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Definitive Care for the Critically Ill During a Disaster: A Framework for Allocation of Scarce Resources in Mass Critical Care^*

From a Task Force for Mass Critical Care Summit Meeting, January 26–27, 2007, Chicago, IL

Asha V. Devereaux, MD, MPH, FCCP; Jeffrey R. Dichter, MD; Michael D. Christian, MD, FRCPC; Nancy N. Dubler, LLB; Christian E. Sandrock, MD, MPH, FCCP; John L. Hick, MD; Tia Powell, MD; James A. Geiling, MD, FCCP; Dennis E. Amundson, CAPT, MC, USN, FCCP; Tom E. Baudendistel, MD; Dana A. Braner, MD; Mike A. Klein, JD; Kenneth A. Berkowitz, MD, FCCP; J. Randall Curtis, MD, MPH, FCCP and Lewis Rubinson, MD, PhD

^* From Sharp Coronado Hospital (Dr. Devereaux), Coronado, CA; Presbyterian Hospital (Dr. Dichter), Albuquerque, NM; Mount Sinai Hospital/University Health Network (Dr. Christian), Toronto, ON, Canada; Montefiore Medical Center (Ms. Dubler), New York, NY; University of California, Davis (Dr. Sandrock), Davis, CA; Hennepin County Medical Center (Dr. Hick), Minneapolis, MN; New York State Task Force on Life and the Law (Dr. Powell and Mr. Klein), New York, NY; White River Junction VA Medical Center and Dartmouth Medical School (Dr. Geiling), Hanover NH; Naval Medical Center (Dr. Amundson), San Diego, CA; California Pacific Medical Center (Dr. Baudendistel), San Francisco, CA; Oregon Health and Sciences Center (Dr. Braner), Portland, OR; VHA National Center for Ethics in Health Care and the New York University School of Medicine (Dr. Berkowitz), New York, NY; Harbor View Medical Center (Dr. Curtis), Seattle, WA; University of Washington (Dr. Rubinson), Seattle, WA. A list of Task Force members is given in the ^Appendix.

Correspondence to: Asha Devereaux, MD, MPH, 1224 Tenth St, #205, Coronado, CA 92118; e-mail: ADevereaux{at}pol.net

Background: Anticipated circumstances during the next severe influenza pandemic highlight the insufficiency of staff and equipment to meet the needs of all critically ill victims. It is plausible that an entire country could face simultaneous limitations, resulting in severe shortages of critical care resources to the point where patients could no longer receive all of the care that would usually be required and expected. There may even be such resource shortfalls that some patients would not be able to access even the most basic of life-sustaining interventions. Rationing of critical care in this circumstance would be difficult, yet may be unavoidable. Without planning, the provision of care would assuredly be chaotic, inequitable, and unfair. The Task Force for Mass Critical Care Working Group met in Chicago in January 2007 to proactively suggest guidance for allocating scarce critical care resources.

Task Force suggestions: In order to allocate critical care resources when systems are overwhelmed, the Task Force for Mass Critical Care Working Group suggests the following: (1) an equitable triage process utilizing the Sequential Organ Failure Assessment scoring system; (2) the concept of triage by a senior clinician(s) without direct clinical obligation, and a support system to implement and manage the triage process; (3) legal and ethical constructs underpinning the allocation of scarce resources; and (4) a mechanism for rapid revision of the triage process as further disaster experiences, research, planning, and modeling come to light.

Key Words: critical care • disaster • ethics • health-care rationing • health-care worker • palliative medicine • posttraumatic stress • triage