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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Suggested Citation:"Front Matter." Institute of Medicine. 2009. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. Washington, DC: The National Academies Press. doi: 10.17226/12749.
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Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations A Letter Report Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations Board on Health Sciences Policy Bruce M. Altevogt, Clare Stroud, Sarah L. Hanson, Dan Hanfling, and Lawrence O. Gostin, Editors

THE NATIONAL ACADEMIES PRESS • 500 Fifth Street, N.W. • Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Gov- erning 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 re- sponsible for the report were chosen for their special competences and with re- gard for appropriate balance. This study was requested by the Office of the Assistant Secretary for Prepared- ness and Response, Department of Health and Human Services, and supported by Contract No. HHSP23320042509XI between the National Academy of Sci- ences and the Department of Health and Human Services. Any opinions, find- ings, 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. International Standard Book Number-13: 978-0-309-14430-8 International Standard Book Number-11: 0-309-14430-2 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624- 6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2009 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Suggested citation: IOM (Institute of Medicine). 2009. Guidance for establish- ing crisis standards of care for use in disaster situations: A letter report. Wash- ington, DC: The National Academies Press.

The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal gov- ernment on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of out- standing engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engi- neering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

COMMITTEE ON GUIDANCE FOR ESTABLISHING STANDARDS OF CARE FOR USE IN DISASTER SITUATIONS LAWRENCE O. GOSTIN (Chair), Georgetown University Law Center DAN HANFLING (Vice Chair), Inova Health System DAMON T. ARNOLD, Department of Public Health, Illinois STEPHEN V. CANTRILL, Denver Health Medical Center BROOKE COURTNEY, Center for Biosecurity of the University of Pittsburgh Medical Center ASHA DEVEREAUX, Sharp Coronado Hospital, CA EDWARD J. GABRIEL, The Walt Disney Company JOHN L. HICK, Hennepin County Medical Center JAMES G. HODGE, JR., Sandra Day O’Connor College of Law at Arizona State University DONNA E. LEVIN, Massachusetts Department of Public Health MARIANNE MATZO, University of Oklahoma College of Nursing CHERYL A. PETERSON, American Nurses Association TIA POWELL, Montefiore-Einstein Center for Bioethics, Bronx MERRITT SCHREIBER, UCLA Center for Public Health and Disasters UMAIR A. SHAH, Harris County Public Health and Environmental Service, Houston, TX Study Staff BRUCE M. ALTEVOGT, Study Director CATHARYN T. LIVERMAN, Scholar ANDREW M. POPE, Director, Board on Health Sciences Policy SARAH L. HANSON, Associate Program Officer CLARE STROUD, Associate Program Officer JON SANDERS, Program Associate v

Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical 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 pub- lished report as sound as possible and to ensure that the report meets in- stitutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confi- dential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Frederick M. Burkle Jr., University of Hawaii Kristine M. Gebbie, Hunter College City University, New York Steven Gravely, Troutman Sanders, LLP Sharona Hoffman, Case Western Reserve University Lisa Kaplowitz, Virginia Department of Health Gabor D. Kelen, Johns Hopkins University School of Medicine Nancie McAnaugh, Missouri Department of Health and Services Leslee Stein-Spencer, National Association of State EMS Officials Matthew K. Wynia, American Medical Association Although the reviewers listed above have provided many construc- tive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was over- seen by Bernard Lo, University of California, San Francisco and vii

viii REVIEWERS Georges Benjamin, American Public Health Association. Appointed by the National Research Council and Institute of Medicine, they were re- sponsible for making certain that an independent examination of this re- port 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.

Contents BACKGROUND 10 2009 nH1N1 Influenza Pandemic and Other Public Health Emergencies and Disasters, 12 Scarce Resources, Demand for Healthcare Services, and Standards of Care, 13 State and Local Policies and Protocols, 15 METHODS 16 CRISIS STANDARDS OF CARE: THE VISION 17 Five Key Elements Of Crisis Standards Of Care Protocols, 19 DEVELOPING CRISIS STANDARDS OF CARE PROTOCOLS: A STATE PUBLIC HEALTH AUTHORITY PROCESS 23 ETHICAL FRAMEWORK 27 Ethical Norms, 28 Ethical Process, 31 Applying the Ethics Framework: Ventilator Allocation, 33 ix

x CONTENTS COMMUNITY AND PROVIDER ENGAGEMENT, EDUCATION, AND COMMUNICATION 36 Preincident Community Engagement, 38 Community Engagement to Improve Resiliency, 41 Improving Trust with Vulnerable Populations, 42 LEGAL ISSUES IN EMERGENCIES 44 Distinguishing Medical and Legal Standards of Care and Scope of Practice, 44 The Changing Legal Environment During Declared Emergencies, 46 OPERATIONAL IMPLEMENTATION OF CRISIS STANDARDS OF CARE 51 Clinical Care in Disasters, 51 Disaster Mental Health Crisis Standards of Care, 56 Palliative Care Planning for Crisis Standards of Care, 57 Crisis Standards of Care Indicators, 60 Crisis Standards of Care Implementation Criteria, 65 Crisis Standards of Care Triage, 65 Pre-Requisite Commend, Control, and Coordination Elements, 68 Crisis Standards of Care Operations, 75 Decision Tools and Resource Use Guidance, 81 CONCLUSION 90 APPENDIXES A References 93 B Glossary 111 C Crisis Standards of Care Implementation Guidance Scenarios 119 D Workshop Agenda 133 E Committee Biographical Information 141

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The influenza pandemic caused by the 2009 H1N1 virus underscores the immediate and critical need to prepare for a public health emergency in which thousands, tens of thousands, or even hundreds of thousands of people suddenly seek and require medical care in communities across the United States.

Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations draws from a broad spectrum of expertise--including state and local public health, emergency medicine and response, primary care, nursing, palliative care, ethics, the law, behavioral health, and risk communication--to offer guidance toward establishing standards of care that should apply to disaster situations, both naturally occurring and man-made, under conditions in which resources are scarce.

This book explores two case studies that illustrate the application of the guidance and principles laid out in the report. One scenario focuses on a gradual-onset pandemic flu. The other scenario focuses on an earthquake and the particular issues that would arise during a no-notice event.

Outlining current concepts and offering guidance, this book will prove an asset to state and local public health officials, health care facilities, and professionals in the development of systematic and comprehensive policies and protocols for standards of care in disasters when resources are scarce. In addition, the extensive operations section of the book provides guidance to clinicians, health care institutions, and state and local public health officials for how crisis standards of care should be implemented in a disaster situation.

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