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Key Panel Presses for Clearer Guidance on Who Gets Scarce Resources in Major Medical Disasters

Staff members at Robert Wood Johnson University Hospital treat mock victims during a terrorism response exercise coordinated by the Department of Homeland Security in New Brunswick, N.J., in 2005. (Stan Honda/AFP/Getty Images)An influential panel of experts on Thursday pointed out serious gaps in planning for a public health disaster and called for clear national guidelines for making ethical and medical decisions in crisis situations.

A 15-member committee convened by the Institute of Medicine said there was an "urgent and clear need" for consistent standards of care that would apply during catastrophes -- particularly on such thorny questions as which patients should receive scarce treatments or equipment and which should go without.

In its report, the committee said that an overwhelming disaster "will dramatically strain medical resources and could compromise the ability of healthcare professionals to adhere to normal treatment procedures and conventional standards of care." The committee was not talking about day-in, day-out problems. Rather, it referred to crises that come without warning, such as earthquakes and hurricanes, or those that progressively get worse, such as a disease pandemic.

ProPublica reported yesterday that state and federal officials are pushing ahead with plans that -- during a severe flu outbreak -- would divert ventilators from certain patients to assure they would be available for patients who may benefit more from them.

The committee -- composed of doctors, lawyers and public health officials -- acknowledged that such steps might be necessary but emphasized repeatedly that public input must be sought before any such plan is finalized.

Even decisions to withhold treatments from patients must be based on ethics and research, the report said. And some key research is lacking, particularly on how to prioritize care for children and the elderly.

Committee members strongly recommended against reallocating resources based on a patient's decision to sign a "Do Not Resuscitate" order. The committee met just days after ProPublica and the New York Times Magazinereported that after Hurricane Katrina, patients with Do Not Resuscitate orders at Memorial Medical Center in New Orleans were deemed the lowest priority for evacuation -- a decision that was not in the hospital's disaster plan.

The article also emphasized that doctors at Memorial, like most doctors in America, had received little, if any, guidance or training on how to function in disasters.

"Disaster planning must include advance ethical guidance," the committee report said. "Factors such as do-not-resuscitate (DNR) status have on occasion been considered in allocation schemes. However, DNR orders reflect individual preferences and foresight to establish advance directives more than an accurate estimate of survival. Accordingly, DNR orders are not useful parameters for considering the allocation of scarce resources."

Dr. Dan Hanfling, the vice chairman, said the committee's "galvanizing point was the horror, the tragedy of Katrina."

"We recognize as a nation we can do better. We must do better," said Hanfling, a special adviser for emergency preparedness and response at Inova Health System in Falls Church, Va.

The report comes as public health experts over recent months have planned for -- and been fearful of -- what could happen if the H1N1 influenza outbreak spreads or becomes more deadly. So far, hospitals and other health facilities have been able to cope with cases without having to ration ventilators or drugs. But if the number of hospitalizations increases dramatically in many regions at once, that could change quickly.

Calls for better and more thorough planning are not new. After the terrorist attacks of Sept. 11, 2001, and the subsequent mailing of anthrax-tainted packages, health officials and politicians talked about the need to increase preparedness for a bioterrorist attack. And after Katrina in 2005, officials said they needed to be better prepared for natural disasters.

Even so, the Institute of Medicine committee found that "many states have only just begun to address this urgent need."

Hanfling said communities with more advanced plans include those directly affected by the Sept. 11 attacks and disaster-prone areas such as Florida and California. "It's a quilted patchwork of capabilities," he said of the nation.

Because disasters can put health providers under tremendous physical and mental stress, Hanfling said there is a need to plan as much as possible ahead of time. "We have an obligation not to throw our hands up and say, 'Oh my God. I don't know what I'm going to do ... I'm just going to make it up as I go along.'" The most vulnerable people in society, he said, "will be even more vulnerable during disasters and we must be accountable to everyone."

The nation is a long way off from a comprehensive plan. Among the obstacles, the report said, community groups and health professionals haven't talked enough about which actions are ethically justified during a crisis. Regional partnerships between hospitals and health professionals are incomplete and inconsistent. And inadequate liability protections exist for health professionals who may have to place some patients' needs ahead of others in crisis situations, the report said.

The committee's report revealed a troubling conundrum. On the one hand, panelists expressed support for using "evidence based tools" over random or "first come first served" approaches to allocating ventilators and other resources. At the same time, it expressed concerns about the quality of the available tools and research used to rationalize this allocation.

"None of the current systems or guidance was designed for pediatrics or other medical special needs patients," the report said, urging that the gap be addressed by groups of experts. "The needs of other vulnerable populations should also be kept in mind to ensure fairness in the system that is developed," the report continued, but did not offer specifics on how to do so.

The committee looked in particular at the Sequential Organ Failure Assessment (SOFA) score, which helps doctors assess the functioning of key body systems through a relatively simple set of tests. States such as New York, Minnesota, Utah and Colorado use the SOFA score as a major criterion for removing certain patients from ventilators -- and giving the equipment to other patients -- in the scenario of a severe influenza pandemic.

But the tool "was not designed as a prospective predictor of survival," the report said, and "differences in a single point on the SOFA scale are of unknown clinical significance for prediction of outcomes."

The committee believed that additional research was needed to improve the tools available to guide decision-making, said one member, Dr. Tia Powell, director of the Montefiore-Einstein Center for Bioethics in New York. SOFA, she said, "is the best there is, but it’s not optimal."

Typically, doctors and hospitals use a patient-focused standard of care, in which they do what they think is best for each patient they treat. Moving to what the committee termed "crisis standards of care" -- focusing primarily on the best outcomes for a population -- should only occur after all other measures are exhausted, Powell said. These include advance planning and then, when crisis hits, bringing in additional staff and equipment and sending patients to places where more resources are available.

"This is not something a hospital can decide to do because it's crowded in the emergency room some Tuesday," Powell said. "It has to be a declared emergency with a severe impact on the ability to provide health care."

Asked whether anyone on the committee raised concerns about the ethics of withdrawing lifesaving resources, such as ventilators, from certain patients to direct them to others, Powell said, "it's certainly a very difficult question."

The committee, she said, tried to balance trying to "save as many lives as possible" against the "need to take care of and provide empathic, ethically sound care to all patients, whether they are likely to survive or not."

The report was produced quickly. Officials at the U.S. Department of Health and Human Services requested it only last month. The committee held a four-day meeting, including a one-day public workshop, earlier this month.

During a planned second phase, the committee is charged with soliciting feedback from the public and health professionals and updating its recommendations. Reports from the institute, part of the congressionally chartered National Academy of Sciences, carry great sway with Congress and federal agencies.

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