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Tough Choices in Times of Disaster

In the event of a flu pandemic or other large-scale medical disaster, who will decide which of us receives life-saving health care?

That's one of the big questions addressed in this report in the May issue of the journal Chest.

A task force set up to figure out how the medical communities in the U.S. and Canada can prepare to handle huge numbers of people suddenly requiring critical care made a set of recommendations on the training and equipment that would be required to respond to a large-scale emergency, be it an outbreak of SARS (the threat of which was a factor leading to the establishment of the task force) or an act of terrorism.

The report is straightforward and clinical, and it makes the case that planning and preparedness should go a long way in such a situation. But when it comes to the part about deciding, in the midst of a major, widespread emergency, how to allocate limited resources to save the greatest number of lives possible, even the dispassionate language can't stop a chill from running down my spine.

Should push come to shove, when even the best-prepared hospitals find their resources stretched, medical professionals may have to make tough decisions about whether to withhold or withdraw critical care from patients whose potential for long-term survival is low. This is grim: Patients with terminal cancer, dementia or a host of other grave conditions may be denied certain life-extending measures so that these can be administered to others with better long-term prospects.

The report emphasizes that palliative care -- pain-relief and comfort -- must be provided for all patients; nobody's going to be left to suffer unaided. But beyond that, doctors, nurses, and other health-care professionals are going to face some tough choices.

Even with a process in place, decisions are likely to be wrenching -- and memorable. Health section editor Frances Stead Sellers recalls

I remember my father talking about treating TB patients with antibiotics in British hospitals soon after the second World War. Streptomycin was a miracle cure, he remembered, but there simply wasn't enough to go around -- so the doctors had to make choices. Just think about having to perform that kind of triage in the baby ward: This one almost certainly lives; this one doesn't....

The report's recommendations are aimed in part at relieving care providers of the emotional, legal and ethical burdens such decisions might entail. Steve Gravely, a Richmond lawyer who deals in health-care issues and is familiar with the report, says "Everyone agrees that [in the event of a mass-casualty situation] we are not going to have enough resources to treat everyone the way we do today. As to where you go from there, there is no consensus."

"The emotional toll on doctors, nurses, and other health-care providers is going to be pretty significant," Gravely says. "Asking them to make these life-and-death decisions in a vacuum is asking a great deal." The report's recommendations, Gravely notes, should provide "psychological and emotional support for the medical staff. They know there's a process, and it doesn't all rest on their shoulders."

Gravely points out that the new report should serve as a "clarion call. Every hospital needs to be preparing for this right now."

Let's hope they are.

By Jennifer LaRue Huget  |  May 7, 2008; 7:02 AM ET
Categories:  Hospitals  
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