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Institute of Medicine (US) Forum on Medical and Public Health Preparedness for Catastrophic Events. Crisis Standards of Care: Summary of a Workshop Series. Washington (DC): National Academies Press (US); 2010.

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Crisis Standards of Care: Summary of a Workshop Series.

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How can healthcare providers and facilities, with the support of state and local public health officials, the federal government, and their communities, provide the best care possible during a crisis? What steps can the health system take to avoid resource scarcity, manage demand, and minimize impact on clinical care? If these steps become insufficient, how should resources be allocated fairly and consistently? How can these steps be taken in an ethical, legal, and effective manner?

These were the questions that knitted together the four regional workshops in California, Florida, New York, and Illinois. While the individual approaches varied, participants were unified in recognizing that these were important questions, and that they were questions that had to be answered before it was too late.

A great deal of progress has been made over the past decade, motivated in part by events such as September 11, 2001, the anthrax attacks, and Hurricane Katrina. Ten years ago, hospital administrators and healthcare officials wouldn’t touch the third rail of crisis standards of care; now working groups are approaching this problem in regions, states, and communities around the nation. The workshops presented dozens of approaches, many of which shared common basic principles, even if they differed on the specifics. National efforts from the CDC, AHRQ, and others were widely praised for laying the groundwork, even as participants identified more work that needs to be done.

These are not easy issues. The scenarios addressed at these meetings are uncomfortable. Fearsome words like “rationing” and dire concepts like discontinuing life-sustaining treatment in critically ill patients must be considered and confronted head-on, at every level—from federal oversight to local administrations—and by every party—from politicians to lawyers to primary caregivers.

Ultimately, the discussions are held with the aim of providing the best and most fair treatment to as many patients as possible during a crisis.

Healthcare providers will not have time during an emergency to develop programs from a standpoint of fairness and equity. There will not be time to develop laws to facilitate information sharing, dramatically increase staff, or provide legal liability. Any on-the-spot efforts to develop triage protocols, conduct evidence-based studies, or build relationships of trust among hospitals in different regions and communities will be impossible.

As a result, participants said, officials have a duty to plan for these scenarios. They have a duty to develop crisis standards of care protocols based on reasoned and ethical approaches that reflect the views and beliefs of the broader community. While much has been done, that work needs to be gathered into a central resource where other jurisdictions can reference and use it, and more evidence-based research is needed. Importantly, more work needs to be done to build relationships and ensure consistency in the approach of different regions and settings.

But there is more work to do, especially in some areas that will be critical during crises:

  • Palliative care planning: Caregivers and administrators need everything from simple definitions to detailed guidance on when and where it is given and who can provide it.
  • Mental/behavioral health implications for the public as well as care providers.
  • Preparedness planning for vulnerable populations, such as pediatric, geriatric, and mental health patients.
  • Public and provider engagement in the planning process.
  • Consistency across borders and regions.

“How far do we need to get in standards?” asked Phillips, summarizing the Irvine meeting. “Are they general principles that we should all be adhering to? Do we need to be setting some national standards? Should we be just aiming toward principles that ensure consistency, but allowing individual flexibility?”

Overall, participants said that the workshops had been helpful in highlighting how much work is going on around the nation on this issue, but also emphasized that much work remains to be done in order to ensure that the best care possible is provided under catastrophic circumstances.

Copyright © 2010, National Academy of Sciences.
Bookshelf ID: NBK32743
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