Ethics in a Pandemic

Laura Webster, DBE, RN, HEC-C, CEN; Lucia D. Wocial, PhD, RN, FAAN, HEC-C


Am Nurs Journal. 2020;15(9) 

In This Article

Disaster Planning

In 2009, the Institute of Medicine, motivated by a looming H1N1 pandemic, created a toolkit to guide disaster planning. The toolkit includes definitions for conventional, contingency, and crisis states with strategies for each state when communities are faced with a patient surge.

In our normal state, conventional, we can handle a surge of up to 120% of our normal intensive care unit (ICU) patients. To handle this minor surge, we may call in extra staff and conserve or substitute resources. When a larger surge of ICU patients (up to 200% of normal volume) occurs, we use contingency standards and begin to adapt and reuse. In contingency, the spaces, staff, and supplies used aren't consistent with daily practices, but they support care that's functionally equivalent to usual patient care practices. All of these efforts aim to avoid crisis. If crisis is reached, we must allocate and reallocate dwindling critical care resources with life-and-death consequences. (See Standards of care: Conventional to crisis.)

Many U.S. states have developed and made publicly available guidelines for crisis standards of care. Two main goals frame all disaster planning: Do everything to avoid a crisis state and, if those efforts fail, work to fairly save the greatest number of lives possible. Leaders will continue to refine plans, although no amount of planning can account for all that an emergency may bring. Leaders must, however, consider how to manage a surge.

Surge Strategies

In the midst of the COVID-19 pandemic, many parts of the country are operating under contingency standards, and some organizations may be closer to crisis than others. For example, personal protective equipment (PPE) appears to be at or near crisis standards in many locations, with those in healthcare being asked to adapt and reuse PPE in ways normally considered unacceptable. Based on the best information available in a rapidly changing environment, we're addressing resource shortages by conserving, substituting, adapting, reusing, and reallocating PPE and other supplies. (See Scarce resource allocation.)

Surge Collaboration

Cities, counties, and states are collaborating to meet surge needs. For example, patients who arrive at a hospital lacking resources will be transferred to one that has what's needed, or the resources will be redistributed to the hospital in need until all hospitals are at or near capacity. The decision to move to crisis standards of care is made by an institution, region, and/or state. For example, a state might declare a crisis at the state level, yet allow each hospital to determine whether it is at crisis. These types of decisions are made at the incident command level. Incident command varies by location; for instance, the person in charge could be a state health officer or a local hospital administrator.