Catastrophic disasters occurring in 2011 in the United States and worldwide--from the tornado in Joplin, Missouri, to the earthquake and tsunami in Japan, to the earthquake in New Zealand--have demonstrated that even prepared communities can be overwhelmed. In 2009, at the height of the influenza A (H1N1) pandemic, the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services, along with the Department of Veterans Affairs and the National Highway Traffic Safety Administration, asked the Institute of Medicine (IOM) to convene a committee of experts to develop national guidance for use by state and local public health officials and health-sector agencies and institutions in establishing and implementing standards of care that should apply in disaster situations-both naturally occurring and man-made-under conditions of scarce resources. Building on the work of phase one (which is described in IOM's 2009 letter report, Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations), the committee developed detailed templates enumerating the functions and tasks of the key stakeholder groups involved in crisis standards of care (CSC) planning, implementation, and public engagement-state and local governments, emergency medical services (EMS), hospitals and acute care facilities, and out-of-hospital and alternate care systems. Crisis Standards of Care provides a framework for a systems approach to the development and implementation of CSC plans, and addresses the legal issues and the ethical, palliative care, and mental health issues that agencies and organizations at each level of a disaster response should address. Please note: this report is not intended to be a detailed guide to emergency preparedness or disaster response. What is described in this report is an extrapolation of existing incident management practices and principles. Crisis Standards of Care is a seven-volume set: Volume 1 provides an overview; Volume 2 pertains to state and local governments; Volume 3 pertains to emergency medical services; Volume 4 pertains to hospitals and acute care facilities; Volume 5 pertains to out-of-hospital care and alternate care systems; Volume 6 contains a public engagement toolkit; and Volume 7 contains appendixes with additional resources.

Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response

Allocating Scarce Resources in Disasters: Emergency Department Principles

Major depression is prevalent, difficult to assess, underrecognized, and undertreated in hospice settings. Furthermore, it is associated with significant morbidity and mortality. A retrospective chart review of 2716 patients receiving hospice care was conducted in order to determine the baseline rate of recognition of depression in patients with advanced, life-threatening illnesses by frontline hospice clinicians. Documentation of “depression” as either a diagnosis or problem was used as an estimate of how often these disorders were considered significant issues by the treating interdisciplinary team. Of the patients receiving home/long-term care, 10.8% (234/2168) had depression documented as a diagnosis or significant problem. The presence of recognized depression in this setting was associated with significant differences in gender, marital status, and terminal diagnoses. Total length of hospice care was also significantly longer. Of patients receiving inpatient care, 13.7% (75/548) had depress...

https://www.researchgate.net/profile/Jeanne_Maglione/publication/5349286_Psychiatric_issues_in_palliative_care_Recognition_of_delirium_in_patients_enrolled_in_hospice_care/links/0deec531f3f647be81000000.pdf

Psychiatric issues in palliative care: recognition of depression in patients enrolled in hospice care.

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders. Language: en

/pdf/allocation-of-scarce-resources-after-a-nuclear-detonation-mkesko13ri.pdf

Allocation of scarce resources after a nuclear detonation: setting the context.

This paper presents findings from a systematic review of the literature (2005–2017) on palliative care in humanitarian crises (e.g., disasters, armed conflicts, epidemics). This review set out to describe palliative care needs, practices, barriers, and recommendations in humanitarian crisis settings. It contributes to current discussions within the field of humanitarian healthcare aimed at clarifying whether or not and how best to respond to palliative care needs in humanitarian crises. Analysis of 95 peer-reviewed and gray literature documents reveal a scarcity of data on palliative care needs and interventions provided in crises, challenges of care provision particularly due to inadequate pain relief resources and guidelines, a lack of consensus on the ethics of providing or limiting palliative care as part of humanitarian healthcare response, and the importance of contextually appropriate care. These findings suggest that more research and open discussion on palliative care in humanitarian crises are needed. This review contributes to defining palliative care needs in humanitarian crises, building consensus on humanitarian healthcare organizations’ ethical responsibilities towards individuals and families with palliative needs, and developing realistic and context-appropriate policies and guidelines.

/pdf/palliative-care-in-humanitarian-crises-a-review-of-the-qi0nrqf83l.pdf

Palliative care in humanitarian crises: a review of the literature

In this issue of Biosecurity and Bioterrorism, Matzo and colleagues introduce the roles of palliative care in the response to catastrophic mass casualty events. This work is part of a larger effort supported by the Agency for Healthcare Research and Quality (AHRQ) to define and plan for the ‘‘altered standards of care’’ considered inevitable during a mass casualty event. Here we offer some additional perspective on a number of issues raised in their article. The authors and the AHRQ conferees are to be congratulated for their thoughtful deliberations and for disseminating their recommendations through the peerreviewed literature. We hope that publication of their work will both catalyze scholarly discourse on the subject and broaden the base of stakeholder input. Matzo and colleagues conclude that planning for the medical response to a mass casualty event should include provisions for palliative care surge capacity. The authors offer some creative ways to address this requirement, including developing Disaster Palliative Assistance Teams under the aegis of the Medical Reserve Corps or the National Disaster Medical System. Such teams could be specially trained and equipped to provide some level of palliative care under the demanding operational constraints of a mass casualty event response. These are valuable suggestions to planners at all jurisdictional tiers of response. Their assertion, however, that palliative care may ‘‘free up resources to optimize survival of others’’ is unproven and counterintuitive. The addition of a large number of patients rendered terminally ill or injured in a mass casualty event to the population of patients already receiving palliative care will certainly generate the need for palliative care surge capacity. Patients from a mass casualty event who will require some elements of palliative care include those who have been assigned to several different triage categories: (1) ‘‘expectant’’ patients, who are considered so unlikely to benefit from life-saving interventions that those interventions are not offered; (2) ‘‘immediate’’ patients, who could potentially survive with aggressive therapy, but limited medical or transportation resources render it temporarily unavailable; and (3) both ‘‘immediate’’ and ‘‘delayed’’ patients, who will eventually receive life-saving, definitive care but require supportive care, symptom control, and other comfort measures while waiting for it. Although the categories listed above are generally used in the field or emergency department triage of trauma victims who need surgical care, they can be readily correlated with patients requiring critical care during a pandemic. Different ethical principles inform management of the patients within these various triage categories. In the first, the availability or scarcity of resources has little bearing on whether attempts at curative therapy should be offered or provided. Palliative care is the only efficacious option for these patients, and the ethical principles relate primarily to proving that other therapeutic interventions would be futile. The second group faces rationing of potentially useful resources, and different ethical principles apply. It is the responsibility of planners and responders to minimize the size of this group through both prospective and real-time solutions to the challenges presented by various types of

Karen Jubanyik

Papers

Triage, Rationing, and Palliative Care in Disaster Planning