Caring for patients during a disaster

To continue our conversation about the management of dying patients in the setting of a mass casualty event, I want to turn to how we might care for these patients.

Consider the strain that a sudden bolus of hundreds of thousands of patients would place on the medical system. Many of these patients would be triaged to palliative care immediately and asked to stay at home. Many of these patients would present to the hospital where, because of advanced illness or limited resources, they would be triaged to palliative care. With local communities faced with caring for hundreds or thousands of dying patients, our panel recommended a “surge-in-place” strategy of utilizing available space in current hospitals to care for the dying. We imagined classrooms, cafeterias, auditoriums or other available spaces where cots could be placed to set up emergency “palliative care units” for the dying. Staffing would be limited but health care providers could float among the beds administering care and symptom-relieving medications to many patients. Local volunteers and clergy would be vital to assist in caring for the emotional state of these patients and families. The image this conjures is frightening. And yet, to not have a plan for dealing with the dying is a more frightening reality.

In Hurricane Katrina, we saw that during a disaster many of the already ill and acutely ill will not survive the change in conditions. In the Superdome in New Orleans, which housed approximately 23,000 refugees, a reported 10 citizens died; nearly 1,000 people died in New Orleans in total in the storm or aftermath. Bodies of the dead in the Superdome were placed into stairwells or left where they sat. Several medical doctors and their staff are facing criminal and civil charges stemming from charges they euthanized dying patients in the aftermath of Hurricane Katrina. In Wisconsin, we are hopeful that creating a plan for dealing with the dying in a disaster will both improve conditions for those patients and provide protections for the providers caring for the dying.

We are developing a stop-gap system, which will try and keep palliative care patients at home while providing their families access to symptom-relieving medications: opioids and benzodiazepines. We will maintain a virtual stockpile of these medications, which may be distributed to communities in the event of a disaster. We are also creating very simple and clear instruction sheets for families so they know when and how to administer these symptom medications. We intend to use existing hospice and home health organizations in the local community as a phone resource for patients and families who are unable to manage on their own.

We are early in the planning process, but it has been very intellectually challenging and I thought worthy of sharing for others to consider their state’s plans.