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

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.

Legal Preparedness

“…1 Also integral to the planning process is identifying ethical principles to guide MCC decision-making (see the “Ethical Considerations” article by Daugherty Biddison et al 22 in this consensus statement). 23,24 To help confirm that MCC plans are just, as fair as possible, and accepted when implemented, comprehensive vetting by qualified experts and public engagement are needed (see the “Engagement and Education” article by Devereaux et al 25 in this consensus statement). Training of all relevant responders must occur in advance of disasters.…”

“…They also are accountable for the triage decisions they make and processes in which they are involved. 23,36 Impromptu and independent departures by clinicians from formally adopted and vetted plans may have legal, ethical, and public health ramifications (see the “Ethical Considerations” article by Daugherty Biddison et al 22 in this consensus statement). 11 During MCC (and ideally before such emergencies through public engagement), 1 it is critical that these practitioners effectively and transparently manage patient and family expectations upon arrival at the hospital.…”

“…54 Competent clinicians or hospitals acting in good faith, which includes following formally adopted plans in accordance with applicable emergency declarations, should be reasonably protected from legal liability associated with their disaster-related actions. 1,11,13,23,55,56 …”

Call for national dialogue: Adapting standards of care in extreme events. We are not ready

“…Kuschner et al (2007) Systems approach to resource allocation/US system based A triage and scarce resource allocation team (TSRA) can provide a structure that formally oversees the need for rapid and ethically challenging decision making when there is an enormous surge in the need for care in a public health emergency such as influenza. Levin, Cadigan, Biddinger, Condon, and Koh (2009) Policy working group/USA state-based approach to decision-making for care-givers Identifies 4 goals and 7 principles that would guide decision-making in the case of pandemic influenza overwhelms the care system. Lo and Katz (2005) Hypothetical SARS case studies that highlight application of public health rather than individual ethical view Analysis of conflict between typical individual physician decision-making and public health decision-making are in conflict during a major public health crisis, recommending advance dialogue to increase likelihood of better decision-making in a real event.…”

Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos

“…Se ha realizado una búsqueda narrativa, encontrando 9 artículos especialmente relevantes sobre ética en la toma de decisiones ante situaciones excepcionales de crisis relacionadas con pandemias [7][8][9][10][11][12][13][14][15] . Tres han sido los artículos que en este contexto revisan aspectos específicos de la atención paliativa [16][17][18] .…”