Palliative Care Considerations in Mass Casualty Events with Scarce Resources

Abstract

Catastrophic mass casualty events, such as pandemic flu outbreaks or large-scale terrorism-related events, could yield thousands of victims whose needs would overwhelm local and regional healthcare systems, personnel, and resources. Such conditions will require deploying scarce resources in a manner that is different from the more common single-event disaster. This article introduces the topic of palliative care during a mass casualty event and reviews the major findings for a federally funded planning guide that examined palliative care issues associated with providing medical care under circumstances where resources are scarce. We focus on the role of palliative care in the support of individuals not expected to survive and offer recommendations of specific actions for a coordinated disaster response plan. Semistructured telephone discussions with disaster management experts and a group meeting of experts identified issues, roles, responsibilities, procedures, and resources that offer the benefits of integrating palliative care into disaster planning and response. The investigations identified 5 domains of concern, along with guidance: (1) the role of palliative care in a mass casualty event with resulting scarce resources; (2) the triage and ensuing treatment decisions for those "likely to die"; (3) the critical palliative care services to provide, along with the personnel and settings; (4) the pragmatic plans needed for ensuring training, supplies, and organizational or jurisdictional arrangements; and (5) unusual issues affecting palliative care under mass casualty event scenarios. Palliative care minimizes the suffering of those who die, ensures comfort, addresses their needs, and may also free up resources to optimize survival of others. Planning to provide palliative care during mass casualty events should be part of the current state and local disaster planning/training guidelines, protocols, and activities.

Pandemic palliative care: beyond ventilators and saving lives

“…Generally, these situations fall into 1 of 2 categories: "big bang" events such as airplane or train crashes, and "rising tide" incidents such as viral epidemics. 6 The main goal of a coordinated response from public health and disaster-planning personnel is (appropriately) saving the maximum number of lives possible. Yet, despite a large body of literature and experience with triage, little has been written on how to manage those who are not offered life-sustaining measures.…”

Civilian nuclear incidents: An overview of historical, medical, and scientific aspects

“…Planning should include balancing scarce resources, the triage process, and identifying services that can be reasonably provided given the nature of the mass casualty incident. [41] While the general focus of end-of-life care is on the patient, palliative care should extend to all individuals involved in that patient's care, both family and healthcare providers. Physicians may be forced to deal with ethical issues not usually encountered in daily practice with the need to triage patients, prioritize limited resources, and face altered standards of care unique to the incident.…”

Distributive justice in disaster triage

“…These circumstance require more lifesaving care than the available medical services can provide, creating a bottleneck in which some patients cannot be saved. [1][2][3][4][5] The fact that some patients will die because there are not enough resources to save all severely injured people is what differentiates disaster triage from normal emergency department triage. [1][2][3]6,7 These conditions make triage a decision of which patients will receive curative treatment and which will be categorized as expectant, expected to succumb to their injuries, and be given only palliative care.…”

“…[1][2][3]6,7 These conditions make triage a decision of which patients will receive curative treatment and which will be categorized as expectant, expected to succumb to their injuries, and be given only palliative care. 1,2,5 How can one make such a tragic choice justly? The most commonly used and accepted disaster triage algorithms, START and SALT, direct care towards patients that need it to survive, but also prioritizes patients that have the best prognosis.…”