The potential for an unprecedented influenza pandemic and the lessons learned from the recent outbreaks of severe acute respiratory syndrome and the novel influenza A (H1N1) virus challenge nursing leaders to consider the current limited capacity to provide critical care services for large numbers of victims of infectious pandemic events. Experts predict the potential for a rapid exhaustion of critical care services, resulting in a dangerous scarcity of resources such as critical care beds and mechanical ventilation devices. Of additional concern is the potential for the death toll to be inversely proportional to the ability to increase critical care capacity.1 As a consequence, a triage process will be required to guide and prioritize access to scarce critical care resources and ensure allocation to those individuals who are most likely to benefit.1-5

The Importance to Nursing Leaders

The importance of the issue to nursing leaders is underscored by the findings of predictive impact models, such as that developed for the Ontario healthcare system. It is anticipated that at the height a pandemic, the demand for critical care beds for influenza victims will peak at 171% of current capacity, whereas the demand for mechanical ventilators will exceed 118% of current capacity. These numbers do not take into account the current demand for these resources, which is often at 100%.2 Clearly, current surge processes will be insufficient to meet the overwhelming demands on critical care resources.

Projection figures such as these forecast the need for nursing leaders at all levels to address difficult issues such as withholding or withdrawing care or the need for premature discharge of patients from the critical care unit (CCU) to make room for pandemic victims who are competing for scarce resources. These processes, often referred to as "lifeboat ethics," have the potential to put leaders and providers at risk for accusations of malpractice, euthanization, or practicing outside of what is considered a medically prudent manner.4-6

Further, the projections challenge nursing leaders and disaster planners to recognize that a system of resource allocation must be developed in advance of the disaster to ensure an ethical, just, and legal distribution of scarce resources while protecting against racial, ethnic, socioeconomic, or other forms of inequity.4

Review of the Evidence

The current body of literature addressing the issue of the allocation of critical care resources during a pandemic event is primarily nonresearch evidence from the disciplines of medical ethics, medicine, public health, and the law. A preponderance of literature is in the form of written advice of experts and descriptions of the processes used to develop critical care resource allocation triage protocols.7,8 Limitations to the quality of these sources of nonresearch evidence include difficulty in discerning the expertise and credibility of some experts, poorly defined methods for protocol development, and inconsistent recommendations.9 An additional major limitation to the protocol development literature is that no attempt has been made to validate the protocol for use on the population of interest, critically ill victims of pandemic influenza.1,4,5

A paucity of scientific research evidence exists to inform the practice of nurse leaders. A thorough search of the literature revealed a complete lack of experimental or quasi-experimental research designs. It is important to note, however, that ethical or logistic issues related to the topic could prove to be a challenge to the use of these high-level research designs. Only one well-designed research study was identified that used an analysis of prospective data to identify and validate a triage protocol for the allocation of scarce critical care resources.4 This study had a significant limitation, however, in that the sample consisted of patients admitted to the emergency department with a diagnosis of suspected infection who were meant to serve as surrogates for pandemic influenza victims. Consequently, the generalizability of the findings is limited.

Challenges for Nursing Leaders

Professional Responsibility

Nursing leaders have the professional responsibility to participate in the planning for the allocation of scarce critical care resources. To effectively participate, leaders must become educated in national and local surveillance practices, become familiar with local and regional pandemic plans, and collaborate with disaster experts, professional societies, and others to develop expertise in emergency planning and response activities.8,10

Development and Validation of Triage Protocols

The literature supports the importance of planning, developing, disseminating, testing, validating, and adopting critical care triage protocols prior to the pandemic event.2-6 The nursing leader will play a key role in the development and validation of evidence-based, empirical, data-driven clinical criteria for allocation of scarce critical care resources. These criteria will address predictors of patient survivability, identification of those at least risk for a deleterious event because of a premature discharge from the CCU, and inclusion, exclusion, and prioritization criteria for critical care admission and/or mechanical ventilator use.2,4,5 Nursing leaders must collaborate with disaster planners, who may or may not have critical care or healthcare expertise, and those of other disciplines to ensure that the triage plan augments current critical care practices, has clinical utility, and is accepted by the healthcare professionals who must implement and enforce the plan.10 In addition, the call for the adoption and implementation of standardized regional or statewide triage plans rather than organization-based plans mandates the need for collaboration with others at the federal, state, and local levels.3,10

Ethical Impact

Because science alone will be inadequate to support decision making, nursing leaders will be required to clearly and convincingly articulate the ethical underpinnings for resource allocation and triage decisions. The use of sound critical thinking skills and ethical reflection will be required to reconcile the dissonance between the current egalitarian principles of equal right of access to critical care resources and the disaster-driven ethical principles of utilitarianism that mandates the greatest good for the greatest number and proportionality, which addresses the competition for access between victims of disaster and those who are already using the resources.3,5,7

Alternate Models and Standards of Care

Clearly, the enormity of the pandemic event, the scarcity of resources, and the paradigm shift in the ethical underpinnings of critical care triage and resource allocation will mandate the development of alternate models and standards of care. Nursing leaders will collaborate with other disciplines to develop standards of sufficient care that are defined by a limited group of key critical care interventions that will be offered to all.5 These altered standards will be used to address issues such as futility versus benefit, minimum criteria for survival, and the maximum amount of resources that can be used on any one individual. Equally important, leaders will be charged with the development of palliative care processes that will be offered to those who are refused or removed from access to critical care resources.2,4,5

Communication and Collaboration

Nursing leaders will be required to use the most effective collaboration and crisis communication skills at the national, regional, state, and community levels. Political leaders and public health officials, rather than medical professionals, will be the drivers of decision making and policy development during pandemic preparation.10 Consequently, nursing leaders are advised to develop collaborative relationships with elected officials and policy makers and clearly communicate to them the role of critical care during disaster events. Skilled communication and collaboration will be equally important when dealing with other healthcare providers and the lay public. In advance of the pandemic, triage processes and altered standards of care must be clearly communicated and made transparent to stakeholders to prevent the development of misunderstandings, mistrust, charges of breach of obligation, or sabotage of implementation processes.1,5,6,10

Education, Training, and Testing

The adoption of new processes for critical care triage and resource allocation will require nursing leaders to be involved in stakeholder training, rehearsal, and testing.5 Training and evaluation exercises such as pandemic tabletop exercises or large-scale drills will provide important feedback on the need for additional training or the revision of triage processes. Similarly, nursing leaders will be required to collaborate with other disciplines at the local, statewide, regional, and federal levels to design education curricula and competency testing for healthcare and emergency providers. Finally, leaders will provide significant support for laypersons in the community through the development and dissemination of public awareness and education materials prior to the pandemic event.

Conclusion

Nursing leaders will play a significant role in the planning and implementation of processes for scarce critical care resource allocation during a pandemic event. There is a significant need, therefore, for high-quality research and nonresearch evidence to inform practice. Further, research and dialogue should focus on the validation of proposed triage processes and the evaluation of altered standards and models of care. Finally, there is a need for ongoing research and discussion to address issues such as professional responsibility, crisis communication and collaboration, ethical dissonance, and the rights of patients and families during pandemic events.

References