A very large nuclear war would be a calamity of indescribable proportions and absolutely unpredictable consequences, with the uncertainties tending toward the worse. All-out nuclear war would mean the destruction of contemporary civilization, throw man back centuries, cause the deaths of hundreds of millions or billions of people, and, with a certain degree of probability, would cause man to be destroyed as a biological species.
Apocalyptic predictions require, to be taken seriously, higher standards of evidence than do assertions on other matters where the stakes are not as great. Since the immediate effects of even a single thermonuclear weapon explosion are so devastating, it is natural to assume-even without considering detailed mechanisms-that the more or less simultaneous explosion of ten thousand such weapons all over the Northern Hemisphere might have unpredictable and catastrophic consequences.
And yet, while it is widely accepted that a full nuclear war might mean the end of civilization at least in the Northern Hemisphere, claims that nuclear war might imply a reversion of the human population to prehistoric levels, or even the extinction of the human species, have, among some policymakers at least, been dismissed as alarmist or, worse, irrelevant.
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Subscribe Magazine Newsletter. Login Sign up Search. Throughout the report, the committee emphasized the need for states to develop and implement consistent crisis standards of care protocols both within the state and through work with neighboring states, in collaboration with their partners in the public and private sectors. It also hoped that by suggesting a uniform approach, consistency will develop across geographic and political boundaries so that the guidance will be useful in contributing to a single, national framework for responding to crises in a fair, equitable, and transparent manner.
State departments of health, and other relevant state agencies, in partnership with localities should develop crisis standards of care protocols that include the key elements—and associated components—detailed in this report:.
Francis X. McCarthy (Author of Considerations for a Catastrophic Declaration)
The report also contains guidance to assist state public health authorities in developing these crisis standards of care. This guidance includes criteria for determining when crisis standards of care should be implemented, key elements that should be included in the crisis standards of care protocols, and criteria for determining when these standards of care should be implemented. The five key elements that should be included in crisis standards of care protocols, along with associated components, are summarized in Table B These steps include the following:.
An ethical framework serves as the bedrock for public policy and cannot be added as an afterthought. In addition, ethically and clinically sound planning will aim to secure fair and equitable resources and protections for vulnerable groups. The committee concluded that core ethical precepts in medicine permit some actions during crisis situations that would not be acceptable under ordinary circumstances, such as implementing resource allocation protocols that could preclude the use of certain resources on some patients when others would derive greater benefit from them.
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But even here, it is the situation that changes during disasters, not ethical standards per se. The context of a disaster may make certain resources unavailable for some or even all patients, but it does not provide license to act without regard to professional or legal standards. Healthcare professionals are obligated always to provide the best care they reasonably can to each patient in their care, including during crises. When resource scarcity reaches catastrophic levels, clinicians are ethically justified—and indeed are ethically obligated—to use the available resources to sustain life and well-being to the greatest extent possible.
As a result, the committee concluded that ethics permits clinicians to allocate scarce resources so as to provide necessary and available treatments preferentially to those patients most likely to benefit when operating under crisis standards of care. However, operating under crisis standards of care does not permit clinicians to ignore professional norms nor to act without ethical standards or accountability.
When crisis standards of care prevail, as when ordinary standards are in effect, healthcare practitioners must adhere to ethical norms. Conditions of overwhelming scarcity limit autonomous choices for both patients and practitioners regarding the allocation of scarce healthcare resources, but do not permit actions that violate ethical norms. The committee strongly recommended extensive engagement with community and provider stakeholders.
Such public engagement is necessary not only to ensure the legitimacy of the process and standards, but more importantly to achieve the best possible result. The letter report discusses considerations for engaging with community and provider stakeholders prior to the event, during the event, and after the event. The report also notes that although there are likely to be substantive population-level mental health risks from a mass casualty public health emergency that requires crisis standards of care, there is also an opportunity to promote resilience at the individual and population levels to mitigate these risks.
Thus it is important to develop a national platform to support resilience that can customized by communities at the local level. The report also emphasizes that building trust is particularly important in more vulnerable populations, including those with preexisting health inequities and those with unique needs related to race, ethnicity, culture, immigration, limited English proficiency, and lower socioeconomic status.
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State, local, and tribal governments should partner with and work to ensure strong public engagement of community and provider stakeholders, with particular attention given to the needs of vulnerable populations and those with medical special needs, in:. The letter report also addressed issues related to the implementation of crisis standards of care, including legal considerations. Questions of legal empowerment of various actions to protect individual and communal health are pervasive and complicated by interjurisdictional inconsistencies.
In disaster situations, tribal or state governments should authorize appropriate agencies to institute crisis standards of care in affected areas, adjust scopes of practice for licensed or certified healthcare practitioners, and alter licensure and credentialing practices as needed in declared emergencies to create incentives to provide care needed for the health of individuals and the public. Disasters will have varying impacts on communities, based on many different variables that might affect the delivery of health care during such events.
Conventional patient care uses usual resources to deliver health and medical care that conforms to the expected standards of care of the community. The delivery of care in the setting of contingency surge response seeks to provide patient care that remains functionally equivalent to conventional care. Contingency care adapts available patient care spaces, staff, and supplies as part of the response to a surge in demand for services. Although this may introduce minor risk to the patient compared to usual care e. Crisis care, however, occurs under conditions in which usual safeguards are no longer possible.
Crisis care is provided when available resources are insufficient to meet usual care standards, thus providing a transition point to implementing crisis standards of care.
U.S. Food and Drug Administration
Continuum of incident care and implications for standards of care. The goal for the health system is to increase the ability to stay in conventional and contingency categories through preparedness and anticipation of resource needs prior to serious shortages, and to return as quickly as possible from crisis back across the continuum to conventional care Tables B-2 and B In major disaster and emergencies, there will also be a surge of psychological casualties among those directly affected, including responders, healthcare practitioners, and members of the population who have not experienced direct impact.
Mass psychological casualties and morbidity will occur in those who experience an aggravation of a prior or concurrent mental health condition. New substantial burdens of clinical disorders, including posttraumatic stress disorder, depression, and substance abuse may also arise among those with no prior history. Even in those with no formal disorder, there may be significant distress at a population level, resulting in unparalleled demands on the mental health system.
Therefore, it is necessary to use a mass casualty disaster mental health concept of operations in order to enable a crisis standard of disaster mental health care through the use of currently available, evidence-based mental health rapid triage and incident management systems. Additional details can be found in the complete letter report. Acknowledging that a patient is not likely to survive typically leads to discussions regarding the goals of care, appropriateness of interventions, and efforts to help the patient and family begin to say good-bye Matzo, Prognostication, aided by a risk index or scale, enables healthcare practitioners to plan clinical strategies during a crisis situation.
Palliative Care Triage Tools. Flacker Mortality Score: Flacker and Kiely developed a model for identifying factors associated with one-year mortality the probability of death within the next year by conducting a retrospective cohort study using Minimum more Resources that are likely to be scarce in a crisis care environment and may justify specific planning and tracking include the following:. Get free access to newly published articles Create a personal account or sign in to: Register for email alerts with links to free full-text articles Access PDFs of free articles Manage your interests Save searches and receive search alerts.
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