Hostname: page-component-8448b6f56d-tj2md Total loading time: 0 Render date: 2024-04-23T12:31:09.406Z Has data issue: false hasContentIssue false
  • English
  • Français

Altered Standards of Care During an Influenza Pandemic: Identifying Ethical, Legal, and Practical Principles to Guide Decision Making

Published online by Cambridge University Press:  08 April 2013

Donna Levin ,
Rebecca Orfaly Cadigan ,
Paul D. Biddinger ,
Suzanne Condon ,
Howard K. Koh  and
Joint Massachusetts Department of Public Health-Harvard Altered Standards of Care Working Group
Get access Rights & Permissions [Opens in a new window]

Abstract

Although widespread support favors prospective planning for altered standards of care during mass casualty events, the literature includes few, if any, accounts of groups that have formally addressed the overarching policy considerations at the state level. We describe the planning process undertaken by public health officials in the Commonwealth of Massachusetts, along with community and academic partners, to explore the issues surrounding altered standards of care in the event of pandemic influenza. Throughout 2006, the Massachusetts Department of Public Health and the Harvard School of Public Health Center for Public Health Preparedness jointly convened a working group comprising ethicists, lawyers, clinicians, and local and state public health officials to consider issues such as allocation of antiviral medications, prioritization of critical care, and state seizure of private assets. Community stakeholders were also engaged in the process through facilitated discussion of case scenarios focused on these and other issues. The objective of this initiative was to establish a framework and some fundamental principles that would subsequently guide the process of establishing specific altered standards of care protocols. The group collectively identified 4 goals and 7 principles to guide the equitable allocation of limited resources and establishment of altered standards of care protocols. Reviewing and analyzing this process to date may serve as a resource for other states. (Disaster Med Public Health Preparedness. 2009;3(Suppl 2):S132–S140)

Keywords

altered standards of careethicspublic health preparednessallocation of scarce resources
Type
Concepts in Disaster Medicine
Information
Disaster Medicine and Public Health Preparedness , Volume 3 , Issue S2 , December 2009 , pp. S132 - S140
Copyright
Copyright © Society for Disaster Medicine and Public Health, Inc. 2009

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

REFERENCES

1.Trust for America’s Health. A Killer Flu. June 2005. http://healthyamericans.org/reports/flu/Flu2005.pdf. Accessed July 14, 2008.Google Scholar
2.Mehta, S.Disaster and mass casualty management in a hospital: how well are we prepared? J Postgrad Med. 2006;52:89–90.Google Scholar
3.Gostin, LO, Powers, M.What does social justice require for the public’s health? Public health ethics and policy imperatives. Health Affairs. 2006;25:1053–1060.CrossRefGoogle ScholarPubMed
4.Huber, SJ, Wynia, MK.When pestilence prevails Physician responsibilities in epidemics. Am J Bioethics. 2004;4:W5–W11.CrossRefGoogle ScholarPubMed
5.Reid, L.Diminishing returns? Risk and the duty to care in the SARS epidemic. Bioethics. 2005;19:348–361.CrossRefGoogle ScholarPubMed
6.Ruderman, C, Tracy, CS, Bensimon, CM, et alOn pandemics and the duty to care: whose duty? Who cares? BMC Medical Ethics. 2006;7:5.CrossRefGoogle ScholarPubMed
7.Singer, PA, Benatar, SR, Bernstein, M, et alEthics and SARS: lessons from Toronto. BMJ. 2003;327:1342–1344.CrossRefGoogle ScholarPubMed
8.Sokol, DK.Virulent epidemics and scope of healthcare workers’ duty of care. Emerg Infect Dis. 2006;12:1238–1241.CrossRefGoogle ScholarPubMed
9.University of Toronto Joint Center for Bioethics (Working Group). Ethics and SARS: Learning Lessons from the Toronto Experience. http://www.yorku.ca/igreene/sars.html. Accessed August 21, 2007.Google Scholar
10.Nossiter A. Grand Jury Won’t Indict Doctor in Hurricane Deaths. New York Times. July 25, 2007. http://www.nytimes.com/2007/07/25/us/25doctor.html?scp=1&sq=Grand%20Jury%20Won%92t%20Indict%20Doctor%20in%20Hurricane%20Deaths&st=cse. Accessed May 4, 2009.Google Scholar
11.Okie, S.Dr. Pou and the hurricane—implications for patient care during disasters. New Engl J Med. 2008;358:1–5.CrossRefGoogle ScholarPubMed
12.US Centers for Disease Control and Prevention. FluSurge. http://www.cdc.gov/flu/flusurge.htm. Accessed November 27, 2006.Google Scholar
13.Commonwealth of Massachusetts. The General Laws of Massachusetts. http://www.mass.gov/legis/laws/mgl/index.htm. Accessed October 3, 2008.Google Scholar
14.Challen, K, Bentley, A, Bright, J, et alClinical review: mass casualty triage—pandemic influenza and critical care. Crit Care. 2007;11:212.CrossRefGoogle ScholarPubMed
15.US Department of Health and Human Services, Agency for Healthcare Research and Quality. 2005. Altered Standards of Care in Mass Casualty Events. http://www.ahrq.gov/research/altstand. Accessed May 2, 2009.Google Scholar
16.Hick, JL, Rubinson, L, O’Laughlin, DT, et alClinical review: allocating ventilators during large-scale disasters—problems, planning, and process. Crit Care. 2007;11:217.Google ScholarPubMed
17.Daniels, N.Accountability for reasonableness. BMJ. 2000;321:1300–1301.CrossRefGoogle ScholarPubMed
18.Larkin, GL, Arnold, J.Ethical considerations in emergency planning, preparedness, and response to acts of terrorism. Prehosp Disast Med. 2003;18:170–178.CrossRefGoogle ScholarPubMed
19.Koenig, KL, Cone, DC, Burstein, JL, et alSurging to the right standard of care. Acad Emerg Med. 2006;13:195–198.CrossRefGoogle Scholar
20.Kinlaw K, Levine R. Ethical Guidelines in Pandemic Influenza—Recommendations of the Ethics Subcommittee of the Advisory Committee to the Director, Centers for Disease Control and Prevention. 2007. http://www.pandemicflu.utah.gov/docs/20070515-PanFluEthicGuides.pdf. Accessed May 2, 2009.Google Scholar
21.Bernstein, M, Hawryluck, L.Challenging beliefs and ethical concepts: the collateral damage of SARS. Crit Care. 2003;7:269–271.CrossRefGoogle ScholarPubMed
22.Thompson, AK, Faith, K, Gibson, JL, et alPandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006;7:12.CrossRefGoogle ScholarPubMed
23.Pesik, N, Keim, ME, Iserson, KV.Terrorism and the ethics of emergency medical care. Ann Emerg Med. 2001;37:642–646.CrossRefGoogle ScholarPubMed
24.Schoch-Spana, M, Chamberlain, A, Franco, C, et alDisease, disaster, and democracy: the public’s stake in health emergency planning. Biosecur Bioterror. 2006;4:313–319.CrossRefGoogle ScholarPubMed
25.Hawryluck, L.Ethics review: position papers and policies—are they really helpful to front-line ICU teams? Crit Care. 2006;10:242.CrossRefGoogle ScholarPubMed
26.The Proceedings of the Public’s Health and the Law in the 21st Century: Fifth Annual Partnership Conference.J Law Med Ethics. 2007;35 (Suppl 4):11–137.CrossRefGoogle Scholar
27.White, DB, Katz, MH, Luce, JM, et alWho should receive life support during a public health emergency? Using ethical principles to improve allocation decisions. Ann Intern Med. 2009;150:132–138.CrossRefGoogle ScholarPubMed
28.Hodge, JG, Gostin, LO, Vernick, JS.The Pandemic and All-Hazards Act: improving public health emergency response. JAMA. 2007;297:1708–1711.CrossRefGoogle ScholarPubMed
29.World Health Organization. WHO Global Influenza Preparedness Plan. 2005. http://www.who.int/csr/resources/publications/influenza/GIP_2005_5Eweb.pdf. Accessed December 20, 2007.Google Scholar
30.US Department of Health and Human Services, Agency for Healthcare Research and Quality. Mass Medical Care with Scarce Resources. 2007. http://www.ahrq.gov/research/mce. Accessed May 2, 2009.Google Scholar
31.Devereaux, A, Christian, MD, Dichter, JR, et alSummary of suggestions from the Task Force for Mass Critical Care Summit, January 26–27, 2007. Chest. 2008;133:1S–7S.CrossRefGoogle ScholarPubMed
32.Rubinson, L, Nuzzo, JB, Talmor, DS, et alAugmentation of hospital critical care capacity after bioterrorist attacks or epidemics: recommendations of the Working Group on Emergency Mass Critical Care. Crit Care. 2005;33:E1–E13.Google ScholarPubMed
33.Hick, JL, O’Laughlin, DT.Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emerg Med. 2006;13:223–229.CrossRefGoogle Scholar
34.US Government Accountability Office. States Are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scarce Medical Resources. GAO-08-668. June 13, 2008. http://www.gao.gov/new.items/d08668.pdf. Accessed March 1, 2009.Google Scholar
35.Daniels, N.Just Health: Meeting Health Needs Fairly. Cambridge, UK: Cambridge University Press; 2008.CrossRefGoogle Scholar
36.Tai, DYH.SARS plague: duty to care or medical heroism? Ann Acad Med Singapore. 2006;35:374–378.CrossRefGoogle ScholarPubMed
37.Nick, GA, Savoia, E, Elqura, L, et alEmergency preparedness for vulnerable populations: people with special health-care needs. Public Health Rep. 2009;124:338–343.CrossRefGoogle ScholarPubMed