Key Features

The ethical framework set forth in the letter report includes substantive and process features and should support ethical behavior for those at every level of disaster response, from government planners to individual providers. Its key features are as follows:

• fairness,
• the duty to care,
• the duty to steward resources,
• transparency,
• consistency,
• proportionality, and
• accountability.

Each of these features is discussed in turn below.

The Need to Make Difficult Choices

A major objective of public health preparedness is to build surge capacity so adequate medical care can be maintained even when numbers of patients rapidly increase and access to outside resources may not exist. Nonetheless, a disaster may force a community, at least temporarily, to confront the question of how to allocate medical resources that are insufficient for all those in need. Many different allocation systems may be proposed. Any ethically acceptable allocation system should adhere to the principles detailed above, including, most important, the principle of fairness. Generally, an allocation system will be more likely to pass the test of fairness if it reflects the additional principles of transparency, consistency, proportionality, and accountability. The ethics framework’s greatest potential for impact is during the development of CSC plans. Personnel with the responsibility for ensuring that CSC plans incorporate such ethical principles benefit the process best when they themselves are well versed in the specific issues affecting and affected by CSC plans and their implementation. It is also important to recognize how those issues expand upon and differ from ethical issues associated with routine medical practice. To ensure that the issues entailed in the process are resolved in a way that reflects community values, the committee recommends that the public be engaged in a dialog to help establish the standards that will be applied (see Chapter 9).

Any resource allocation system will reflect underlying values regarding who should receive limited resources, irrespective of whether the plan is simple or complex. For instance, plans that attempt to assess survival by using such tools as the Sequential Organ Failure Assessment (SOFA) score reflect particular value choices, in this case that resources are best used for those likely to survive rather than for those who will not survive despite access to treatment. This particular ethical choice reflects a desire to save the most lives by using resources prudently. Although saving the most lives is a widely accepted goal, it is a value-based choice, and not all may accept it. Others may wish to give priority to the young and thus not necessarily save the most lives, but the greatest number of years of life. In a discussion of values, health care providers, public health officials, and others may have strong views about what groups to privilege or what principles to uphold. Professionals have special training that helps them determine how best to achieve certain goals. However, their expertise regarding values is no greater than that of community members. This equality in expertise regarding values is why community engagement is so crucial. Professionals cannot use medical resources to support the goals and values of the community unless they know what those goals and values are.

Some ethicists have argued that no fair allocation system can be devised other than a random lottery (Peterson, 2008). However, such a system would fail to adhere to the principle of stewardship of resources. Use of a lottery with no reference to prognostic factors in the allocation of scarce medical resources would result in excess mortality since some patients would receive treatment despite having a high probability of mortality with or without treatment, while others who might have survived would die without it. For specific cohorts for whom differences in morbidity and mortality are particularly difficult to predict and no validated scoring system exists, as is the case with critically ill children, some authors believe use of a lottery may be justified (Pediatric Emergency Mass Critical Care Task Force, 2012).

Age as a Factor in Allocating Scarce Medical Resources

The question of whether age is an appropriate factor in determining access to scarce health care resources arises repeatedly in allocation discussions. For instance, the United Network for Organ Sharing sets policy for the allocation of solid organs for transplant. Recently proposed revisions for the allocation of kidneys to adults include changes that take age into account by assessing how long a potential recipient will likely survive with the donated kidney (Organ Procurement and Transplantation Network, 2011). In this context, as in others, consideration of age in allocating scarce resources has been controversial (Hippen et al., 2011).

Critical care physicians have expressed discomfort with using age as a prognostic indicator, as there is substantial physiological variability among elders of similar chronologic age. Age-related changes to organ function may, of course, be reflected in the SOFA score or other variables used by the triage team, even when age is not an overt criterion for allocation. Critical care physicians surveyed expressed a reluctance to triage specifically based on age until age 85 (Society of Critical Care Medicine Ethics Committee, 1994). Yet using age-based allocation only for those older than 85 severely limits the utility of the variable, as only 1.2 percent of the U.S. population falls into this range (Census Scope, 2011). Nonetheless, a Canadian workgroup developed guidance for the allocation of scarce resources in an influenza pandemic and listed age above 85 as an exclusion criterion (Christian et al., 2006). Others have incorporated age into their triage criteria, arguing that younger patients deserve an opportunity for a full life (Persad et al., 2009; Williams, 1997). Community engagement discussions in Minnesota and Seattle supported this general concept, although there was no consensus on age ranges or differences in age, or on how important age should be in the allocation process (Garrett et al., 2011; Public Health-Seattle and King County, 2009). While not specifically focused on age, a community engagement project in Massachusetts produced contrasting results: both consumers and health care providers objected to an allocation process that offered critical care resources only to those with an expected life span of more than 6 months (Levin et al., 2009). Additionally, participants in the community engagement discussions of a severe pandemic in Harris County, Texas, felt that using age alone as a factor in decisions about allocating critical resources was unacceptable; when age was shown to play a role in vulnerability to the disease, however, it was deemed a viable consideration (Shah, 2012). Finally, it is important to note that not all cultural groups value the young; some groups prize their elders and would not agree with giving younger patients priority.

There is no easy answer to the question of age as a triage criterion. Some participants in the disaster planning process see significant relevance in the “fair innings” argument, while others do not. However, all agree that decisions around age should incorporate community values. In particular, community engagement processes should address the following questions:

• How important is age? For example, should age be a criterion in itself, or only when two patients who are otherwise similar in terms of medical prognosis both require a scarce resource?
• What age ranges/differences should be considered? Should age be considered across the life span, or is there a ceiling above which advanced age should limit care options?
• How does this community weigh age in relation to other factors, such as prognosis or a critical work role (e.g., as a first responder)?

The Role of Families in Supplementing Scarce Health Care Resources

Families provide substantial amounts of medical care to injured and ill loved ones every day across the country. The role of family in protecting at-risk members of the population is of more, not less, importance in the setting of a disaster. Tragically, family advocacy can mean the difference between life and death. In the aftermath of Hurricane Katrina, some families in New Orleans were able to overcome a policy forbidding evacuation of patients with do-not-resuscitate orders, while patients who lacked successful advocates stayed and perished (Fink, 2009).

The question of whether families can appropriately supplement medical care in a disaster arises in a number of contexts. Family members may accompany ill relatives into the acute care setting. Indeed, many facilities will likely ask family members to serve as volunteers for nontechnical tasks, such as delivering food trays to acute care patients, to free trained personnel for more complex tasks. Facilities should be mindful, however, of whether family efforts benefit all patients or only the family member. For instance, a family member performing general assistance and custodial chores helps all patients and staff; in contrast, seeking out and harassing overtaxed staff to supply a higher level of care for a loved one than is available to other patients may benefit a single individual while disadvantaging many others. The possibility of threats to staff from family members may increase if and when resources become truly scarce. Facilities will need to consider plans for limiting family access to critical care settings in those circumstances.

The lack of family can be as life-threatening a scarcity as the lack of access to medical resources, and there is no public consensus on how to address the various consequences of social isolation. This problem arises with the question of using bag-valve ventilation as a supplement when critical care resources are in short supply. Those with family members may have willing volunteers to provide manual ventilation, while at-risk members of the community, including many elderly patients, may not have such volunteers. Among the options is to require those who are willing to provide manual ventilation to enter a lottery so they will not know to whom they will be assigned. This approach would allow those connected to large volunteer groups, such as through their church or family, to share their resources with those who are isolated. Depending on the nature of the disaster, other facilities may choose not to permit or encourage manual ventilation, citing its likely lack of efficacy or the exceptionally large use of labor, a scarce resource, needed to support a small number of patients in this fashion.

Summary

CSC permit clinicians to allocate scarce resources so as to provide necessary and available treatments to patients most likely to benefit. CSC do not permit clinicians to simply ignore professional norms and act without ethical standards or accountability. CSC justify limiting access to scarce treatments, but neither the law nor ethics support the intentional hastening of death, even in a crisis.

The Imperative to Provide Palliative Care

Palliative care is a specialty that focuses on relief of pain and other symptoms of serious illness, with the goal of preventing and easing suffering and distress while offering patients and their families the best possible quality of life. Palliative care is appropriate at any stage of a serious or life-threatening illness and is not dependent on prognosis. It can also be provided at the same time as curative and life-prolonging treatment. The provision of palliative care improves health care quality in three key areas:

• relief of pain and other symptoms and emotional suffering for patients and families;
• enhanced communication and decision making among patients, health care practitioners, and families; and
• improved coordination of care across multiple health care settings.

In its 2009 letter report, the committee stated that palliative care should be available to all people affected by a disaster (IOM, 2009). The key services include comfort, compassion, and maintenance of dignity—services that can be provided with essentially no physical resources other than the presence of another human being.

The public would likely benefit from understanding that palliative care, in ordinary times or during a disaster, prevents a sense that society or its health care professionals have abandoned the patient or deliberately caused death. Instead, palliative care respects the humanity of those who will die soon, minimizes their discomfort, supports their loved ones, and provides aggressive treatment of symptoms (e.g., pain, shortness of breath) (Domres et al., 2003; Matzo et al., 2009).

Ethical considerations and principles associated with scarce resources and CSC should be incorporated into CSC planning. As noted earlier, public health disasters justify temporarily adjusting practice standards and/or shifting the balance of ethical concerns from a focus on the needs of individuals to a focus on the needs of the community (Orr, 2003). Yet while the primary goal of a coordinated response to a disaster should be to maximize the number of lives saved, a practical plan also should provide the greatest comfort for those who will live for a while before dying as a result of the incident (Holt, 2008). Palliative care can play an important role in mass casualty incidents when resources are scarce. Special attention should be given to the planning and resources necessary to maximize care for patients with serious, advanced illness prior to a disaster, as well for those facing the end of life as a result of the disaster.

Resiliency in the face of a disaster requires a fully integrated and coordinated strategy to address how services will work together. All sectors of the health care system will be called upon to respond and save lives, or when that is not possible, to ensure a comfortable death. Advanced illness and end-of-life care pose particular challenges during health emergences, given complex care needs and the often competing demands for health care practitioners, supplies, and space. Palliative care surge capacity will be needed across settings. This need brings many challenges, including educating professional staff unfamiliar with delivering palliative care, stockpiling and providing necessary medications for effective symptom management at the end of life, and establishing protocols for symptom management for at-risk populations. Meeting these challenges will require training nonprofessional caregivers in basic comfort measures and ensuring broad-based coordination among EMS, hospitals, hospice and palliative care professional organizations, home care agencies, long-term care facilities, and state and local public health authorities. The emerging role of health care coalitions will also be instrumental in the successful integration of palliative care planning and implementation into regional protocols for disaster response.

What should first responders, disaster personnel, and health care providers do when all in their care cannot reasonably survive given the scope of injuries, the magnitude of exposure, environmental conditions, and pre-existing medical conditions? At a minimum, disaster response palliative care services should include relief of severe symptoms and comfort as people are facing death. There will be a sizable number of people for whom death can be expected, although they may live for hours, days, or weeks. Those who are not expected to survive cannot simply be consigned to holding areas while still alive, nor should they and their family advocates overwhelm hospitals and EMS systems that could be addressing the needs of potential survivors (Matzo et al., 2009).

Those who are dying or near death as a result of or during a disaster can be cared for humanely if plans and protocols for such care are established in advance of the incident. When all people cannot reasonably be saved because of the immediacy and scope of mass injuries and in the face of suddenly scarce resources, choices should be made as to who will most likely benefit from life-saving treatment (i.e., survive in the short as well as long term). The ethical assessment of benefit, burden, and efficacy may shift in the context of a disaster. Facilities should devise plans to meet the needs of excess patients in a disaster. If, despite these planning efforts, triage policies are triggered, scarce curative treatment will likely be directed to those patients most likely to survive the short-term effects of acute injury and/or illness, although the potential for long-term survival will be equally important, taking into consideration the prognosis for pre-existing chronic underlying medical condition(s) for patients in hospital or chronic care facilities.

Identifying transition points in a person’s condition helps the patient, the family, and health care practitioners prepare for the final stage of life. A transition point can be defined as an incident in the trajectory of an illness or injury that moves the patient closer to death. For example, a patient with chronic obstructive pulmonary disease may experience no change in her condition until she contracts influenza and never fully recovers; for that patient, contracting influenza is a transition point in her condition (Berry and Matzo, 2004). Prognostication, aided by a risk index or scale, enables health care practitioners to formulate clinical strategies during a crisis situation. These tools may be helpful in determining whether a patient’s illness has reached a terminal phase (Matzo, 2004). Providing a treatment category of “palliative care” for those not likely to survive will be an important service option for responders and triage officers. Acknowledging that a person is not likely to survive typically leads to discussions regarding goals of care, appropriateness of interventions, and efforts to help the patient and family begin to say goodbye (Matzo, 2004).

The Agency for Healthcare Research and Quality (AHRQ) published a report outlining principles to guide community planning for the delivery of health care in the face of overwhelming numbers of casualties (AHRQ, 2005). The intent of this planning guide was to assist state and local planners in developing plans that would optimize their ability to provide direct care for as many people as possible while protecting the rights of individuals to the extent possible under the circumstances. To achieve this goal, plans should promote the fair and equitable use of scarce resources. These resources may include emergency department, hospital, intensive care unit, or specialty care beds; transport assets; pharmaceuticals/countermeasures; medical equipment and materiel; and personnel. As in all situations of scarce medical resources, clinicians will use available triage tools and their professional judgment in identifying those individuals whose health condition suggests they will obtain the greatest benefit from the available resources (AHRQ, 2005).

A survey of disaster planning and palliative care key informants found that few in the disaster preparedness community or the palliative care community had been involved in coordinated planning activities in which the role of palliative care in emergency response was recognized (Matzo et al., 2009). Key informant discussions and an expert panel dialogue highlighted the importance of palliative care (e.g., aggressive symptom management) in a holistic and humane community disaster planning and response capability (Matzo et al., 2009). These discussions led to several recommendations: that specific roles and responsibilities and incident-driven resource requirements in all settings (e.g., the location of an incident, acute care hospitals, nursing homes and other alternate care sites, home) should be identified, defined, and provided; that palliative care services should be fully incorporated into all levels of state and local disaster planning/ training guidelines, protocols, and activities; and that first responder personnel and local and regional disaster response planners (e.g., EMS; fire, police, and public health departments; community health clinics; local and regional government entities) should be involved in identifying and developing clear specifications for what levels of care are to be delivered in what settings (at the incident, in alternate care sites, in existing secondary referral sites such as nursing homes or individuals’ homes) and by whom (e.g., first responders, rescue personnel, palliative care personnel, long-term care personnel). As discussed in Chapter 8, alternate care sites offer an opportunity to incorporate palliative or end-of-life care. For example, Michigan uses the Modular Emergency Medical System model and has been planning for end-of-life care consistent with the alternate care facilities planning guides (Cantrill et al., 2009).

Pain is the primary symptom in need of management in both disaster and war; “to prevent chronic pain and neuropathic pain as a result of amputation, burn injuries, delayed wound healing, malnutrition or infection, pain relief in disaster victims is of paramount importance” (Domres et al., 2003). Therefore, effective pain and symptom management should be a basic minimum in service delivery and training for palliative care during a disaster. Training for palliative care should be competency based, with programming specific to the individual’s role in emergency response. It should cover, at a minimum, the basic philosophy and goals of palliative care, basic symptom management (e.g., pain, anxiety, shortness of breath), the use and titration of oral and injectable narcotic analgesics for patients in pain and/or near death, symptom recognition in the case of pandemic influenza or a chemical or radiological attack, and basic psychosocial counseling and support. Disaster planning should take into account the potential benefits of stockpiling palliative care medications at accessible sites, including away from acute care hospitals (e.g., in nursing homes), and should include training for disaster responders in how to locate, access, and use these medications. The committee recognizes that federal, state, and local governments are already engaged in creating and maintaining pharmaceutical stockpiles, and while issues may exist with respect to stockpile management and rotation, those issues are beyond the scope of the committee’s charge and expertise.

A Triage Model

A triage model for use in palliative care includes categories not typically seen in other triage models (Cone and MacMillian, 2005; Janousek et al., 1999). Figure 4-1 presents the model of triage used for the expert Catastrophic MCE discussion cited above (Matzo et al., 2009). The term “likely to die” was defined as those people who are too sick or injured to survive hours, days, or weeks, most often categorized as the “expectant/black,” “nonsalvageable,” or “non-savable” victims. In practice, however, this category may also include those labeled “immediate” if needed medical resources are unavailable. This category could also include cases in which an individual is already dependent upon the usual health care system to survive (e.g., ventilator-dependent patients), has an existing life-threatening illness (e.g., extensive cancer), or has illness secondary to injuries sustained in the disaster (Matzo et al., 2009).

FIGURE 4-1

A triage and response model. NOTE: MCE = mass casualty event; PC = palliative care. SOURCE: AHRQ, 2007, p. 107.

The “likely to die” category is very broad but reflects the current state of the triage classification. Established triage schemes have substantial limitations when applied to the special circumstances of a disaster and the provision of palliative care. For example, many of the schemes do not attend to the likelihood of survival for patients with critical pre-existing medical conditions. Furthermore, there is a paucity of data addressing the critical question of whether correctly sorting casualties into the categories of any particular triage system results in improved outcomes, and one system may not handle all potential triage decisions in all triage settings (Cone and MacMillian, 2005). In practice, moreover, the “expectant” category often is applied only to those patients who are not breathing after one attempt at repositioning and opening the airway; all other critically ill or injured persons are treated as “immediate” or “delayed” (red or yellow). Finally, the usual triage schemes do not include palliative and comfort care measures as an alternative to curative treatment (Cone and MacMillian, 2005; Matzo et al., 2009).

A triage system for allocation of scarce resources will function best if it is transparent; fair; valid; consistent across settings and events; dynamic (applied at multiple places and times); and flexible enough to address changing circumstances, including responding when patients triaged as likely to die actually improve or when additional treatment resources become available (Matzo et al., 2009). Preserving a functioning health care system during and after a disaster will require the adoption of principles of field triage, limits on the use of ventilators and surgery, and the creation of alternate care sites. Research is beginning to provide a scientific underpinning for triage (Sacco et al., 2005), as well as to identify basic criteria for critical care triage during a disaster in which medical resources are scarce (Devereaux et al., 2008; Wilkinson et al., 2007). Future research will have to address the applicability of triage to palliative care, as well as the role of palliative care in disaster response. The arguments for incorporating palliative care into disaster response—humane treatment, diversion of dying people away from overburdened hospitals, more effective use of scarce resources, and the provision of care that patients want—have moral weight on their own, but research should still assess their impact.

In developing CSC plans, state and local public health agencies should work with hospice and other relevant partners to incorporate palliative care into disaster response plans. These efforts should include the development of

• evacuation plans for those who would be likely to benefit from palliative care;
• a community response plan, staffing plans, and training programs for first responders and other relevant medical personnel;
• transparent, community-based, explicit triage criteria for those not likely to survive;
• community conversations to engage, educate, and prepare the public;
• a plan for stockpiling needed medications and supplies at hospitals and at sites located away from hospitals (Wilkinson et al., 2007); and
• out-of-hospital considerations that may warrant moving individuals expected to die to care sites other than acute care hospitals.

In addition, palliative care professionals should participate in disaster planning, response and recovery training, and public education (Holt, 2008). First responders and health care providers at all disaster care sites (incident sites, alternate care sites, and hospitals) should have training in effective pharmacological pain and symptom management and psychosocial support. It is recognized that the burden to educate all of these personnel would be out of scope, but just-in-time training for those faced with palliative care responsibilities should be developed as part of the planning process.

Rebmann and colleagues’(2009) survey of 633 infection control professionals found that fewer than one-quarter of hospitals had convened their ethics committee to discuss preparedness issues or developed policies/procedures for CSC during a catastrophic disaster. During Hurricane Katrina, absent supplies and direction, the palliative care response was erratic and inefficient. One way to ameliorate a chaotic palliative care response is to form palliative care response teams comprising psychologists, chaplains, and health care providers with knowledge of palliative care as a core component of the emergency response process. Crosstraining of personnel in other areas to serve in this capacity is also important. As the volume of patients triaged to palliative care expands, so, too, will the strain of providing mass palliative care. Periodic emotional and psychological relief will be necessary for these palliative care providers through their rotation to other groups; this will be an important consideration for the welfare and morale of the provider corps as a whole.

Management of the dead can be one of the most difficult aspects of disaster response, and it has profound and long-lasting consequences for survivors and communities. Immediately after a catastrophic disaster, identification and disposal of human remains often are performed by local communities, primarily through local funeral directors and homes.

Summary

Facing the deaths of large numbers of its members while ensuring that those deaths are as pain and symptom free as possible is a major challenge for a community. Boxes 4-1 through 4-3 summarize key considerations in incorporating palliative care into CSC planning and implementation. Box 4-1 lists essential elements of palliative care under CSC conditions; Box 4-2 presents discussion topics for palliative care planning; and Box 4-3 details key points related to the implementation of palliative care in disaster situations.

BOX 4-1

Essential Elements of Palliative Care Under Crisis Standards of Care Conditions. Principles of palliative care integrated into response structures/plans Rapid palliative care response team trained to provide palliative care at all service delivery sites (more...)

BOX 4-2

Discussion Topics for Palliative Care Planning. Define common medications for community stockpile and cache locations as a potential part of the regional planning effort. Develop the skills, materials, and memorandums of understanding needed to shelter (more...)

BOX 4-3

Implementation of Palliative Care in Disasters: Key Points for Planners. Incident Command and Operations Request the participation of local, regional, and state disaster planning leadership to form a network of leaders in home health, palliative care, (more...)

Scope of the Issue and Range of Impact

CSC poses unique challenges for all involved in a disaster, including health care providers (and their families), patients receiving health care, and the public.

Although health care providers may confront life-and-death decisions on a daily basis and routinely experience the loss of patients, CSC differs from these experiences both quantitatively and qualitatively. For example, as soon as care shifts from a focus on the needs of individual patients to a focus on the greatest good for the most people, the entire health care team may have very different experiences with life-and-death decisions. If a disaster results in mass casualties, a significant threat to the mental health of the health care workforce may result. If not sufficiently addressed, these foreseeable mental health consequences may further degrade the functionality of the health care system and its ability to implement CSC optimally. Health care workers may bear the double burden of stress due to their professional roles and that due to seeing their families and friends requiring care within the CSC context. In some public health emergencies, moreover (such as the epidemic of severe acute respiratory syndrome [SARS]), health care workers themselves are subject to elevated health and mental health risks (Hawryluck et al., 2004; Lin et al., 2007).

Patients and families also will face significant psychosocial impact. The idea that CSC treatment decisions are based on the most good for the most people may run counter to their previous experiences, expectations, and wishes. If patients encounter CSC decisions that involve life-and-death consequences for their loved ones (which also may include disproportionate numbers of children and their parents), a significant population-level mental health burden and even the potential to unravel the social fabric of communities may result. Relationships between providers and their patients and patients’ families will face unprecedented complexities as CSC decisions are communicated and implemented and their consequences unfold at the clinic or bedside. Following the anthrax attacks in 2001, for example, the complexity of evolving risk communications and perceptions of differences in care among patient groups reflected episodic confusion among local and federal public health officials, medical providers, and patients (see Gursky et al. [2003] for a review). Public health emergencies that involve both CSC and social distancing may be particularly challenging as common sources of support, and hence resilience, are reduced (Gostin, 2006).

When these issues evolve on a regional or national scale, the potential for the perception of inequality in the application of CSC grows, and the protective impact of the sense that “we are in this together” is diminished, posing a threat to resilience. Although prosocial behavior is by far the most commonly observed collective response after a disaster (Glass and Schoch-Spana, 2002), planning should take into account the potential for negative social behaviors that may include aspects of panic. Indeed, there is limited consensus that certain features of emergency situations can trigger panic-like phenomena. For example, following the Three Mile Island nuclear incident, for every person that was asked to evacuate, 45 actually did, creating unintended gridlock. The prospect of pandemic influenza, which could entail significant morbidity and mortality, may also generate some undesirable collective behaviors among those attempting to avoid contagion, such as obtaining nonrecommended antiviral prophylaxis. Following the recent nuclear meltdown in Japan, for example, sales of potassium iodide, a treatment that prevents uptake of radioactive iodine by the thyroid gland, skyrocketed. Worldwide availability of potassium iodide ceased altogether for a period of time despite the quadrupling of prices (Aleccia, 2011). Factors that may be tied to the potential for mass panic in the CSC context include

• a belief that there is a small chance of escape from the agent,
• perceived high risk,
• available but limited treatment resources,
• no perceived effective response, and
• loss of credibility of authorities (DeMartino, 2001).

A high-mortality incident entailing CSC may have sufficient triggers to ignite panic behavior in some individuals and subpopulations. These risks occur against a backdrop of the recent finding that only 35 percent “of the American public is confident in the health care system’s readiness to respond effectively to a deadly flu pandemic” (National Center for Disaster Preparedness, 2005, p. 1). For example, among respondents to the Los Angeles County Health Survey, which included questions regarding terrorism preparedness, 17 percent reported having developed an emergency plan and 28 percent maintaining additional supplies of food, water, and clothing (Eisenman et al., 2006).

The full range of these impacts at the public level needs to be considered more fully. Traditional risk communications that focus on content are necessary but not sufficient to facilitate resilience and manage the emotional fallout that public health emergencies can engender. Engagement of the public (and health care providers) is essential to maintaining individual and community resilience (see Chapter 9). In fact, it should be regarded as a fundamental component of preparedness such that it is incorporated throughout the stages of response in a public health emergency that requires CSC.

Finally, there is a largely uncharted opportunity to leverage social media to facilitate national resilience in the face of a disaster. These media could be used to convey the notion that, despite challenges and traumatic outcomes for some, “we are in this together,” and to clarify the use of a common CSC approach governed by the ethical principles outlined in this report.

Patients with Psychiatric Emergencies as a Particular Crisis Standards of Care Subpopulation

In many communities across the United States, the allocation of scarce resource is already necessary to address chronic shortages of inpatient mental health beds for adults and children (Geller and Biebel, 2006; SAMHSA, 2007). In some communities, patients presenting to the emergency department with life-threatening mental health conditions are never transferred to an appropriate level of care or must wait days in the emergency department environment before receiving definitive psychiatric care (Schumacher Group, 2010). In some disaster scenarios, demand on these resources may be even greater, magnifying the need to develop CSC specific to psychiatric emergencies that entail immediate danger to those gravely disabled by their psychiatric illness or others. The development of CSC specific to the management of highly limited involuntary psychiatric resources will also be necessary. Strategies will need to consider cases in which psychiatric patients with comorbid medical conditions require care under CSC (see the HHS [2012] definition of at risk).

Operational Guidance to Enhance Resilience and Manage the Mental Health Consequences of Crisis Standards of Care

The 2009 letter report offered specific strategies and described several national best-practice initiatives with respect to managing the mental health consequences of mass casualty events (IOM, 2009). Here the committee offers more detailed operational guidance tailored to patients, providers, and the general public. At the various levels of hospital facility, local/regional, and state planning, the following elements are necessary to address the continuum of resilience and mental health issues tied to CSC (see also Box 4-4):

BOX 4-4

Functions for Mental Health Response to Crisis Standards of Care. Suggested: Concept of mental health operations in CSC integrated into incident command system and other response structures and plans Specific capabilities and capacities required for patients/families, (more...)

• A disaster mental health concept of operations and operational disaster mental health plan should be developed.

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  These plans may guide the disaster mental health response in an all-hazards context but include incidents that trigger CSC (and surge demand) for mental health resources.

  ο

  The plans should address the full continuum of those affected, from those with pre-existing mental illness, to those directly affected by the implementation of CSC and their families, to health care workers who must implement CSC, to the general public.

• Plans should address the anticipated consequences of CSC incidents through a gap analysis of the range of expected mental health impacts versus current resources. When informed by such an analysis, triage decisions reflect a rational allocation of limited disaster mental health resources. During response, near-real-time awareness of needs and resources informs a floating triage algorithm of risk levels versus resources, guided by the ethical framework set forth in this report.
• Evidence-based interventions should be identified for the high-risk subset of providers; patients; and surviving family members, including children (e.g., trauma-focused cognitive-behavioral therapy for children, prolonged-exposure cognitive-behavioral therapy for adults, and other commonly employed techniques [IOM, 2007; Stokes and Jones, 1995]).
• Core competencies and training curricula should be developed for

  ο

  mental health, social services, and spiritual care staff;

  ο

  health care providers; and

  ο

  the public—basic strategies for community resilience that community members can use with friends and family (such as very basic psychological first aid, created specifically for these populations) (see also Chapter 9 on public engagement).

• Site, local/regional, and state-level incident command operations should be augmented to integrate mental health operations into emergency operations center operations. These efforts should encompass mental health needs assessment and operations for patients/disaster victims and responders (including health care workers and their families) to create user-defined situational awareness of acute mental health gaps, including

  ο

  a user-defined/common operating picture of the continuum of population-level mental health risks (traumatic loss, multiple traumatic losses);

  ο

  a user-defined/common operating picture of the continuum of mental health risks to health care workers; and

  ο

  a user-defined/common operating picture of mental health resources, including telephone, triage, and novel Internet-based interventions.

• Comprehensive resilience programs for health care workers/responders should be developed that integrate personal behavioral coping and agency preparedness. These programs should encompass preincident stress inoculation, development of personal resilience “plans,” simple peer-to-peer psychological first aid, self-triage, and linkage to Internet-based interventions for those at higher risk who desire further support.