Resource allocation after a nuclear detonation incident: unaltered standards of ethical decision making

Ethical values and principles to guide the fair allocation of resources in response to a pandemic: a rapid systematic review

Background

The coronavirus 2019 pandemic placed unprecedented pressures on healthcare services and magnified ethical dilemmas related to how resources should be allocated. These resources include, among others, personal protective equipment, personnel, life-saving equipment, and vaccines. Decision-makers have therefore sought ethical decision-making tools so that resources are distributed both swiftly and equitably. To support the development of such a decision-making tool, a systematic review of the literature on relevant ethical values and principles was undertaken. The aim of this review was to identify ethical values and principles in the literature which relate to the equitable allocation of resources in response to an acute public health threat, such as a pandemic.

Methods

A rapid systematic review was conducted using MEDLINE, EMBASE, Google Scholar, LitCOVID and relevant reference lists. The time period of the search was January 2000 to 6th April 2020, and the search was restricted to human studies. January 2000 was selected as a start date as the aim was to capture ethical values and principles within acute public health threat situations. No restrictions were made with regard to language. Ethical values and principles were extracted and examined thematically.

Results

A total of 1,618 articles were identified. After screening and application of eligibility criteria, 169 papers were included in the thematic synthesis. The most commonly mentioned ethical values and principles were: Equity, reciprocity, transparency, justice, duty to care, liberty, utility, stewardship, trust and proportionality. In some cases, ethical principles were conflicting, for example, Protection of the Public from Harm and Liberty.

Conclusions

Allocation of resources in response to acute public health threats is challenging and must be simultaneously guided by many ethical principles and values. Ethical decision-making strategies and the prioritisation of different principles and values needs to be discussed with the public in order to prepare for future public health threats. An evidence-based tool to guide decision-makers in making difficult decisions is required. The equitable allocation of resources in response to an acute public health threat is challenging, and many ethical principles may be applied simultaneously. An evidence-based tool to support difficult decisions would be helpful to guide decision-makers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00806-8.

Fair prioritization of casualties in disaster triage: a qualitative study

Background

Disasters may result in mass casualties and an imbalance between health care demands and supplies. This imbalance necessitates the prioritization of the victims based on the severity of their condition. Contributing factors and their effect on decision-making is a challenging issue in disaster triage. The present study seeks to address criteria for ethical decision-making in the prioritization of patients in disaster triage.

Methods

This conventional content analysis study was conducted in 2017. Subjects were selected from among Iranian experts using purposeful and snowball sampling methods. Data were collected using semi-structured interviews and were analyzed by the content analysis.

Results

Efficient and effective triage and priority-oriented triage were the main categories. These categories summarized a number of medical and nonmedical factors that should be considered in the prioritization of the victims in disaster triage.

Conclusion

A combination of measures should be considered to maximize the benefits of the prioritization of causalities in disasters. None of these measures alone would suffice to explain all aspects of ethical decision-making in disaster triage. Further investigations are needed to elaborate on these criteria in decision-making.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00515-2.

Meeting Report: A Poly-Pharmacy Approach to Mitigate Acute Radiation Syndrome

The National Institute of Allergy and Infectious Diseases, Radiation and Nuclear Countermeasures Program, was tasked by the United States Congress and the U.S. Department of Health and Human Services to identify and fund early-to-mid-stage development of medical countermeasures (MCMs) to treat radiation-induced injuries. In developing MCMs to treat various sub-syndromes (e.g., hematopoietic, gastrointestinal, lung), it is important to investigate whether a poly-pharmacy approach (i.e., drug cocktails) can provide additive benefits to mitigate injuries arising from the acute radiation syndrome (ARS). In addition, potential drug-drug interactions must be examined. For this reason, a workshop was held, which centered on understanding the current state of research investigating poly-pharmacy approaches to treat radiation injuries. The first session set the stage with an introduction to the concept of operations or support available for the response to a nuclear incident, as this is the key to any emergency response, including MCM availability and distribution. The second session followed the natural history of ARS in both humans and animal models to underscore the complexity of ARS and why a poly-pharmacy approach may be necessary. The third session featured talks from investigators conducting current MCM poly-pharmacy research. The meeting closed with a focus on regulatory considerations for the development of poly-pharmacy approaches or combination treatments for ARS.

Perceptions on principle of priority setting in disaster triage: A Q-method study

INTRODUCTION

An ethical plan is required to make decisions regarding setting the priority for assisting injured patients through triage. The aim of this study was to explore the measures used to sort patients for ethical decision-making in disaster triage.

METHOD

The participants were 54 clinicians and non-clinicians among the Iranian experts. Q-statements were selected from a literature review and face-to-face interviews. Data were analyzed by principal components factor analysis (PCA), Varimax, and hand-rotation techniques.

RESULTS

Distinct perspectives included: Saving patients with greater medical needs, survivability of patients and the community, providing effective treatment based on available capacity, maximizing health gain, supporting the human generation and productive and independent lives. Approximately 61% of the variance in decision is explained by these factors.

CONCLUSION

A combination of saving more people and more positive outcomes has been accepted to make an ethical decision in triage. Public engagement needs to reach a more acceptable view of patients' prioritizing factors in a scarce-resource situation.

Addressing obstacles to the inclusion of palliative care in humanitarian health projects: a qualitative study of humanitarian health professionals' and policy makers' perceptions

Background

Humanitarian non-governmental organizations provide assistance to communities affected by war, disaster and epidemic. A primary focus of healthcare provision by these organizations is saving lives; however, curative care will not be sufficient, appropriate, or available for some patients. In these instances, palliative care approaches to ease suffering and promote dignity are needed. Though several recent initiatives have increased the probability of palliative care being included in humanitarian healthcare response, palliative care remains minimally integrated in humanitarian health projects.

Methods

We conducted a qualitative study using interpretive description methodology to investigate humanitarian policy-makers’ and health care professionals’ experiences and perceptions of palliative care during humanitarian crises. In this article, we report on the analysis of in-depth interviews with 24 participants related to their perceptions of obstacles to providing palliative care in humanitarian crises, and opportunities for overcoming these obstacles. Among the participants, 23 had experience as humanitarian health professionals, and 12 had experience with policy development and organizational decision-making.

Results

Participants discussed various obstacles to the provision of palliative care in humanitarian crises. More prominent obstacles were linked to the life-saving ethos of humanitarian organizations, priority setting of scarce resources, institutional and donor funding, availability of guidance and expertise in palliative care, access to medication, and cultural specificity around death and dying. Less prominent obstacles related to continuity of care after project closure, equity, security concerns, and terminology.

Conclusion

Opportunities exist for overcoming the obstacles to providing palliative care in humanitarian crises. Doing so is necessary to ensure that humanitarian healthcare can fulfill its objectives not only of saving lives, but also of alleviating suffering and promoting dignity of individuals who are ill or injured during a humanitarian crises, including persons who are dying or likely to die.

Learning a palliative care approach during the COVID-19 pandemic: A case study in an Infectious Diseases Unit

BACKGROUND

Hospital palliative care is an essential part of the COVID-19 response, but relevant data are lacking. The recent literature underscores the need to implement protocols for symptom control and the training of non-specialists by palliative care teams.

AIM

The aim of the study was to describe a palliative care unit's consultation and assistance intervention at the request of an Infectious Diseases Unit during the COVID-19 pandemic, determining what changes needed to be made in delivering palliative care.

DESIGN

This is a single holistic case study design using data triangulation, for example, audio recordings of team meetings and field notes.

SETTING/PARTICIPANTS

This study was conducted in the Palliative Care Unit of the AUSL-IRCCS hospital of Reggio Emilia, which has no designated beds, consulting with the Infectious Diseases Unit of the same hospital.

RESULTS

A total of 9 physicians and 22 nurses of the Infectious Diseases Unit and two physicians of the Palliative Care Unit participated in the study.Our Palliative Care Unit developed a feasible 18-day multicomponent consultation intervention. Three macro themes were identified: (1) new answers to new needs, (2) symptom relief and decision-making process, and (3) educational and training issues.

CONCLUSION

From the perspective of palliative care, some changes in usual care needed to be made. These included breaking bad news, patients' use of communication devices, the limited time available for the delivery of care, managing death necessarily only inside the hospital, and relationships with families.

Chemical, Biological, Radiological, Nuclear, and Explosive (CBRNE) Science and the CBRNE Science Medical Operations Science Support Expert (CMOSSE)

A national need is to prepare for and respond to accidental or intentional disasters categorized as chemical, biological, radiological, nuclear, or explosive (CBRNE). These incidents require specific subject-matter expertise, yet have commonalities. We identify 7 core elements comprising CBRNE science that require integration for effective preparedness planning and public health and medical response and recovery. These core elements are (1) basic and clinical sciences, (2) modeling and systems management, (3) planning, (4) response and incident management, (5) recovery and resilience, (6) lessons learned, and (7) continuous improvement. A key feature is the ability of relevant subject matter experts to integrate information into response operations. We propose the CBRNE medical operations science support expert as a professional who (1) understands that CBRNE incidents require an integrated systems approach, (2) understands the key functions and contributions of CBRNE science practitioners, (3) helps direct strategic and tactical CBRNE planning and responses through first-hand experience, and (4) provides advice to senior decision-makers managing response activities. Recognition of both CBRNE science as a distinct competency and the establishment of the CBRNE medical operations science support expert informs the public of the enormous progress made, broadcasts opportunities for new talent, and enhances the sophistication and analytic expertise of senior managers planning for and responding to CBRNE incidents.

Special issues raised by evolving areas of clinical research

Each study presents its own set of ethical considerations. Certain kinds of ethical issues are inherent in particular areas of clinical research, regardless of specific ethical questions associated with a specific study. In this chapter, some of the most common special areas of clinical research are presented, highlighting the ethical issues most frequently associated with each.

Emergency Logistics in a Large-Scale Disaster Context: Achievements and Challenges

There is growing research interest in emergency logistics within the operations research (OR) community. Different from normal business operations, emergency response for large scale disasters is very complex and there are many challenges to deal with. Research on emergency logistics is still in its infancy stage. Understanding the challenges and new research directions is very important. In this paper, we present a literature review of emergency logistics in the context of large-scale disasters. The main contributions of our study include three aspects: First, we identify key characteristics of large-scale disasters and assess their challenges to emergency logistics. Second, we analyze and summarize the current literature on how to deal with these challenges. Finally, we discuss existing gaps in the relevant research and suggest future research directions.

Ethical prioritization of patients during disaster triage: A systematic review of current evidence

INTRODUCTION

Triage is a dynamic and complex decision-making process in order to determine priority of access to medical care in a disaster situation. The elements which should govern an ethical decision-making in prioritizing of victims have been debated for a long time. This paper aims to identify ethical principles guiding patient prioritization during disaster triage.

METHOD

Electronic databases were searched via structured search strategy from 1990 until July 2017. The studies investigating patients' prioritization in disaster situation were eligible for inclusion. All types of articles and guidelines were included.

RESULT

Of 7167 titles identified in the search, 35 studies were included. The important factors identified in patient prioritization were grouped into two categories: medical measures (medical need, likelihood of benefit and survivability) and Nonmedical measures (saving the most lives, youngest first, preserving function of society, protecting vulnerable groups, required resources and unbiased selection). Demographic characteristics, health status of patients, social value of patient, and unbiased selection are discriminatory factors in disaster triage.

CONCLUSION

Various factors have been introduced to consider ethical patient prioritization in disaster triage. Providers' engagement, public education, and ongoing training are required to reach a fair decision.

Preparedness Is More Than a Plan: Medical Considerations for Radiation Response

The goals herein are to describe and discuss existing plans for the medical preparedness and response to a radiological incident/nuclear detonation, present the systems approach to nuclear response, introduce methods to assess operational capabilities, and posit suggestions for the way forward to implementation. This discussion seeks to review where these U.S. government efforts began 10 y ago, then moves through the collective National progress in preparedness planning for an improvised nuclear device detonation and differentiates between important preparedness planning efforts and the challenges of understanding national implementation. Finally, a way forward for the immediate future is suggested.

Disaster Preparedness and Response for the Burn Mass Casualty Incident in the Twenty-first Century

The effective and efficient coordination of emergent patient care at the point of injury followed by the systematic resource-based triage of casualties are the most critical factors that influence patient outcomes after mass casualty incidents (MCIs). The effectiveness and appropriateness of implemented actions are largely determined by the extent and efficacy of the planning and preparation that occur before the MCI. The goal of this work was to define the essential efforts related to planning, preparation, and execution of acute and subacute medical care for disaster burn casualties. This type of MCI is frequently referred to as a burn MCI."

Biodosimetry: Medicine, Science, and Systems to Support the Medical Decision-Maker Following a Large Scale Nuclear or Radiation Incident

The public health and medical response to a radiological or nuclear incident requires the capability to sort, assess, treat, triage and to ultimately discharge, refer or transport people to their next step in medical care. The size of the incident and scarcity of resources at the location of each medical decision point will determine how patients are triaged and treated. This will be a rapidly evolving situation impacting medical responders at regional, national and international levels. As capabilities, diagnostics and medical countermeasures improve, a dynamic system-based approach is needed to plan for and manage the incident, and to adapt effectively in real time. In that the concepts and terms can be unfamiliar and possibly confusing, resources and a concept of operations must be considered well in advance. An essential underlying tenet is that medical evaluation and care will be managed by healthcare professionals with biodosimetry assays providing critical supporting data.

Disaster planning: the basics of creating a burn mass casualty disaster plan for a burn center

In 2005, the American Burn Association published burn disaster guidelines. This work recognized that local and state assets are the most important resources in the initial 24- to 48-hour management of a burn disaster. Historical experiences suggest there is ample opportunity to improve local and state preparedness for a major burn disaster. This review will focus on the basics of developing a burn surge disaster plan for a mass casualty event. In the event of a disaster, burn centers must recognize their place in the context of local and state disaster plan activation. Planning for a burn center takes on three forms; institutional/intrafacility, interfacility/intrastate, and interstate/regional. Priorities for a burn disaster plan include: coordination, communication, triage, plan activation (trigger point), surge, and regional capacity. Capacity and capability of the plan should be modeled and exercised to determine limitations and identify breaking points. When there is more than one burn center in a given state or jurisdiction, close coordination and communication between the burn centers are essential for a successful response. Burn surge mass casualty planning at the facility and specialty planning levels, including a state burn surge disaster plan, must have interface points with governmental plans. Local, state, and federal governmental agencies have key roles and responsibilities in a burn mass casualty disaster. This work will include a framework and critical concepts any burn disaster planning effort should consider when developing future plans.

Disaster Documentation for the Clinician

Documentation of the patient encounter is a traditional component of health care practice, a requirement of various regulatory agencies and hospital oversight committees, and a necessity for reimbursement. A disaster may create unexpected challenges to documentation. If patient volume and acuity overwhelm health care providers, what is the acceptable appropriate documentation? If alterations in scope of practice and environmental or resource limitations occur, to what degree should this be documented? The conflicts arising from allocation of limited resources create unfamiliar situations in which patient competition becomes a component of the medical decision making; should that be documented, and, if so, how?

In addition to these challenges, ever-present liability worries are compounded by controversies over the standards to which health care providers will be held. Little guidance is available on how or what to document. We conducted a search of the literature and found no appropriate references for disaster documentation, and no guidelines from professional organizations. We review here the challenges affecting documentation during disasters and provide a rationale for specific patient care documentation that avoids regulatory and legal pitfalls. (Disaster Med Public Health Preparedness. 2013;0:1–7)

Radiation disasters: role of the BMT team

Bone marrow transplant (BMT) teams do not generally consider themselves to be emergency responders. But the bone marrow is the most radiosensitive organ in the body, and early changes in peripheral blood counts remain the best indicator of major total-body radiation exposures. Following a mass casualty incident, such as that occasioned by a nuclear detonation, BMT teams should expect that they will be called upon for their expertise in managing severe myelosuppression. Numerous resources, including the Radiation Injury Treatment Network, are available to assist BMT teams in planning for such a role.

Social, psychological, and behavioral responses to a nuclear detonation in a US city: implications for health care planning and delivery

A nuclear detonation in a US city would have profound psychological, social, and behavioral effects. This article reviews the scientific literature on human responses to radiation incidents and disasters in general, and examines potential behavioral health care provider (BHCP) contributions in the hours and days after a nuclear detonation. In the area directly affected by the blast, the immediate overarching goal of BHCP interventions is the support of lifesaving activities and the prevention of additional casualties from fallout. These interventions include 6 broad categories: promoting appropriate protective actions, discouraging dangerous behaviors, managing patient/survivor flow to facilitate the best use of scarce resources, supporting first responders, assisting with triage, and delivering palliative care when appropriate. At more distant sites, BHCP should work with medical providers to support hospitalized survivors of the detonation. Recommendations are also made on BHCP interventions later in the response phase and during recovery.

Medical response to a nuclear detonation: creating a playbook for state and local planners and responders

For efficient and effective medical responses to mass casualty events, detailed advanced planning is required. For federal responders, this is an ongoing responsibility. The US Department of Health and Human Services (DHHS) prepares playbooks with formal, written plans that are reviewed, updated, and exercised regularly. Recognizing that state and local responders with fewer resources may be helped in creating their own event-specific response plans, subject matter experts from the range of sectors comprising the Scarce Resources for a Nuclear Detonation Project, provided for this first time a state and local planner's playbook template for responding to a nuclear detonation. The playbook elements are adapted from DHHS playbooks with appropriate modification for state and local planners. Individualization by venue is expected, reflecting specific assets, populations, geography, preferences, and expertise. This playbook template is designed to be a practical tool with sufficient background information and options for step-by-step individualized planning and response.

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

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.

Triage and treatment tools for use in a scarce resources-crisis standards of care setting after a nuclear detonation

Based on background information in this special issue of the journal, possible triage recommendations for the first 4 days following a nuclear detonation, when response resources will be limited, are provided. The series includes: modeling for physical infrastructure damage; severity and number of injuries; expected outcome of triage to immediate, delayed, or expectant management; resources required for treating injuries of varying severity; and how resource scarcity (particularly medical personnel) worsens outcome. Four key underlying considerations are: 1.) resource adequacy will vary greatly across the response areas by time and location; 2.) to achieve fairness in resource allocation, a common triage approach is important; 3.) at some times and locations, it will be necessary to change from "conventional" to "contingency" or "crisis" standards of medical care (with a resulting change in triage approach from treating the "sickest first" to treating those "most likely to survive" first); and 4.) clinical reassessment and repeat triage are critical, as resource scarcity worsens or improves. Changing triage order and conserving and allocating resources for both lifesaving and palliative care can maintain fairness, support symptomatic care, and save more lives. Included in this article are printable triage cards that reflect our recommendations. These are not formal guidelines. With new research, data, and discussion, these recommendations will undoubtedly evolve.

Health care system planning for and response to a nuclear detonation

The hallmark of a successful response to a nuclear detonation will be the resilience of the community, region, and nation. An incident of this magnitude will rapidly become a national incident; however, the initial critical steps to reduce lives lost, save the lives that can be saved with the resources available, and understand and apply resources available to a complex and dynamic situation will be the responsibility of the local and regional responders and planners. Expectations of the public health and health care systems will be met to the extent possible by coordination, cooperation, and an effort to produce as consistent a response as possible for the victims. Responders will face extraordinarily stressful situations, and their own physical and psychological health is of great importance to optimizing the response. This article illustrates through vignettes and supporting text how the incident may unfold for the various components of the health and medical systems and provides additional context for the discipline-related actions outlined in the state and local planners' playbook.