Public Health Emergency Preparedness

Chapter 7 (continued)

Palliative Care Is a New Component of MCE Planning

Given that the issue of planning for palliative care during a mass casualty event (MCE) is a new component of disaster planning, both professional and layperson education is necessary and likely will take some time and persistence on the part of community planners. It may be appropriate to target retired health care professionals and volunteers for training. Both generic in-advance training and "just-in-time" curricula will need to be developed.

• Train all first responders to use oral and injectible morphine to manage pain and symptoms until licensed personnel are available to manage these symptoms. These medications should be stockpiled in the community as part of basic disaster planning, and the ways to locate and access it should be part of emergency response training.
• Provide personal protection and individual response training that first responders ordinarily receive to lay or professional individuals designated as responsible for providing care to those expected to die.
• Provide community and family member education regarding individual response actions and personal protection under various disaster scenarios or MCEs. Specifically, people will need to know how to protect themselves from contamination while still palliating symptoms for dying patients.
• Ensure that all first responders serving those who are expected to die soon know:
  • How to access the medication stockpile.
  • The basics of psychosocial counseling and support for peer-to-peer support and provider/patient services in MCE scenarios.

Recruitment of Professional Providers and Lay Volunteers

With planning, a community could develop a reasonable reserve capacity for serving those who will live a short time before dying from a disaster. Palliative care, home health care, and long-term care professionals have valuable skills, but they are seldom called on for planning or for response during and after large-scale emergencies and disasters. Retired health care professionals often do not have a current skill set to be optimally useful in hospital settings, but their skills could be readily sufficient for medication and assessment in palliative care settings.

Furthermore, volunteering to help the dying has a long tradition among older persons and faith-based organizations.

Palliative care and long-term care professionals, retired health care professionals, and lay volunteers could be recruited and trained in their "defined roles" in disaster events in advance. Local palliative assistance teams could be recruited from a variety of practice settings (hospices, hospitals, long-term care, etc.) and disciplines (physicians, nurses, social workers, chaplains, etc.). These teams could be developed locally, potentially in conjunction with the Medical Reserve Corps (MRC). Potential groups that might serve as sponsors of these teams include senior centers, churches and synagogues, hospices, long-term care providers, nurses' organizations, senior organizations such as American Association of Retired Persons (AARP), the National Hospice and Palliative Care Organization, and the American Academy of Hospice and Palliative Medicine as well as local hospitals, hospices, and palliative care programs.

These teams would be deployed to the site of an MCE, would assist with triaging victims as needed, and then would provide palliative care to patients deemed to be expectant (black tag) or in critical need of pain and symptom management. These rapid response teams would supplement, not replace, local palliative care services.

Recommended actions include the following:

• Create specialized rapid response teams made up of palliative care professionals and lay volunteers recruited and trained to serve as local, statewide, and regional providers.
• Consider incorporating these teams under the MRC, and the Community Response Team for deployment depending on the nature and scope of an incident.
• Consider extending the credentialing of palliative care disaster volunteers into the existing disaster response Federal/State and local legal/insurance systems in order to expand community capacity through such mechanisms as the Emergency Systems for Advance Registration of Volunteer Healthcare Personnel (go to Chapter 5 and Chapter 6).
• Develop central registries of local health care providers and lay volunteers in the community who can be called on in the event of a disaster. Recruit these volunteers and providers into emergency response teams. Barriers to implementing these recommendations include identifying sponsors and funding. In addition, it may be that some of the people who are dedicated to providing palliative care services in normal times may be unwilling to take on these roles under dire circumstances of a catastrophic MCE.

Mental Health and Spiritual Care Services

Dying, suffering, and death quite reasonably incite strong emotions and responses in patients, family members, professional caregivers, and bystanders. Reactions to disasters or MCEs will vary, and stress reactions can occur immediately following the disaster or many months later. In addition, because the medical community are the primary first responders in a catastrophic event or natural disaster, a broad-based mental health and counseling educational and service delivery plan (determined by the community that it will serve) for this group is essential. Local mental health providers, such as psychologists, chaplains, and health care providers, are a vital resource not only for the provision of palliative care services to mass casualties but also for the psychosocial support services that they can provide to the response providers. As the volume of patients triaged to palliative care expands, so will the strain of providing mass palliative care. These individuals also will need to have periodic emotional and psychological relief (e.g., by having them rotate to teams that are doing other types of work, such as delivering food); this would be important for the welfare and morale of the provider corps as a whole.

A number of behavioral, psychological, and spiritual response plans have been developed and should serve as the basis for the planning and delivery of these services in an MCE.

Resources for Planners Standing Together: An Emergency Planning Guide for America's Communities. Joint Commission on Accreditation of Healthcare Organizations; 2005. Preparing for the Psychological Consequences of Terrorism: A Public Health Strategy. Institute of Medicine; 2003. Mental Health All-Hazards Disaster Planning Guidance (HHS Pub. No. SMA3839) and Mental Health Response to Mass Violence and Terrorism: A Training Manual (HHS Pub. No. SMA 3959). Both available at http://nmhicstore.samhsa.gov/publications/browse.asp. Accessed November 28, 2006.

While many individuals will die outright as a result of an MCE, there may be many more that are imminently dying or expected to die, in both the short and long terms. In times of crisis, many people look to clergy and other religious leaders for guidance. Spiritual counseling and support regarding the effects of the event should be made available to those not expected to survive and their families, as well as those expected to survive.

The potential post-traumatic stress and long-term psychological impacts of such disasters should be anticipated for those who are likely to survive and those experiencing the event but unharmed over the long term. Recommended actions include ensuring that response planning and activities include mental health and spiritual care services, especially for those not expected to survive and the first responders and health care professionals serving these populations. Mental health professionals and laypeople with training as well as pastoral and spiritual caregivers should be recruited and integrated into current disaster planning and response. Reluctance to integrate these nontraditional initial response professionals into catastrophic MCE planning and response could pose a barrier.

Communications and Chain of Command

Local and State leaders will have a great deal of influence over the individuals and community's expectations, understanding, and responses to an MCE. The management of the acute situation sets the tone for the ways society will respond. The accurate portrayal of ongoing efforts and successful forecasting of predictable events will enhance the credibility of authorities and diminish negative outcomes such as panic and chaos.

Two principal goals of communications in disaster events are:

1. To establish and maintain a common operating picture.
2. To ensure accessibility and interoperability across jurisdictions and functional agencies.

Establishing the role of communication in the integration of palliative care services in an MCE requires understanding how communications are transmitted and planning for alternative and backup communications and links.

Recommended actions include:

• Integrating information about service capacity in long-term care, home care, and hospice care and these professionals and laypersons into public education and disaster response training and activities.
• Ensuring ways to communicate the need to transfer persons needing palliative care to designated alternative care sites (ACSs) as well as to transfer revised classification patients from palliative care treatment sites.
• Ensuring ways for authorities to direct community members to palliative sites.

Planners should be aware that under the dire circumstances of a catastrophic MCE, training first responders either to classify as not expected to survive or to reclassify as expected to survive will not be an easy task. In addition, there will need to be clear lines of authority and responsibility for transfer to palliative care treatment sites.

Management of the Dead

Recommended actions include the following:

• Pay attention to and be respectful of varying religious beliefs and approaches to body management.
• Do all that is possible to document the identity of the dead and the disposition of the body, for the benefit of the survivors. Deciding how to manage the dead has profound and long-lasting consequences for survivors and communities and is one of the most difficult features of disaster management. Immediately after a major disaster, the identification and disposal of human remains is typically handled by the local community.

The remains typically pose no immediate health risk in the case of a natural disaster but may pose considerable risk in the case of an epidemic.

• Address issues such as the supply of body bags, refrigerator trucks, ways to catalog bodies, and cremation with local funeral directors prior to an MCE. Communities may decide to purchase and stockpile body bags.
• Includethe disaster mortuary operational response team (go to box below), public health planners, funeral directors, and medical examiners in disaster planning and drills.

Disaster Mortuary Operational Response Teams (DMORTs) DMORTs are composed of private citizens, each with a particular expertise, who are activated in the event of a disaster to deal with the myriad issues of victim identification and mortuary services. During an emergency response, DMORTs work under the guidance of local authorities, providing technical assistance and personnel to recover, identify, and process deceased victims.

Discussions With Key Informants Given the fact that palliative care issues in the context of an MCE have not benefited from substantial prior work, the authors conducted telephone discussions with a sample of key informants from the fields of disaster planning and palliative care regarding the relevant issues and requirements for palliative care under a catastrophic MCE. General domains experts were asked to discuss: How should decision guidelines for who receives this care be delivered? How do we handle large numbers of people expected to die and those already very sick or disabled? What services/equipment/providers should be available? How should we use (or reuse) common supplies and equipment (e.g., gloves, gowns)? What skills, materials, and memoranda of understanding are needed to shelter and/or evacuate people with supportive/palliative care needs? What criteria would you suggest to allocate scarce and highly specialized clinical resources concerning supportive/palliative resources in the two scenarios? What differences and similarities are there in the general considerations for the delivery of supportive/palliative care in an MCE such as bioterrorism and pandemic 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 at the State and local levels? Do you perceive a need for evacuation decisions for the supportive/palliative populations? What are the vital skills for first responders to have? How to maintain infection control and safe care environment? 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 their bodies? What are the clinical algorithms to make decisions regarding allocation of scarce resources? What are the protocols for those who we need to help die comfortably? What role does euthanasia play in disaster planning in supportive/palliative care? How do you communicate these tough decisions to the public?

Issues Related to Palliative Care in the Context of an MCE All disaster planning and response should include plans for patients who will be unlikely to survive under catastrophic circumstances (e.g., events with mass casualties and/or long-term scarce resources), those already living with short prognosis in the community (since their existing services will be disrupted by the event), and those newly dying as a result of the event. Most skilled professionals who usually serve those with fatal chronic illness may be diverted to active treatment settings to treat the medically salvageable, so first responders, less well-trained health care personnel, and potentially laypersons may have to fill in to care for the dying. Health care personnel who are skilled in the principles of palliative care, long-term care, and hospice need to be involved in disaster response planning. Specific palliative care supplies; disaster preparedness equipment; and health, mental health, and social service personnel (including volunteer laypersons) must be available and trained to use supplies such as narcotics and psychoactive drugs, dressings and splints, supportive surfaces, antipyretics or steroids, anti-infectives, and PPE. Palliative care should be integrated into the case mix of ACSs or special locations: "palliative care" treatment sites should be established to treat those not expected to survive. "First responders" and transport personnel should be trained in appropriate triage of patients so that palliative care patients do not overwhelm acute care hospitals. The patients designated as "too sick to survive" initially should have their pain or other symptoms managed at the scene of the event and then should be transported to an ACS for continued palliative care services when transportation becomes available. Locations ordinarily used to care for persons with eventually fatal chronic illnesses (e.g., nursing facilities, home health agencies) need to be ready to handle more severe complications. Plans should address the prospect of not transferring patients needing ventilator support if they are too sick to survive but prepared to provide appropriate palliative care services. Preplanning for the provision of palliative care following a catastrophic event should not be seen as euthanasia or a cause of wrongful death. Managing the ethics interface requires thoughtful training, peer support, and extensive public education. Long-term care providers and palliative care experts are encouraged to become part of all disaster planning and response activities. The challenges of serving people who are frail or in need of palliative care prior to the disaster event should be addressed. At a minimum, this would include establishing a way to find and identify them. There must be an honest recognition of death; this will be particularly difficult for certain groups such as children.

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