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Crisis Standards
of Care
A Systems Framework for
Catastrophic Disaster Response
Public Engagement
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Crisis Standards of Care
A Systems Framework for Catastrophic Disaster Response
Volume 6: Public Engagement
Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations
Board on Health Sciences Policy
Dan Hanfling, Bruce M. Altevogt, Kristin Viswanathan, and Lawrence O. Gostin, Editors
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Governing Board of the National
Research Council, whose members are drawn from the councils of the National Academy of Sciences, the
National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for
the report were chosen for their special competences and with regard for appropriate balance.
This study was supported by Contract No. HHSP23320042509XI between the National Academy of Sciences
and the Department of Health and Human Services. Any opinions, findings, conclusions, or recommendations
expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations
or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Crisis standards of care : a systems framework for catastrophic disaster
response / Committee on Guidance for Establishing Standards of Care for Use in
Disaster Situations, Board on Health Sciences Policy ; Dan Hanfling ... [et al.], editors.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-25346-8 (hardcover) — ISBN 978-0-309-25347-5 (pdf ) I. Hanfling, Dan.
II. Institute of Medicine (U.S.). Committee on Guidance
for Establishing Standards of Care for Use in Disaster Situations.
[DNLM: 1. Disaster Medicine—standards—United States. 2. Emergency
Medical Services—standards—United States. 3. Emergency Treatment—
standards—United States. WA 295]
363.34—dc23
2012016602
Additional copies of this report are available from the National Academies Press, 500 Fifth Street, NW, Keck 360,
Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu.
Copyright 2012 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since
the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carv-
ing from ancient Greece, now held by the Staatliche Museen in Berlin.
Suggested citation: IOM (Institute of Medicine). 2012. Crisis Standards of Care: A Systems Framework for Cata-
strophic Disaster Response. Washington, DC: The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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cal matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences.
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www.national-academies.org
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COMMITTEE ON GUIDANCE FOR ESTABLISHING STANDARDS OF CARE
FOR USE IN DISASTER SITUATIONS
LAWRENCE O. GOSTIN (Chair), O’Neill Institute for National and Global Health Law, Georgetown
University Law Center, Washington, DC
DAN HANFLING (Vice-Chair), Inova Health System, Falls Church, VA
DAMON T. ARNOLD, Illinois Department of Public Health, Chicago (retired)
STEPHEN V. CANTRILL, Denver Health Medical Center, CO
BROOKE COURTNEY, Food and Drug Administration, Bethesda, MD
ASHA DEVEREAUX, California Thoracic Society, San Francisco, CA
EDWARD J. GABRIEL,* The Walt Disney Company, Burbank, CA
JOHN L. HICK, Hennepin County Medical Center, Minneapolis, MN
JAMES G. HODGE, JR., Center for the Study of Law, Science, and Technology, Arizona State University,
Tempe
DONNA E. LEVIN, Massachusetts Department of Public Health, Boston
MARIANNE MATZO, University of Oklahoma Health Sciences Center, Oklahoma City
CHERYL A. PETERSON, American Nurses Association, Silver Spring, MD
TIA POWELL, Montefiore-Einstein Center for Bioethics, Albert Einstein College of Medicine,
New York, NY
MERRITT SCHREIBER, University of California, Irvine, School of Medicine
UMAIR A. SHAH, Harris County Public Health and Environmental Services, Houston, TX
JOLENE R. WHITNEY, Bureau of Emergency Medical Services (EMS) and Preparedness, Utah
Department of Health, Salt Lake City
Study Staff
BRUCE M. ALTEVOGT, Study Director
ANDREW M. POPE, Director, Board on Health Sciences Policy
CLARE STROUD, Program Officer
LORA TAYLOR, Senior Project Assistant (until January 2012)
ELIZABETH THOMAS, Senior Project Assistant (since February 2012)
KRISTIN VISWANATHAN, Research Associate
RONA BRIER, Editor
BARBARA FAIN, Consultant for Public Engagement
* Resigned from the committee October 2011.
v
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Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and techni-
cal expertise, in accordance with procedures approved by the National Research Council’s Report Review
Committee. The purpose of this independent review is to provide candid and critical comments that will
assist the institution in making its published report as sound as possible and to ensure that the report meets
institutional standards for objectivity, evidence, and responsiveness to the study charge. The review com-
ments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish
to thank the following individuals for their review of this report:
Richard Alcorta, Maryland Institute for Emergency Medical Services Systems
Knox Andress, Louisiana Poison Center
Connie Boatright-Royster, MESH Coalition
Susan Cooper, Tennessee Department of Health
Lance Gable, Wayne State University Center for Law and the Public’s Health
Carol Jacobson, Ohio Hospital Association
Amy Kaji, Harbor-UCLA Medical Center
Jon Krohmer, Department of Homeland Security
Onora Lien, King County Healthcare Coalition
Suzet McKinney, The Tauri Group
Peter Pons, Denver Health Medical Center
Clifford Rees, University of New Mexico School of Law
Linda Scott, Michigan Department of Community Health
Robert Ursano, Uniformed Services University School of Medicine
Lann Wilder, San Francisco General Hospital and Trauma Center
Matthew Wynia, American Medical Association
Although the reviewers listed above have provided many constructive comments and suggestions, they were
not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before
vii
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its release. The review of this report was overseen by Dr. Georges Benjamin, American Public Health Asso-
ciation. Appointed by the Institute of Medicine, he was responsible for making certain that an independent
examination of this report was carried out in accordance with institutional procedures and that all review
comments were carefully considered. Responsibility for the final content of this report rests entirely with the
authoring committee and the institution.
viii REVIEWERS
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Contents
VOLUME 1: INTRODUCTION AND CSC FRAMEWORK
Summary 1-1
1 Introduction 1-15
2 Catastrophic Disaster Response: Creating a Framework for Medical Care Delivery 1-31
3 Legal Issues in Emergencies 1-55
4 Cross-Cutting Themes: Ethics, Palliative Care, and Mental Health 1-71
VOLUME 2: STATE AND LOCAL GOVERNMENT
5 State and Local Governments 2-1
VOLUME 3: EMS
6 Prehospital Care: Emergency Medical Services (EMS) 3-1
VOLUME 4: HOSPITAL
7 Hospitals and Acute Care Facilities 4-1
VOLUME 5: ALTERNATE CARE SYSTEMS
8 Out-of-Hospital and Alternate Care Systems 5-1
ix
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VOLUME 6: PUBLIC ENGAGEMENT
Acronyms ix
9 Public Engagement 6-1
Goals and Benefits of Public Engagement, 6-1
A Model for Public Engagement: Resources for State and Local Authorities, 6-2
Essential Principles of Public Engagement, 6-2
Challenges and Strategies, 6-4
Toolkit Description, 6-9
Conclusion, 6-10
References, 6-11
Sponsor Guidebook, 6-13
Lead Facilitator Guidebook, 6-23
Guidebook for Table Facilitators and Note Takers, 6-63
Introductory Slides, 6-93
VOLUME 7: APPENDIXES 7-1
Appendixes
x CONTENTS
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6-94
“Disaster” Defined
Defined
What do disasters have
i n c o m m o n?
How do disasters differ?
People’s needs exceed available
Some are long-lasting and
resources
widespread (flu pandemic)
Help cannot arrive fast enough
Others are sudden and
geographically limited
(earthquake, terrorist attack)
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Preparing for Disasters: The Challenge
Disasters can lead to shor tages of critical medical resources
Shortages require hard decisions, for example—
Who should be at the front of the line for vaccines or antiviral drugs?
Which patients should receive lifesaving ventilators or blood?
In extreme cases, some people will not receive all of the
treatment they need
How do we give the best care possible under
i
the worst possible circumstances?
6-95
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6-96
Recent
Recent Examples
Hurricane Katrina
Hospital overload
H1N1 Pandemic
Vaccine shortage
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The Response: “Crisis Standards of Care”
Crisis
Guidelines developed before disaster strikes—
To help healthcare providers decide how to administer...
THE BEST POSSIBLE MEDICAL CARE
…when there are not enough resources to give all patients the level
of care they would receive under normal circumstances.
6-97
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6-98
When Might We Need Crisis Standards of Care?
Scarce
Scarce
Extreme Medical
Medical
Crisis
Crisis Resources
Resources
• Hurricane • Blood
• Flu Pandemic • Ventilators
• Earthquake • Drugs
• Bioterrorism • Vaccines
• Staff
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How Are Crisis Standards of Care Different?
Focus of Normal Care
Individual patient
Community
Focus of Crisis Care
6-99
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6-100
Possible Reasons
for Crisis Standards of Care
To make sure that critical resources go to those who will benefit the most
To prevent hoarding and overuse of limited resources
To conserve limited resources so more people can get the care they need
To minimize discrimination against vulnerable groups
So all people can trust that they will have fair access to the best possible
care under the circumstances
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Possible Strategies
to Maximize Care
Space
Put patient beds in hallways, conference
conference
rooms, tents
Use operating rooms only for urgent cases
Supplies
Sterilize and reuse disposable equipment
Limit drugs/vaccines/ventilators to
patients most likely to benefit
Prioritize comfort care for patients who
will die
Staff
Have nurses provide some care that
doctors usually would provide
Have family members help with feeding
and other basic patient tasks
6-101
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6-102
When there isn’t enough to save ever yone…
how should we decide who gets what?
Some options--
1. First-come, first-served?
2. Lottery?
3. Save the most lives possible by giving more care to people
who need it the most?
4. Favor certain groups?
The old OR the young?
Healthcare workers and other emergency responders?
Workers who keep society running (utility workers, transportation
workers, etc.)?
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Where Do You Come In?
Community Conversations help policy makers:
Understand community concerns about the use of limited
medical resources during disasters
Develop crisis standards of care guidelines that reflect
community values and priorities
6-103
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6-104
Community
Community Informing
the
Community Emergency
Recovery Public
Preparedness Operations
Mass Care
Fatality Management Detection
Sharing Info
Preparing for
Non-Medical Aid
CSC
Disaster
Get Medical
Get Medical
Get Medication
Equipment to
Crisis Standards of to the Public
the Public
Care (“CSC”)---
a pi e c e o f t h e pu z z l e
Palliative Care Manage Volunteers
Protect
Lab Testing
Responders
