Chest
Volume 146, Issue 4, Supplement, October 2014, Pages e145S-e155S
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Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Online Only Articles
Ethical Considerations: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement

https://doi.org/10.1378/chest.14-0742Get rights and content

BACKGROUND

Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients' vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns.

CONCLUSIONS

Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide health-care decisions during disasters.

Section snippets

Triage and Allocation

1. We suggest resources not be held in reserve once a mass disaster protocol is in effect.

2. We suggest disaster and pandemic policies reflect the broad consensus that there is no ethical difference between withholding and withdrawing care and that education regarding such policies be incorporated into training.

3. We suggest triage systems based even on limited evidence are ethically preferable to those based on clinical judgment alone.

4. We suggest critical care resources be allocated based on

Materials and Methods

We followed the CHEST Guidelines Oversight Committee's methodology to develop suggestions (see the “Methodology” article by Ornelas et al9 in this consensus statement). Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions (e-Appendix 1 for key questions list and corresponding search terms and results). Searches were limited from 2002 to 2012, and only English-language papers were included. The detailed literature reviews produced

Triage/Allocation

1. We suggest resources not be held in reserve once a mass disaster protocol is in effect.

Once a triage/allocation protocol is in effect, patients who require and meet criteria for resources should be provided care in accordance with the protocols in effect at the time. Government agencies and health-care institutions should stockpile resources that are essential during or after a mass casualty event (eg, ventilators, antibiotics, vaccines, ICU beds).10 Although these stocks are scarce and may

Areas for Research

New evidence-based triage tools that predict survival, resource consumption, and quality-of-life outcomes with a high degree of accuracy for individual patients in specific circumstances would add significantly to current efforts to fairly allocate scarce critical care resources during public health disasters. All current tools fall short of this goal, despite major efforts on the part of many researchers. Pediatric research in developing triage tools lags significantly behind even that

Conclusions

Ethics issues permeate virtually all aspects of disaster and pandemic response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. We have not covered areas and issues conclusively addressed in prior documents but instead have focused on questions for which debate, controversy, or inadequate information

Acknowledgments

Author contributions: L. D. B. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., N. K., B. E. R., C. L. S., J. R. D., M. D. C., and T. P. contributed to the development of PICO questions; L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., B. E. R., C. L. S., and T. P. conducted the literature review; L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., N. K.,

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    Ms Roxland is currently at the Office of the Chief Medical Officer, Johnson & Johnson (New Brunswick, NJ).

    Funding/Support: This publication was supported by the Cooperative Agreement Number 1U90TP00591-01 from the Centers of Disease Control and Prevention, and through a research sub award agreement through the Department of Health and Human Services [Grant 1 - HFPEP070013-01-00] from the Office of Preparedness of Emergency Operations. In addition, this publication was supported by a grant from the University of California–Davis.

    COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

    DISCLAIMER: American College of Chest Physicians guidelines and consensus statements are intended for general information only, are not medical advice, and do not replace professional care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this consensus statement can be accessed at http://dx.doi.org/10.1378/chest.1464S1.

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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