Disaster Ethics in Critical Care: Sara Gray

Sara Gray tackles the controversial topic of disaster ethics in critical care. Most hospitals develop a disaster plan, but few jurisdictions develop a plan for triaging or rationing scarce resources when the existing supply is overwhelmed.

Rather than leaving individual health care workers to make these decisions, we should work together as a community of experts to develop ethical, practical and appropriate policies for triaging scarce resources during a disaster.

Healthcare resources are finite. In the case of large-scale trauma with large numbers of casualties, such as a disaster scenario, how do you decide who gets what?

Sara discusses her guiding principles when thinking about disaster triage.

First and foremost, avoid having to triage or ration scarce resources. Have a plan and make first part of the plan to be “Never use the plan”. Mitigate all the risks and possibilities that would see the plan being enacted. This involves sharing with partner hospitals, urgently reordering supplies and repurposing what is available.

The second guiding principle relates to the ethics. Normal circumstances dictate offering the best for every individual patient. In a disaster, a shift to the utilitarian philosophy – the greatest good for the greatest number – is necessary. This means not everyone is going to get what they need, which is a difficult concept for people.

Thirdly, Sara stresses the importance of developing a disaster plan in a public way. This stops a plan being “sprung” on staff, the public and stakeholders. It encourages buy-in and engagement which makes it a smoother process should the plan ever be enacted. Sara next discusses the inclusion and exclusion criteria when dictating who should receive the finite resources of a hospital in a disaster. This, she admits, is the tricky part. She backs her thoughts up with the available data. Sara concludes with some points regarding the implementation of disaster plans.

Making these plans is tough, however not having them is tougher. Hospitals and health authorities should have a clear criteria for when a crisis is declared. This needs to come from the hospital level, if not the health region or government.

It is not an individual decision. Next a dedicated team should review de-identified patient files to allocate resources according to the inclusion and exclusion criteria. This team needs to be multi-disciplined and received adequate support. This is a tough job.

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