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Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science

Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science http://mc.manuscriptcentral.com/biosecurity

Palliative Care for Mass Casualty Events with Scarce Resources

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draft Original Articles Mass casualty care, Medical management/response, Volunteers, First responders

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Re Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Palliative Care for MCEs

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Pe Palliative Care for Mass Casualty Events with Scarce Resources

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1 Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801


Palliative Care for MCEs Abstract Catastrophic mass casualty events (MCEs), such as pandemic flu outbreaks or large-scale terrorism-related events, could yield thousands of victims whose needs would overwhelm local and regional health care systems, personnel, and resources. Such conditions will require deploying scarce resources in a manner that is different from the more common single-event disaster. The purpose of this paper is to examine the issues associated with providing medical care under MCE circumstances where resources are scarce, focusing on the role of palliative care in support of individuals not expected to survive and recommending specific actions for a coordinated disaster response plan. Semi-structured telephone discussions with key experts and consensus development group meeting to identify what issues, roles and responsibilities, procedures, arrangements, and resources are necessary to integrate palliative care in disaster planning and response. The investigations identified five domains of concern: (1) the role of palliative care in a mass casualty event with resulting scarce resources; (2) the triage and ensuing treatment decisions for those “likely to die;” (3) the critical palliative care services to provide, along with the personnel and settings; (4) the pragmatic plans needed for ensuring training, supplies, and organizational or jurisdictional arrangements; and (5) unusual issues affecting palliative care under MCE scenarios. Palliative care minimizes the suffering of those who die, ensures comfort, addresses the needs of those who will not survive, and may also free up resources to optimize survival of others. Planning to provide palliative care during mass casualty events should be part of the current state and local disaster planning/training guidelines, protocols, and activities.

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Palliative Care for MCEs Introduction A catastrophic mass casualty (MCE) an act of bioterrorism or other public health or medical emergency involving thousands, or even tens of thousands, of victims whose needs are likely to overwhelm the resources of a community’s health care system.1,2 Mass casualty events occur frequently worldwide, with hundreds happening annually, presenting daunting challenges to community planners and disaster response professionals3. In general, MCEs fall into two categories: (1) immediate or sudden impact, airplane or train crashes; and (2)

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prolonged impact, e.g., pandemic flu, or widespread ongoing exposure to chemical, biological and nuclear agents. The first type yields large numbers of casualties at the outset of the event with few added over time. The second type yields a gradual increase in the

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number of people affected, rising to a catastrophic number of victims and necessitating a more prolonged response. 4

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Vulnerable populations already existing in the community (e.g., children, the frail

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elderly, those with physical or intellectual disabilities, those with mental health issues) and those living in institutional settings (e.g., hospitals, nursing homes, and in-patient hospice)

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disproportionately suffer harm during and after an MCE,.5-10 These individuals may not be

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able to seek help, care for themselves, or pursue other survival and recovery strategies pursued by non-vulnerable populations. They also are at greater risk of suffering and death because many of the resources that usually support existing vulnerable populations will be diverted to treat newly injured persons who are likely to survive. For example, nearly 19,000 elderly lived within a three-block radius of the World Trade Center’s Twin Towers on September 11th. Many frail elders and persons with disabilities were trapped for days in their high-rise apartments awaiting rescue, without



Palliative Care for MCEs electricity, fresh supplies of food and medications, or any way to communicate with the outside world. While animal protection groups were on the scene within 24 hours rescuing pets from evacuated buildings, it took up to seven days for rescuers to address the challenge of finding and rescuing the older people who were left behind in otherwise evacuated buildings. Home care workers could not get to their clients, and community service providers could not access their computers that held client information. In addition, many frail adults were unknown to community workers because they had never applied for services.11-13

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Hurricane Katrina and the subsequent flooding resulted in approximately 1,330 deaths, 71% over the age of 65.5,14-16 Health care providers in marooned New Orleans

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hospitals worked in almost unimaginably difficult conditions while awaiting rescue. In one

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hospital alone, 34 elderly and critically ill patients died during and after the storm as health care workers struggled to care for critically ill patients in a building with no electrical power,

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a nonfunctional sanitation system, flooding, and an interior temperature above 100 degrees Fahrenheit.17

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Many existing state and local disaster plans assume that in any large-scale MCE

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emergency, health care delivery will continue to adhere to established standards of care. However, an MCE with very large numbers of casualties and scarce resources, such as Hurricane Katrina4, the ethical mandate for clinicians may shift from a traditional focus on optimal care for individuals to a focus on allocating scarce equipment, supplies, and personnel in a way that saves the largest number of lives. People on the scene will have to make judgments as to who will most likely benefit from life saving treatment. Allowing authorities to make decisions concerning the allocation of scarce resources in an MCE and


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Palliative Care for MCEs their making well-grounded decisions could mean the difference between health care systems continuing to serve the public versus being overwhelmed and disintegrating into chaos and direct struggle. Failure could cost many thousands of lives.4 In such circumstances, access to medical treatment should become utilitarian and egalitarian, with the improved likelihood of survival with treatment and the availability of resources for treatment having a higher priority than loyalty to earlier patients or conventional standards of care. What should first responders, disaster personnel, and health care providers do when

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many affected people cannot reasonably survive, due to the scope of injuries, the magnitude of exposure, environmental conditions, or pre-existing medical conditions? This paper aims to contribute a palliative care perspective to the development of community planning for

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responding to mass casualty events with scarce resources. This paper was part of an

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initiative coordinated by the Agency for Healthcare Research and Quality (AHRQ),18 focusing on the broad range of critical issues public officials could face in a mass casualty

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event. We presented an earlier version at an expert meeting in Washington, DC, in June, 2006, which AHRQ published as Mass Medical Care with Scarce Resources: A Community

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Planning Guide.18

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The authors conducted a series of semi-structured telephone discussions with key experts in palliative care and public health disaster preparedness to identify what roles, responsibilities, procedures, and resources they considered to be necessary for communities to include in planning for the delivery of palliative care during a disaster. The survey team identified respondents by starting with five experts known by having published relevant research or position papers and used snowballing to identify ten others. The fifteen



Palliative Care for MCEs respondents included state and local public health department personnel; state and regional disaster planners; ambulatory care physicians; long-term care providers in areas of the country prone to disaster; nurses who were involved in caring for victims following the Oklahoma City, World Trade Center bombings, or Hurricane Katrina; researchers following the survivors of Hurricane Katrina and other disasters (e.g. Northridge earthquake); faculty from the Uniform Services University of the Health Sciences; ethics professors; and bioterrorism experts. [NOTE – surely many of these are singular – e.g., “an ethics professor”

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or “an ambulatory care physician” – and that one is an odd descriptor – why is that relevant?] All interviews were by telephone and occurred in a two-week period in April 2006. The interviewers asked each respondent to address a standardized set of open-ended questions

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and recorded the responses in notes, which were then typed as a narrative report from the interview.

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INSERT FIGURE 1: DISCUSSION TOPIC DOMAINS HERE

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The two lead authors (AW and MM) developed a categorization framework in advance from reviewing existing disaster planning and response guidelines, professional

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literature, and public reports. They then reviewed the written responses and coded them

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independently. Each reviewer proposed improvements to the framework arising from insights in the responses. In addition to coding by category, each reviewer summarized the overall assessment of each respondent and of all respondents taken together, focusing especially on generally held views on recommendations for basic levels of care and triage procedures under different circumstances. The two reviewers then compared their independent categorizations of responses and discussed any disagreements before preparing a summary of the responses. That summary was the subject of discussion at an in-person


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Palliative Care for MCEs meeting of experts in Washington, DC, in June, 2006, and the authors revised the presentation to highlight the issues that experts ranked as important and having strong consensus. Results Key expert telephone interviews and the consensus development expert meeting identified the following five centrally important issues: 1. What is the role of palliative care in a mass casualty event with resulting

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scarce resources?

2. What should triage and ensuing treatment decisions for those “likely to die?” 3. What palliative care services should be provided, along with the personnel and settings?

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4. What pragmatic plans are needed for ensuring training, supplies, and organizational or jurisdictional arrangements?

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5. What are the unusual issues affecting palliative care under MCE scenarios?

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What is the role of palliative care in a mass casualty event with resulting scarce resources?

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Aggressive management of symptoms and relief of suffering generally constitute

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“palliative care.” The World Health Organization defines palliative care as “an approach which improves the quality of life of patients and their families facing life-threatening illness, through the prevention, assessment, and treatment of pain and other physical, psychosocial, and spiritual problems.”19 The U.S. National Consensus Project for Quality Palliative Care states that palliative care focuses on the “relief of suffering and distress for people facing serious, life-limiting illness to help them and their families to have the best possible quality of life, regardless of the stage of the disease or the need for other therapies.” 20



Palliative Care for MCEs Key experts agreed that all disaster planning and response should include plans for people who will be unlikely to survive under catastrophic circumstances; that is, those already living with short prognosis in the community, and those newly dying as a result of the event. The experts’ uniformly held that planning ahead would greatly improve the likelihood of humane and efficient care for those who are unlikely to survive as a result of an MCE. Moreover, key experts recommended that all parties (planners, responders, health

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care providers, and the public) understand that palliative care, in ordinary times or during an MCE, eliminates the sense that society or its health care professionals have abandoned the patient or deliberately caused death. Instead, palliative care respects the humanity of those

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who will die soon and assures their comfort while supporting their loved ones. (See Table 1).

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After an MCE, palliative care would provide the aggressive treatment of symptoms, such as pain and shortness of breath.

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Table 1.

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Palliative Care Is:

Palliative Care Is Not:

Evidence-based medical treatment Vigorous care of pain and symptoms throughout illness Care that patients want

Abandonment Euthanasia Hastening death

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What should triage and ensuing treatment decisions for those “likely to die?” Many scenarios of catastrophic MCEs would create large numbers of fatally injured or critically ill short-term survivors. Instead of treating the sickest or the most critically injured first, MCE triage would correctly allocate resources in order to maximize the number of lives saved by focusing on identifying and reserving immediate treatment for those individuals 8 Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Palliative Care for MCEs who have a critical need for treatment and are likely to survive long term.4 Depending on the event, short-term survivors may die within hours or days (e.g., pulmonary injury from airborne chemicals) or may die over a few months (e.g., radiation sickness). In many cases, the prognosis will depend not only on the extent of injury but also on the resource scarcities the MCE creates. Disaster planners, policy makers, first responders, health care providers, and the public must come to recognize that the relative scarcity of services during a widespread MCE means that some people who might be cured under other circumstances

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will die. In addition, triage to palliative care should allow for the fact that initial prognostication for some patients will change, whether by virtue of their doing better than expected or by finding that additional treatment resources become available.

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Triage systems should include the categorization of palliative care treatment for

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casualties not likely to survive. However, planners have developed few decision tools to support MCE triage, and the traditional tools from battlefield conditions 21 do not include

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palliation as a treatment category. Those responsible for triage decisions at incident and treatment sites will have to assess prognosis in relation to limited resources and these

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decisions will reflect the decision-maker’s adherence to triage protocols and understanding of

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the estimated size, scope, and nature of the incident. These casualty decisions will include triage of existing sick, elderly, disabled and terminally ill patients already under medical and nursing care at the time of the MCE. Family members and other caregivers may bring these patients to triage and treatment sites for lack of their usual alternatives, or the patients may already be in institutional settings suddenly being used as treatment sites for casualties. Figure 2 presents a model of response and triage for victims of an MCE and the potential impacts on the prevailing health and social service system. The triage endeavor seeks to



Palliative Care for MCEs classify all people in need of medical care, whether their injuries or illnesses result from the MCE, from ensuing resource scarcity, or from pre-existing conditions, into the following three general categories: • • •

Those “unscathed” by the event or too well to require more than first aid; Those too sick or injured to survive days or weeks (the “not likely to survive”); and Those casualties deemed appropriate for acute medical treatment and transport to an acute medical care facility.22 INSERT FIGURE 2 HERE

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Triage procedures aim to send each group to appropriate care and care sites.

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Palliative care patients go to alternative care sites rather than to acute care hospitals, which will often be inundated with the “walking wounded” and those deemed “salvageable.” First

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responders may have to manage people classified as “not likely to survive” at the triage site if

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priority for transport for other patients delays relocation. Thus, both triage and palliative care sites need to have supplies and protocols for providing comfort measures, including pharmacologic treatment.23

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Finally, the key experts contended that planners and emergency response personnel should build strong support for complying with triage decisions by redefining public expectations and ensuring appropriate training of both palliative care and other health professionals. Civilian physicians and others need training in disaster or battlefield triage and the public and medical personnel need to understand evacuation protocols. Experts also recommended that policies and guidelines allow for the revision of triage and treatment decisions for casualties that do better than expected or who might survive when more resources become available. 10 Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Palliative Care for MCEs What palliative care services should be provided, along with the personnel and settings? An MCE will overwhelm and may eliminate some or all available health care resources, including EMS services, emergency departments (as EMS transport destinations), hospital capabilities to admit casualties, and resources to handle death and dead bodies. Disaster planning and management may allocate the skilled professionals who usually serve those with fatal chronic illness instead to treat the “medically salvageable” while EMS response agencies that remain operational will likely encounter demand for services that

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exceeds the resources available. Thus, services to those expected to die soon may fall more heavily upon people without substantial prior experience and expertise, such as first responders, less well-trained healthcare personnel, and potentially, laypersons and bystanders.

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Key experts recommended that disaster planners incorporate health care personnel who are skilled in the principles of palliative care, long-term care, and hospice in order to

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develop appropriate numbers of skilled professionals and laypersons able to provide disasterrelated palliative care as well as to develop the necessary guidelines, procedures, and policies

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to address the needs of those who may not survive. At a minimum, disaster response

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palliative care services should include relief of severe symptoms. In addition, the key experts recognized the potential psychological impacts of catastrophic MCEs, noting that palliative care requires attention to the psycho-social needs of dying patients and their families. They recommended that mental health providers (e.g., psychologists, chaplains, etc.) be integrated into palliative care disaster planning and response to provide support services for both the public as well as disaster response personnel. Local disaster management initiatives could recruit and train palliative care and longterm care professionals, retired health care professionals, and lay volunteers to take on 11 Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801


Palliative Care for MCEs defined palliative care roles during emergencies. Local “Disaster Palliative Assistance Teams” (DPATs) could combine interdisciplinary experience from diverse practice settings (e.g. hospitals, hospice, long-term care, etc.) which could be part of the Medical Reserve Corps, or organized under the National Disaster Medical System (NDMS).24 Each DPAT sponsor could recruit the team, arrange for training their members, and coordinate team deployment rapidly to supplement remaining local palliative care services.24 Just as for other disaster response personnel, DPAT members could be paid as part-time Federal employees,

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all States could recognize their licensure and certifications, and they could provide services under the protection of the Federal Tort Claims Act (should a malpractice claim occur).24 Palliative Care Delivery Sites. All interviewees agreed that palliative care services

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should be part of all disaster response health care delivery sites. In addition, planners should

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designate “palliative care sites” to treat those not expected to survive. Key experts recommended that disaster planning should link with supportive service organizations and

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personnel, e.g., traditional vulnerable population service providers such as long-term care providers, home health, disability support services, and hospice and palliative care providers.

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What pragmatic plans are needed for ensuring training, supplies, and organizational or jurisdictional arrangements?

Training/Skills. Given the scope, nature and size of a MCE, treatment for injuries or for existing conditions may be unavailable and/or delayed. Pain and other symptoms will likely be the primary issues faced by disaster response and medical personnel.25 Therefore, effective pain and symptom management should be a basic minimum of service delivery and training for palliative care during MCEs. Education and training should be competency based, with programming specific to the individual’s role in emergency response and should 12 Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Palliative Care for MCEs cover, at a minimum, the basic philosophy and goals of palliative care (including the principle of double effect), basic symptom management (e.g., for pain and shortness of breath); the use and titration of oral and injectible morphine in patients in pain and/or near death; symptom recognition in the case of pandemic flu or chemical or radiological attack; and basic psycho-social counseling and support. Basic disaster planning should include stockpiling palliative care medications at accessible sites away from acute care hospitals (e.g., in nursing homes) and should train disaster responders as to how to locate, access and

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use them. In addition, the broad community will need education regarding disaster response and medical care delivery under altered standards of care to ensure that the public is aware of the issues and choices that triage and public health officials must make under MCE circumstances.

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Training in palliative care must occur prior to an MCE and can be incorporated into current Community Emergency Response Team (CERT) training activities. Disaster

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planners should build on existing models of emergency response training to develop and implement a variety of training methodologies that incorporate generic and “just in time”

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palliative care services for all disaster response team members. Cross-training of personnel

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from other areas of expertise, other areas of the state and region, and the lay public (e.g., bus drivers, mail deliverers, etc.) could augment the work of palliative care providers. Medical Supplies and Equipment. Planners can reasonably anticipate most palliative care MCE resource requirements: workers, equipment, medications, food, bedding, water, shelter, and transportation to and from the site. Mutual-Aid agreements made ahead of time with community agencies, other health care providers, and backup suppliers can help ensure adequate resources for palliative care services needs. The palliative care medications that



Palliative Care for MCEs most need stockpiled in each community for disaster response, as recommended by our interviews, included injectible morphine and dihydromorphone (to treat anxiety, pain, dyspnea, agitation), haloperidol (to treat delirium, anxiety, agitation, nausea), antipyretics, steroids, and diuretics, as well as subcutaneous butterfly needles and adhesive tape or a sterile adhesive dressing to cover parenteral medication administration sites. Some special needs populations, such as those dependent upon dialysis or ventilators, will be at critical risk during a mass casualty. If needed services are not going to be available in time, patients with

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such critical medical and technological dependency will become palliative care patients, and responders need to be able to offer symptom management and preparation for dying. If services later become available, the sorting at triage can be reversed.

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What are the unusual issues affecting palliative care under MCE scenarios?

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Management of the Dead. One of the most difficult aspects of disaster response is

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management of dead bodies. These activities have profound and long-lasting consequences for survivors and communities and they can be among the most difficult features of disaster

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management. Immediately after a major disaster, the local community usually has to handle

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identifying and disposing of human remains. In the case of a natural disaster, the dead body poses no public health risk right away, but bodies may spread disease in an infectious epidemic.26 The experts recommended that MCE disaster planning include body bags, refrigerator trucks, methods to catalog and identify bodies, and cremation services. Identifying and Locating Special Populations. The evacuation and sheltering of vulnerable and special needs populations living in the community and in institutional settings pose many challenges to disaster planners. Many of these individuals may require separate special accommodations during evacuation, relocation and return. One underlying challenge 14 Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Palliative Care for MCEs is to establish criteria for identifying special needs populations, particularly during an emergency, in order to ensure their prompt evacuation and to direct them to appropriate shelter arrangements. These special needs populations include people living with frailty associated with aging, serious mental illness, intellectual or cognitive disabilities, sensory impairments (e.g., low vision, impaired hearing), mobility problems or activity limitations, dependence on special equipment such as oxygen or wheelchairs, and no available transportation. Many special needs populations do not have regular contact with the health

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care system and essentially none are on registries, so finding these people before and after a disaster or emergency will be very difficult without planning. For example, transportation of special needs populations became a serious issue in the aftermath of Hurricane Katrina when

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people who needed stretchers or wheelchairs could not use busses or cars to get to shelters or

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could not follow instructions to move to another shelter.27 In all likelihood, public health disaster planning and response agencies will have to develop registries of people who otherwise might be abandoned at home.

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Ethical Considerations and Community Education. Communities cannot assume that

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federal and/or state governments will be able to respond effectively or to even to function

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under MCE conditions, overstretched as they may be by the multiple challenges and locations of such events. Serious ethical discussion, considerations and decision-making must shape a community’s MCE disaster response, ranging from: Whom do we evacuate first? When do we stop expending resources on rescue efforts and shift to recovery mode? What conditions must accrue to shift disaster response to an “altered” set of standards? How do we balance “greatest good” against fairness and individual rights? How do we measure the “value” of an individual or groups of individuals when resources are scarce? Who shall



Palliative Care for MCEs we “let die” when we cannot save all who might have survived in normal times? While no one expects these to become settled issues, having the community understand both the general outlines of the procedures and protections in place and the urgent need to be compliant with them is likely to prove essential in maintaining optimal efficiency for the remaining resources for services.

Discussion

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A mass casualty event would involve thousands of victims, both newly created as well as among existing vulnerable populations. Preserving a functioning health care system during and after an MCE will require the adoption of principles of field triage, limiting the

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use of ventilators and surgery, and the creation of alternative care sites. Triage and

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treatment practices that focus on maximizing the number of lives saved means that some people who might be successfully treated or cured under normal circumstances will likely

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die. Providing a treatment category of “palliative care” for those not likely to survive will be an important service option for responders and triage officers.28

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Since Hurricane Katrina, research studies and proposed disaster response

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recommendations and guidelines have addressed special planning for seniors, the disabled and children.5,27,29,30 For example, the National Organization on Disability’s Emergency Preparedness Initiative (EPI), established after 9/11, ensures that emergency managers address disability concerns and that people with disabilities are included in all levels of emergency preparedness- planning, response, and recovery.31 However, few projects in research or planning have addressed catastrophic mass casualty events specifically or discussed the role of palliative care in disaster response, including national and international


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Palliative Care for MCEs palliative care organizations. Only recently have official recommendations explicitly advocated the provision of palliative care. For example, the American College of Physicians in 2008 issued the following: “Suggestion 4.6: Palliative care is a requirement of mass critical care”32 and these suggestions augment the work conducted for the AHRQ/ASPE initiative Providing Mass Medical Care with Scarce Resources.18 There will be a sizable number of people for whom death can be expected, though they may live for hours, days or weeks. Those who are not expected to survive cannot simply

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be consigned to holding areas or body bags while still alive; nor should they and their family advocates overwhelm hospitals and EMS systems that could be addressing the needs of potential survivors. Careful consideration of the special needs of those individuals who are

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at greatest risk of not surviving in circumstances of catastrophic disaster, and those of their

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family and formal caregivers, can avert suffering and help sustain a working care delivery system. By including these populations in existing disaster and mass casualty preparation,

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response, and management, most communities could ensure humane care for those who will die in such disasters. Although the primary goal of a coordinated response to a catastrophic

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MCE should be to maximize the numbers of lives saved, a practical plan also must provide

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the greatest comfort for those whose will live a while before dying as a result of a MCE. Community planners face several significant challenges in the integration of palliative care services and personnel into MCE response planning. First, the provision of palliative care in the context of an MCE is a new component of disaster planning. As such, little research or thoughtful planning is available to guide planners. Second, palliative care, longterm care, and home care are already resource-poor; thus, identifying and securing funding for palliative care disaster response services may face more challenges than some other types



Palliative Care for MCEs of services with well-established funding. Third, both disaster planners and palliative care professionals do not yet understand the potential utility of incorporating community-based palliative care professionals into MCE response planning efforts. Finally, the public does not generally understand or accept the limitations that the health care system will have under austere circumstances. Without attention to these issues at the local, state and Federal level, medical providers and responders will continue to face disasters unprepared and citizens will be

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unaware of the choices that they may confront. However, hospitals and communities are unlikely to take up such questions without leadership from government and other disaster preparedness organizations, in part because discussions of accepting altered standards of care

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are controversial and involve liability and political risks. On the other hand, community

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planning activities surrounding MCEs and altered standards of care disaster preparedness may have some protections if they are transparent, community-based ethical discussions of

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the best possible decision-making processes regarding the hard choices to be faced under dire circumstances. A useful process would likely entail the involvement and accountability of

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political leadership.

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Our interviews also held that a good process will educate the wider community so that individuals will have realistic expectations of what first responders and other disaster personnel will be able to achieve and what may be asked of the community. In the U.S. at least, this public discourse will probably start from a presumption of “absolute” equity, counting each person as being of the same worth and giving to each without regard to status or history. Communities must examine and affirm this mandate and then decide what it


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Palliative Care for MCEs means with regard to people who have existing care needs and other vulnerabilities during mass casualty events. In order to do well, communities need a reasonable array of palliative and comfort care services (including psychological/mental health support and pastoral care for patients, families, and disaster responders). When resources are scarce, planners can make available alternative means of palliative care delivery and treatment. Community planners should (1) develop evacuation plans for existing and new palliative care patients; (2) develop a

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community response plan, staffing plans and training programs for first responders and other relevant medical personnel, (3) establish transparent, community-based, explicit triage criteria for casualties not likely to survive the MCE; (4) develop a community education

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program to prepare the public; and (5) stockpile needed medications and supplies away from

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hospitals. In addition, palliative care professionals should participate in disaster planning, response and recovery training, and public education for MCEs. Plans should direct moving

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people expected to die to care sites other than acute care hospitals. First responders and health care providers at all disaster care sites (event sites, alternative care sites, and hospitals

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should have training in effective pharmacological pain and symptom management and

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psycho-social support). Optimal support of those who will live a while before dying depends, in large part, on having done a good job in planning for the inevitability of mass casualty events.



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Figure 1 DISCUSSION TOPIC GUIDE DOMAINS

What services /equipment/providers should be available in the event of a MCE and how should we use (reuse?) common supplies and equipment (e.g., gloves, gowns, etc.); What skills, materials and memorandums of understanding are needed to shelter and/or evacuate people with supportive/palliative care needs; Decision guidelines for who should receive palliative care, how it should it be delivered, and how to handle large numbers of people expected to die, and those already very sick, or disabled; What criteria would you suggest to allocate scarce and highly specialized clinical resources concerning supportive/palliative resources in MCE; What differences and similarities are there in the general considerations for the delivery of supportive/palliative care in a mass casualty event such as bioterrorism and avian flu; Is the current system, given what is needed for shelter and evacuation sufficient, and if not what if any additional support needs to be provided to individual nursing homes and to Public Health at the State and local level; How should evacuation decisions be made for the supportive care/palliative populations; What are the vital skills for first responders to have regarding supportive care/palliative populations; How should we modify documentation standards to ensure enough information to support care and obtain legal protection without posing an undue administrative burden; How to manage excessive deaths and the disposal of the bodies; What protocols should be in place for those who are dying and in extreme pain; What role (if any) does euthanasia play in disaster planning in supportive/palliative care and how are these tough decisions communicated to the public?

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Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801

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Figure 2 Catastrophic MCE: Triage and Response

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Reprinted with permission from Agency for Healthcare Research and Quality18

Mary Ann Liebert, Inc., 140 Huguenot Street, New Rochelle, NY 10801