Thursday, September 24, 2009

Resource-constrained medical situations: What would a grown-up do?

Today the Institute of Medicine has released their "Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations". This report was specifically commissioned by Nicole Lurie, MD, MSPH, the Assistant Secretary for Preparedness and Response at the Department of Health and Human Services. The committee was charged with the following:
1). Identify and describe key elements to include in standards of care protocols to develop a framework for care in crisis situations.
2). Review roles and responsibilities as well as ways of integrating public opinion in the guidance.
3). Incorporate ethical principles into the guidance.

The committee admits that, due to an "accelerated time frame", they might not have examined the totality of evidence or included all relevant stakeholders. This begs the question of why the time line was so aggressive, given that we have been expecting an avian flu pandemic for years. Is this yet another failure of the previous administration or just the usual government inefficiency? I give Nicole Lurie credit for jumping into this morass with much needed alacrity.

Nevertheless, their conclusions are sobering (and not unlike what I have written in my previous posts on the matter). They state
... the committee recognizes that although some federal, state, municipality, territorial, and health-sector agencies and institutions have made considerable progress in developing protocols, many states have only just begun to address this urgent need. [emphasis mine]
Additionally, the IOM committee concludes that
... there is an urgent and clear need for a single national guidance for states for crisis events and is not specific to certain event. [emphasis mine]
The committee then goes on to define what they call "crisis standard of care", which is "the level of health and medical care capable of being delivered during a catastrophic event". The change in the level of care is to be declared by the state government. They then go on to develop ethical drivers for crisis standards, emphasizing fairness, equitability, community and provider education and communication, and the rule of law. Finally, the report makes specific recommendations for the states for the development of these standards of care.

Now, it is obvious that there is plenty of room for paranoia, similar to what we have witnessed recently in conjunction with our healthcare reform discussions, to hijack this very important topic. If that is the way we choose to handle the matter, the results are potentially disastrous. Instead, the press really need to step up to the plate and present a rational and nuanced discussion of the realities of the choices in the setting of a crisis. The lazy and insidious metaphors of fascism, socialism, communism, Hitler, Stalin, McCarthy, etc., accomplish nothing other than to promote chaos (we have to ask ourselves what the advantages of chaos may be for those who are working so hard to promote it).

The fundamental question is "What is the role of the government in a crisis situation?" I am certainly not a civics scholar, but it seems reasonable to expect the government to act in the best interest of all citizenry, to be a unifying force where there needs to be a concerted response, and to promote fairness and equity within some ethically accepted standards. In a potential mass casualty like H1N1 pandemic, the resource constraints are real. Instead of saying an outright "no" to any plans, be they from Washington, the states, or the healthcare institutions, let's engage in a logical public dialogue. Like grown-ups. As I've said before, we won't all agree, but we should all have our polite and considered say. That is, after all, what Democracy is all about!

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