In a world of “what ifs” and “worst case scenarios,” planning for patient care during a disaster may be as overwhelming as the disaster itself. However, these events are on the rise and patients expect health care institutions to be prepared. [1] This has given rise to the relatively new profession of hospital emergency preparedness. In Boston, multiple tertiary care facilities all have full-time employees dedicated to ensuring the hospitals and the employees are prepared to respond to a disaster, anytime.
As the profession grows and finds its way through the maze of health care, there are many intersections with the field of bioethics. Both emergency preparedness and hospital ethics committees often provide support and guidance to those facing challenging decisions. Traditionally, many envision ethical consults as an exhaustive and deliberative process handled by a small group of experts; however, many ethics committees are diverse groups, with diverse expertise, that collaborate on a wide range of issues—some more time sensitive than others. Likewise, emergency preparedness brings a diverse group of experts together to face difficult decisions in times of crisis. Currently, there is an opportunity for the two professions to learn from the past and join forces to build a more resilient workforce within health care.
Historically bioethics was not an overt part of the emergency preparedness process. Emergency planning generally begins with an annual risk analysis and follows with a plan to prepare for sudden events, unforeseen risks, and the difficult decisions they may involve. Boston offers a resource-rich health care environment; however, adaptability is key to ensuring hospitals can care for patients even if an event is so catastrophic that it overwhelms systems, outpaces planning efforts, and threatens to bring everything to a screeching halt. When a disaster does occur, hospital leaders will implement a structured decision-making framework or Hospital Incident Command System (HICS), to streamline communication and bring together preidentified subject matter experts from a variety of hospital departments.
As the planning process adapts to the changing nature of disasters, one must consider the external and internal factors such as evolving weather forecasts, infectious disease outbreaks, or even national supply chain interruptions that bring increasingly difficult decisions to the hospital’s doorstep, and an opportunity to incorporate bioethics into the planning process. For all types of events, one critical priority is balancing resource allocation with individual patient needs. The preparedness planning must also consider human factors and ensure health care staff are mentally prepared to make difficult decisions in chaotic situations that can often be a source of additional stress as clinicians struggle to support patient autonomy in a resource constrained environment. Traditionally, the expertise focused on clinical care and the logistical support needed to support clinicians. Many large academic hospitals offer resource-rich environments, if supplies run low, the solution is to order more; but what if there is a shortage and ordering more is no longer an option? Which patients should receive the limited supply available, and how might that impede patient autonomy? A critical aspect of both disaster planning and response is the ability to recognize the difficult decisions and also determine which ethical framework to use in the decision-making process.
Current events have presented a more immediate need to bring bioethics principles to the floor. Over the past several months hospitals were caught up in a national shortage of IV opioid medications; there were times when clinicians reached for bags of standard pain medications (IV Morphine, IV hydromorphone) and found that the shelves were empty. As supplies dwindled, hospitals faced difficult decisions regarding who should receive the small supply of available IV pain medications: Should it be the most acute patients? The most complex? The youngest? Who should be top on the list? As hospitals transitioned from planning to response, the HICS frameworks were critical to facilitate consistent decision-making. National shortages are not a novel challenge; however the power and potency of IV Opioids made collaborative decision-making process critical. Detailed clinical guidance was important to ensure patient safety and provide a consistent framework across the hospital for individual bedside decisions. The secondary effect of the collaborative decision-making was that it facilitated shared resource allocation, meaning not only were resources shifted from one location to another to address patient needs, expertise was also shared to expand pain relief options available, including non-opioid medications, and supplementing pain relief medications with thermotherapy, meditation, massage, and other physical therapy.
The unexpected challenge during the shortage was implementing the operational protocols necessary to conserve limited supplies in a way that balanced the need for consistent practice but also considered patients’ right to autonomy. The best disaster planning and response approach will face difficult decisions in a way that incorporates diverse feedback from available experts and provide clear guidance. For example, at one point during the shortage an approach was discussed that would have held back small quantities of a particular drug to create a reserve to treat more unstable patients with less pain relief options available. The more stable patients would have received alternative pain medication (no patient was left without medication), but the alternative medication may have represented a shift in thinking from what the patient and/or the provider were accustomed to. Given the unpredictability of the supply chain, there was concern that a stable patient may be asked to bear the burden of changing pain medications, only to then have a shipment arrive replenishing the supply, negating the need for their sacrifice after the fact. There is no easy answer to such questions, but it is important that hospitals lean into these discussions well in advance of the crisis; a partnership between emergency preparedness professionals and bioethics professionals are well poised to introduce such topics ahead of time in multiple forums. Incorporating bioethics into a Hospital Incident Command System ensures the collaboration remains active during a response, drawing on overlapping skill sets to provide more comprehensive support for staff thus recognizing that the transition of a well-thought-out decision from a conference room to the bedside can be very complex, often challenging the moral resiliency of providers.
Integrating bioethics into emergency preparedness is not about judging decisions made during a disaster, in reality, each of us has a slightly different perspective based on our personal beliefs, diverse cultural norms, life experiences, and of course, training. Balancing professional obligations with personal feelings in very real and very emotional situations is difficult, but it must be done. A strong decision-making framework during a disaster instills confidence in all involved parties as they can see the natural evolution of decision-making. This also allows and encourages people to contribute, question, and accept the final outcomes. That said, a well-thought-out plan is just one piece of the puzzle; a good plan is worthless if the implementation is subpar.
When a community is faced with a disaster, patients expect their hospital to be prepared, and emergency preparedness teams work tirelessly to meet these expectations. However, no single person has perfected the art of disaster preparedness and management. By nature, disaster brings about unexpected variables that often calls for centralized decision-making. This approach may appear at times to override the autonomous decision-making generally bestowed upon hospital clinicians, as well as the autonomous wishes of the patients. However, autonomy is more than one’s right to self-rule or free will; it is also about choice. [2] Patients generally arrive at the hospital with a predetermined set of expectations regarding the care they will receive. However, during a disaster it may be impossible to meet these expectations; causing patients to change or adjust their expectations. The best way to facilitate realistic patient expectations is to provide a consistent policy. If clinicians allocate resources based on their personal beliefs rather than a central policy, there is no way for patients to know what to expect. This decentralized model interferes with the patient’s ability to make an informed decision regarding their own care. Autonomy is not about guaranteeing every parent will be happy with the options available. At times, truly respecting patient autonomy may mean overriding individual clinician decisions with a central operational policy. As disaster planning evolves from providing water and other critical supplies, to providing decision frameworks to support allocation of limited supplies, bioethics needs to be a priority objective in the planning process to properly prepare for, and respond to, disasters.
Similar to ethics committees, during a disaster, the emergency preparedness response structure provides an organizational framework to discuss difficult decisions, during times of crisis and under stress of time constraints. Combining these two resources to incorporate ethics representation within the emergency preparedness framework invites a richer and more diverse conversation that is more likely to bring forth issues of moral conflict early on and better address the needs of both patients and staff and ultimately ensure that the outcome is not just time appropriate, but also ethically sound. As with all aspects of emergency preparedness, it is important that key stakeholders work together through the planning, training, response, and recovery processes to assemble a rich pool of skill sets to draw upon to better cater to the constantly evolving patient needs during a disaster.
[1] "Weather-related disasters are increasing." The Economist. (London, United Kingdom) August 29, 2017. https://www.economist.com/graphic-detail/2017/08/29/weather-related-disasters-are-increasing
[2] Beauchamp, Tom L. and James F. Childress. Principles of Biomedical Ethics. 7th ed. (New York: Oxford University Press, 2013).
