the Manuscript Submission Agreement in this issue for examples of specific conflicts covered by this statement.
PII: S0196-0644(10)00490-7
doi:10.1016/j.annemergmed.2010.05.018
