disaster bioethics. preparing and taking care of the carers

Disaster Bioethics.Disaster Bioethics. Preparing and taking care of the Preparing and taking care of the

carers.carers.

Geneva, 4 and 5 April 2011Geneva, 4 and 5 April 2011

Herman Delooz, Professor Emeritus of Emergency medicineHerman Delooz, Professor Emeritus of Emergency medicine, , Catholic University of Leuven, Belgium.Catholic University of Leuven, Belgium.

OutlineOutline

Who are the carers ?Who are the carers ?

What are the ethical issues/dilemmaWhat are the ethical issues/dilemma’’s ?s ?

How to prepare ?How to prepare ?

How to take care ?How to take care ?

1. 1. WhoWho are the carers ?are the carers ?

11°° The sequential development of disaster management:The sequential development of disaster management:

-- 19601960’’s: responses: response

-- 19701970’’s: systematic preparedness approachs: systematic preparedness approach

-- 19801980’’s: mitigation, s: mitigation, protection of infrastructureprotection of infrastructure

-- 19901990’’s and early 2000: risk reduction, build resiliences and early 2000: risk reduction, build resilience

Jean-Luc Poncelet, Herman Delooz, International Perspectives on Disaster Management, in Koenig and Schultz’s Disaster Medicine, 2010. Cambridge.


22°° The development of different kinds of activities:The development of different kinds of activities:

Risk assessmentRisk assessmentLegislationLegislationLogisticsLogisticsOrganisation/coOrganisation/coöördinationrdinationEducation/trainingEducation/trainingCommunicationCommunicationEvaluation/research.Evaluation/research.


33°° The development of activities at different The development of activities at different levels:levels:

InternationalInternationalNationalNationalRegionalRegionalLocal: communityLocal: community

MatrixMatrixlegislegis-- lationlation

logisticslogistics OrganiOrgani-- sationsation

trainingtraining CommuCommu-- nicationnication

EvaluaEvalua-- tiontion

internationalinternational XX XX

nationalnational XX XX XX XX XX

regionalregional XX XX XX XX

locallocal XX XX XX XX


Growing number of Growing number of volunteersvolunteers, , semisemi-- professionalsprofessionals and professionals are and professionals are involvedinvolved..

IncludingIncluding thosethose whowho go in the fieldgo in the field+ + thosethose whowho investigateinvestigate the the risksrisks

and prepare and prepare fromfrom a a multidisciplinarymultidisciplinary and and multimulti--hazardhazard perspectiveperspective..


All these players are to be considered as All these players are to be considered as

CARERS !CARERS !

Stakeholders = Carers.Stakeholders = Carers.

An ethical framework to guide decision An ethical framework to guide decision making is robust to the extent that it making is robust to the extent that it reflects the values and beliefs of the reflects the values and beliefs of the decision makers who refer to it and the decision makers who refer to it and the values and beliefs of those affected by the values and beliefs of those affected by the decisions being taken.decisions being taken.

Alison K. Thompson et al. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Medical Ethics 2006, 7:12 1-11.

2. What are the ethical 2. What are the ethical issues/dilemmas ?issues/dilemmas ?

Last decade: Last decade:

The vast majority of publications are The vast majority of publications are concerned with issues related to concerned with issues related to preparedness planning and decision preparedness planning and decision making for pandemics and bioterrorism.making for pandemics and bioterrorism.

What are the ethical What are the ethical issues/dilemmasissues/dilemmas

Last decade:Last decade:

The rest of the publications are mainly The rest of the publications are mainly concerned with issues related to concerned with issues related to funding/donations, vulnerability and public funding/donations, vulnerability and public accountability.accountability.

MacroMacro--ethical Issues:ethical Issues:

Inequality in funding/resources: ex. Inequality in funding/resources: ex. tsunami versus HIVtsunami versus HIV

Access to care: the issue of Access to care: the issue of social/distributive justice and solidarity social/distributive justice and solidarity

Barriers as a result of cultural/religious Barriers as a result of cultural/religious backgroundbackground

Need for public information/participationNeed for public information/participation

NGONGO’’s leaving one country/region to s leaving one country/region to provide assistance in a different one provide assistance in a different one

MicroMicro--ethical issues:ethical issues:

Triage: Triage: --order of careorder of care--access to intensive care/ventilationaccess to intensive care/ventilation

Surveillance/reporting versus privacySurveillance/reporting versus privacy

Protection of privacy from the media/researchProtection of privacy from the media/research

Containment/isolation/quarantine versus Containment/isolation/quarantine versus autonomy/personal freedomautonomy/personal freedom

Duty to care versus risk for Duty to care versus risk for person/family/environmentperson/family/environment

NonNon--issues:issues:

The requests for:The requests for:

Legal regulation/limitation of responsibility of Legal regulation/limitation of responsibility of health care providershealth care providers

Legal definition of the reduced level of care to be Legal definition of the reduced level of care to be applied in a disaster and the cutapplied in a disaster and the cut--off point for off point for applicationapplication

These requests are the result of medicoThese requests are the result of medico--legal legal concerns, a means to avoid legal responsibility, concerns, a means to avoid legal responsibility, rather than the result of ethical reasoningrather than the result of ethical reasoning

The standard of care for a physician is The standard of care for a physician is what a reasonably prudent physician what a reasonably prudent physician would do in the same or similar would do in the same or similar circumstances, taking into account the circumstances, taking into account the resources available.resources available.

Marc A. Rothstein. Currents in Contemporary Ethics. J of Law, Medicine & Ethics. Spring 2010; 149-153.George G. Annas. Standard of Care. N. Engl.J.Med 2010,362;22, 2126-2131.

NonNon--issues:issues:

The allocation of respiratory support through The allocation of respiratory support through the use of ventilators.the use of ventilators.

““First medical data then ethicsFirst medical data then ethics””

To consider CPAP as a means to avoid the To consider CPAP as a means to avoid the use of ventilators.use of ventilators.

Medical data:Medical data:

1970: George Gregory (SF) introduced the use 1970: George Gregory (SF) introduced the use of CPAP as an alternative for controlled PEEP of CPAP as an alternative for controlled PEEP ventilation for Neonatal Respiratory Distress ventilation for Neonatal Respiratory Distress Syndrome.Syndrome.

Adult intensive care adopted CPAP as a means Adult intensive care adopted CPAP as a means of weaning.of weaning.

19801980’’s: ED University Hospital Leuven s: ED University Hospital Leuven introduced the use of CPAP for thoracic trauma.introduced the use of CPAP for thoracic trauma.

:

Sabbe MB: Recent advances in the diagnosis and therapy of thoracic injury. Current Opinion in Critical Care 1995: 1: 503-508

Issue not considered: Issue not considered:

Eliminating useless practices as a means Eliminating useless practices as a means of cost containment is an ethical obligation of cost containment is an ethical obligation towards patients and society.towards patients and society.

Herman H. Delooz, Ethical issues in critical care: criteria for treatment. In K. Wim. Wildes(ed.) Critical Choices in Critical Care, 79-101. 1995 Kluwer.

The bioethicist.The bioethicist.

The role of the bioThe role of the bio--ethicist does not ethicist does not involve concrete decision making, but involve concrete decision making, but concerns the study of the circumstances concerns the study of the circumstances and issues at stake and the instruction of and issues at stake and the instruction of the physician and other decision makers the physician and other decision makers as to the criteria and procedures to follow as to the criteria and procedures to follow in decision making.in decision making.

Ibidem.

3. 3. HowHow to prepare ?to prepare ?WHO:WHO:ExperienceExperience teachesteaches thatthat onon average, average, itit takestakes

betweenbetween 48 and 72 48 and 72 hourshours forfor assistanceassistance fromfrom otherother countriescountries to to bebe mobilizedmobilized and set up and set up operationsoperations at a at a massmass casualtycasualty scene.scene.

WhatWhat is is donedone duringduring thisthis criticalcritical periodperiod is is vitalvital in in determiningdetermining the the outcomeoutcome of the incident in of the incident in termsterms of of mortalitymortality, , morbiditymorbidity and and controlcontrol of of disabilitiesdisabilities

WHOWHOExperienceExperience shows shows thatthat the the communitycommunity is the is the firstfirst to provide to provide emergencyemergency assistanceassistance in in suchsuch incidentsincidentsPreparednessPreparedness planning planning increasinglyincreasingly emphasizesemphasizes building building capacitycapacity ((humanhuman, , organizationalorganizational and and infrastructuralinfrastructural) at ) at the the communitycommunity level. level.

The The CommunityCommunity is is defineddefined as a as a divisiondivision ofof

a country a country smallsmall enoughenough to permit to permit effectiveeffective

participationparticipation and and largelarge enoughenough to have theto have the

necessarynecessary resources to resources to implementimplement plannedplanned

activitiesactivities ( WHO 2006 )( WHO 2006 )

WHO.WHO.

SixtiethSixtieth World Health Assemblee, May 23 2007:World Health Assemblee, May 23 2007:

““improvedimproved organisationorganisation and planning and planning forfor provisionprovision of trauma and of trauma and emergencyemergency care is care is anan essentialessential part of part of integratedintegrated healthhealth--carecare deliverydelivery, , playsplays anan important important rolerole in in preparednesspreparedness forfor and and response to response to massmass--casualtycasualty incidentsincidents, and , and cancan lowerlower mortalitymortality, , reducereduce disabilitydisability, and prevent , and prevent otherother adverseadverse healthhealth outcomesoutcomes arisingarising fromfrom the the burdenburden of of everydayeveryday injuriesinjuries..””

WHO WHO basicbasic message:message:

EmergencyEmergency Care Care as part of an integrated as part of an integrated hhealthealth care care deliverydelivery system, is system, is essentialessential in in the response in cases of all the response in cases of all emergenciesemergencies..

StrenghteningStrenghtening existingexisting healthhealth systemssystems !!


We have to createWe have to create

A CULTURE OF ETHICS,A CULTURE OF ETHICS,

through implementation of biothrough implementation of bio--ethical debate ethical debate in everyday practice of health care.in everyday practice of health care.Matthew R. Hunt. Ethics beyond borders. Developing World Bioethics. Vol 8 No 2, 2008, 59-69.

Culture of Ethics: Example 1 :Culture of Ethics: Example 1 :

Decision making in Critical Care.Decision making in Critical Care.

Procedure: Question of limitation of care Procedure: Question of limitation of care can be raised at any time by the patient, can be raised at any time by the patient, his close family and any teamhis close family and any team--member member involved in the care of the patient.involved in the care of the patient.

Herman H. Delooz, Ethical Issues in Critical Care: criteria for treatment. In K. Wim. Wildes (ed.) Critical Care and Critical Choices, 79-101. 1995 Kluwer.

Triage Critical Patient:Triage Critical Patient:

Code 0: all care as indicated.Code 0: all care as indicated.

Code 1: DNR: no thoracic compression, no Code 1: DNR: no thoracic compression, no defibrillation in case of circulatory arrest.defibrillation in case of circulatory arrest.

Code 2: no extension of therapy in general, or in Code 2: no extension of therapy in general, or in a limited, well defined way.a limited, well defined way.

Code 3: stop intensive therapy in general, or in a Code 3: stop intensive therapy in general, or in a limited, well defined way. Comfort therapy is limited, well defined way. Comfort therapy is assured.assured.


The process includes broad consultation The process includes broad consultation at staff level, information and clear at staff level, information and clear communication of the basis for the communication of the basis for the decision with the patient, the close family decision with the patient, the close family of the patient and all involved in the care of the patient and all involved in the care of the patient.of the patient.

The final decision is unequivocally posted The final decision is unequivocally posted in the patientin the patient’’s record.s record.

Ibidem.


As in triage it is always a dynamic process: any As in triage it is always a dynamic process: any decision can be reviewed at any time.decision can be reviewed at any time.

If a therapeutic trial is considered, a timeIf a therapeutic trial is considered, a time--limited limited trial of a therapeutic intervention where upon is trial of a therapeutic intervention where upon is agreed by all involved, may increase the agreed by all involved, may increase the certainty of the prognosis.certainty of the prognosis.

Culture of Ethics:Culture of Ethics:

Systematic coding of critical patients:Systematic coding of critical patients:

1989 introduced in ED, Univ. Hospital Leuven. 1989 introduced in ED, Univ. Hospital Leuven. Reported to Bioethics Committee of Medical Reported to Bioethics Committee of Medical Faculty.Faculty.

1990 presented during Academic Lecture, Univ. 1990 presented during Academic Lecture, Univ. Leuven. Picked up in the Media.Leuven. Picked up in the Media.

1992 introduced in the Univ. Hospital by Bioethics 1992 introduced in the Univ. Hospital by Bioethics Committee.Committee.

1994 introduced in curriculum of Medical School 1994 introduced in curriculum of Medical School and of Master in Nursing.and of Master in Nursing.

Culture of Ethics: Example 2:Culture of Ethics: Example 2:

The question of access to care and the The question of access to care and the distributive justice. distributive justice.

The issue of solidarity. The issue of solidarity.

Access to care:Access to care:

Natural and social lottery cannot be denied. Vulnerable Natural and social lottery cannot be denied. Vulnerable population groups are a reality.population groups are a reality.

Society has the moral duty to correct the effect of these Society has the moral duty to correct the effect of these lotteries to a certain extent, through the assurance of lotteries to a certain extent, through the assurance of equal access to basic human needs, such as health equal access to basic human needs, such as health care.care.

If this correction is not provided, the negative effects of If this correction is not provided, the negative effects of these lotteries will amplify each other and will produce a these lotteries will amplify each other and will produce a downward spiral leaving the subject without any downward spiral leaving the subject without any prospect.prospect.

Herman H. Delooz, Ethical Issues in Critical Care: criteria for treatment.

In K. Wm. Wildes (ed) Critical Choices in Critical Care, 79-101. 1995, Kluwer

Access to care:Access to care:

Society can only achieve this goal through an Society can only achieve this goal through an insurance system based on SOLIDARITY, in insurance system based on SOLIDARITY, in which all citizens are required to participate which all citizens are required to participate according to their revenue.according to their revenue.

Of course such a system, while assuring access Of course such a system, while assuring access to basic needs, such as health care, should to basic needs, such as health care, should preserve an acceptable difference in revenue preserve an acceptable difference in revenue and financial status, in order to safeguard and financial status, in order to safeguard human incentive.human incentive.

Ibidem.


We can not expect to base access to We can not expect to base access to health care on solidarity in times of health care on solidarity in times of disaster, if solidarity is not part of our disaster, if solidarity is not part of our planning for access to health care in planning for access to health care in everyday life !everyday life !

How to prepare ?How to prepare ? Education.Education.

An educational curriculum for medical students, An educational curriculum for medical students, residents and practicing physicians is required residents and practicing physicians is required to best prepare all physicians who might be to best prepare all physicians who might be called upon, in the future to triage patients, called upon, in the future to triage patients, allocate resources and make difficult allocate resources and make difficult decisions about treatment priorities and decisions about treatment priorities and comfort care.comfort care.

The issues at stake should be addressed in The issues at stake should be addressed in advance as part of ethics education of the advance as part of ethics education of the medical and nursing profession.medical and nursing profession.

How to prepare ? How to prepare ? Education.Education.

Cultural/philosophical background differences:Cultural/philosophical background differences:

Western notion of caring seems to be aiming at Western notion of caring seems to be aiming at developing a more integrated empathic view of this developing a more integrated empathic view of this relationship relationship –– one of sharing and partnership.one of sharing and partnership.

Eastern notion translates into trying not to treat people Eastern notion translates into trying not to treat people as if they have an illness, but letting them be as if they have an illness, but letting them be –– the the deepest ethical motive of caring involves respect for the deepest ethical motive of caring involves respect for the absolute dignity of the human being.absolute dignity of the human being.

H-H Chiang et al. To have or to be: ways of caregiving identified duringRecovery from the earthquake disaster in Taiwan. J. Med Ethics 2005;31:154-158

How to prepare ? How to prepare ? Organisation.Organisation.

Public and private bodies should have Public and private bodies should have their ethical commitments stipulated in their ethical commitments stipulated in their mission statement and objectives.their mission statement and objectives.

When establishing their staff, these ethical When establishing their staff, these ethical commitments should be taken into commitments should be taken into account, in order to assure the necessary account, in order to assure the necessary expertise in ethical issues.expertise in ethical issues.

How to prepare ?How to prepare ? Organisation:Organisation:

All Committees/Boards of Public All Committees/Boards of Public Institutions and Institutions and NGONGO’’ss, must include on , must include on the agenda for all meetings, the ethical the agenda for all meetings, the ethical implications of whatever decisionimplications of whatever decision--making making issue/process.issue/process.

Membership of the Committees /Boards Membership of the Committees /Boards should assure ethical expertise. should assure ethical expertise.

4. How to care ?4. How to care ?

Both ethical good and aesthetical good are Both ethical good and aesthetical good are experienced as a feeling of wellbeing:experienced as a feeling of wellbeing:““a feeling of having done wella feeling of having done well””““a thing of beauty is a joy forevera thing of beauty is a joy forever””..

The carerThe carer’’s confrontation with ethical s confrontation with ethical dilemmas will create dilemmas will create ““emotionalemotional”” involvement and may create distress.involvement and may create distress.

How to care ?How to care ?

Training in ethics and teamwork strategies Training in ethics and teamwork strategies not only can assist responders in not only can assist responders in optimizing decisionoptimizing decision--making, but also can making, but also can decrease the psychological stress decrease the psychological stress imposed on them by difficult choices.imposed on them by difficult choices.

Paul G. Firth. To the editor. New England J. of Med. 2010, 363;14:1379-1380


Israeli field hospital in Haiti:Israeli field hospital in Haiti:

““ To deal with the ethical aspects of decisions To deal with the ethical aspects of decisions regarding patient placement and treatment regarding patient placement and treatment options, we created a system of ad hoc ethics options, we created a system of ad hoc ethics committees. The physician directly in charge of committees. The physician directly in charge of the patient presents the case to a panel of three the patient presents the case to a panel of three senior physicianssenior physicians…….relieve individual physician .relieve individual physician of burdenof burden…… decisions recorded in patientdecisions recorded in patient’’s file.s file.””

““Guidelines for triage, management and discharge Guidelines for triage, management and discharge were subject to continuous rewere subject to continuous re--evaluation and evaluation and revision.revision.””

Ofer Merin et al. Ethical Dilemmas in Early Disaster Response. New Engl J of Med. 2010; 362.38.


Culture of resilience building.Culture of resilience building.

Resilience. Resilience.

Resilience is the ability to reduce the effect Resilience is the ability to reduce the effect of a distressing event by anticipation and of a distressing event by anticipation and preparation or to preparation or to ““bounce backbounce back”” once it once it has occurred.has occurred.

Robert G. Maunder et al. Pandemic stress in Healthcare workers.Canadian Journal of Public Health. Vol 99, No 6, 486-488.

Individual resilience building.Individual resilience building.

FolkmanFolkman and Greerand Greer’’s framework describes a s framework describes a sequence of appraisal and coping processes sequence of appraisal and coping processes that are designed to recover positive emotions that are designed to recover positive emotions and effective adaptation.and effective adaptation.

Psychological first aid teaches a respectful Psychological first aid teaches a respectful approach to reducing distress through approach to reducing distress through enhancing safety and comfort, helping to identify enhancing safety and comfort, helping to identify needs, providing information and facilitating needs, providing information and facilitating social connection.social connection.

Ibidem

Organisational resilience building.Organisational resilience building.

CfrCfr Magnet hospitals:Magnet hospitals:

Decentralised decisionDecentralised decision--makingmakingCareCare--givers among institutional executivegivers among institutional executiveFlexible schedulingFlexible schedulingContinuous educationContinuous educationUnitUnit--level selflevel self--governmentgovernment

Ibidem.

Organisational resilience building.Organisational resilience building.

Organisational justice:Organisational justice:

Employees viewpoints are taken into Employees viewpoints are taken into account : relational justiceaccount : relational justice

Fairness in formal decisionFairness in formal decision--making making procedures: decisional justiceprocedures: decisional justice

Ibidem.

Conclusion: messagesConclusion: messages

1/ All involved are carers1/ All involved are carers

2/ Differentiate issues and non2/ Differentiate issues and non--issues. First issues. First medical data then ethics.medical data then ethics.

3/ Culture of ethics based on everyday handling 3/ Culture of ethics based on everyday handling of ethical issues in health care.of ethical issues in health care.

4/ Ethical training and resilience building 4/ Ethical training and resilience building integrated in professional education.integrated in professional education.

disaster bioethics. preparing and taking care of the carers

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