Addressing the Need, Ethical Decision Making in Disasters, Who Comes First?

Disasters exhaust resources, complicate care, and force a level of decision-making that is outside the usual framework of medical care providers. A group of experts was convened to discuss and explore the ethical decision-making that takes place during a disaster. 37 professionals from the fields of emergency medicine, emergency planning, emergency services, clinical ethics, public health, palliative care and various clinical disciplines were tasked with ethical decision-making in a disaster. They were divided into three breakout groups and presented with a detailed drill scenario involving mass casualties following an explosion and partial building collapse with several victims presenting simultaneously in the Emergency Department with similar severe injuries and were tasked with deciding which patient would be treated first. The groups considered various principles in establishing the triage approach for the scenario patients which included "social value", and first come first served but ultimately, they triaged the patients based primarily on their clinical presentations and likely prognosis, followed by age and professional affiliations in the case of similar medical conditions and had similar outcomes. The groups also agreed that the presence of palliative care in the setting of disaster, as well as, including community leaders in disaster planning would be of critical assistance. A senior physician should be assigned as a primary decision maker and leader in a mass casualty incident. Participation of a palliative care teams during crisis and disaster situations would expand the options of care and help the family feel more comfortable with difficult decisions regarding limiting care for their loved ones. Community involvement prior to disaster was strongly recommended to help communication and trust between community and practitioners and to also assign point people.