Chapter 30 Ryan Carter The prevailing standard of care under usual operating conditions assumes a baseline level of resource availability. In a disaster zone, resources become scarce or insufficient, leading to altered standards of care. In this context, the term standard of care has two overlapping but distinct aspects: one legal and one ethical. The legal standard of care is defined by federal statutes, such as the Health Insurance Portability and Accountability Act (HIPAA) and the Emergency Medical Treatment and Active Labor Act (EMTALA), and state law, a breach of which is one required element to prove malpractice. The ethical standard of care is derived from professional codes of conduct, based on core principles of patient autonomy, justice, beneficence, and non-maleficence. The unique circumstances of disaster zones may lead to changes in one or both of these standards. In April 2005, the Agency for Healthcare Research and Quality published a report containing five principles, covering both of these aspects, to guide planners in prospectively developing and defining altered standards of care [1]. More recently, the National Research Council published a letter report offering guidance and a national framework for key elements which should be included in standards of care protocols for disaster situations. It also acknowledges both the legal and ethical aspects to such protocols and further specify that a “crisis standard of care” should include five key elements (Table 30.1) [2]. Table 30.1 Key elements of crisis standards of care protocols HICS, hospital incident command system; NIMS, National Incident Management System. Legal standards of care may only be altered by an executive governmental official. A report from the Institute of Medicine in August 2009 details the process by which that may occur: “This change in the level of care delivered [in a disaster zone] is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternate care facility operations” [3]. In addition to state governors, as alluded to in the IOM report, the president and directors of federal agencies, such as the Secretary of Health and Human Services, may also make declarations of emergency which waive certain specific regulatory provisions. Note that none of these declarations is a blanket authorization to disregard all laws, rules, and regulations. Resource limitations in a disaster setting may also force changes in ethical standards of care. This occurs in two major ways: ethical standards become more utilitarian and less individualistic, and resource scarcity changes the relative risks of standard treatment options. Utilitarianism defines an ethical action as one that creates “the greatest amount of good for the greatest number” [4]. Prioritizing the health of the larger population over the needs of a single patient often requires a different course of action than heeding traditional professional ethics. As an example, some disaster triage algorithms require withholding treatment from critically injured (black tag) patients in the earliest phases of disaster response. Any disaster triage algorithm may require the provider performing the initial assessment to leave the side of a patient who has just been labeled critically injured, rather than immediately providing medical interventions. The discomfort that providers (and patients) experience when faced with these decisions is, in part, a reflection of the deviation from usual standards of care [5]. However, these decisions are justified under utilitarian reasoning because the outcome for the larger group is best advanced by devoting time and resources to patients with the greatest chance for improvement. To reflect this ethical justification and to clarify the relevant standard of care, the World Medical Association released a statement in 2006 which comments on disaster triage.
Special considerations in disaster zones
Altered standards of care
Element
Subsection
Ethical considerations
Community and provider engagement, education, and communication
Legal authority and environment
Indicators and triggers
Clinical process and operations
Local/regional and state government processes to include:
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