Ethics In Disasters: Nurses Play A Key Role In Disaster Response Worldwide

During a disaster, medical personnel will be forced to make many critical decisions. These decisions, made in urgent and high stress environments, should be ethically based on autonomy, beneficence, non-maleficence, and justice. At a disaster site, nurses may triage patients using ethical principles and the theory of utilitarianism. The theory of utilitarianism is an ethical theory based on what is best for the community instead of what is best for the individual. Utilitarianism is often employed during the response to disasters because it provides care to the most people with the limited supplies and personal available.

Utilitarianism also takes in part of distributive justice and keeping ANA scopes and standards set guidelines for nurses. When nurses do not uphold the ANA scopes and standards, they leave themselves open to charges of negligence and malpractice. In the case of Hurricane Katrina there were multiple cases where negligence and justice was not served.

Ethics in Disasters A disaster occurs when a community experiences widespread loss that exceeds the ability of the affected community or society’s own resources.

In normal situations, nurses are able to make ethical decisions based on deontology, but when a disaster occurs, nurses must switch to utilitarian principles (Malia, 2014). Utilitarianism is an ethical theory that focuses on outcomes and what is best for the community instead of what is best for the individual. In a disaster situation, utilitarian principles provide the ethical framework to aid as many people as possible when supplies and personnel are limited. Nurses will also continue to use the ANA scopes and standards when working at a disaster site.

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Their decisions should be ethical and within guidelines of the ANA in order to not be accused of negligence and malpractice. Ethical Principles There are four basic ethical principles: non-maleficence, beneficence, autonomy and justices.

Each principle means to do no harm, contribute to benefit, honor patient’s wishes, and make fair medical decisions. During routine medical situations, nurses are able to adhere to all four principles, but during a disaster, abiding by all four ethical principles becomes impractical and can lead to moral distress (Wagner, 2015). Disasters are unique situations because normal standards of care can change. Non-maleficence is to do no harm, but it can feel very much like doing harm when a nurse is forced to black tag a patient that might be saved under ordinary circumstances, but who cannot be saved within the constraints of a disaster. Nurses can provide beneficence, improvement to the patient’s overall well-being, by treating their pain. However, in uncontrolled disaster environments, these patients cannot be properly monitored and morphine can suppress their respiratory rate. In a disaster situation, the autonomy of a patient is replaced with what a nurse can do with the available supplies and time.

A patient may desire all life saving measures to be given, but this may be impossible because it requires more resources than are available. Justice is the most difficult principle to comply with in a disaster situation. Patients should get fair and equitable treatment. However, when there is a shortage of staff, supplies and resources, medical staff will likely not be able to treat every patient. A nurse has to choose which patients will receive optimal medical care and which patients will not – knowing those patients who are unable to receive medical attention will likely die (Wagner, 2015). Ethical Theory Utilitarianism Utilitarianism is to do the greatest amount of care, for the largest number of people, in order to get the most gain. Utilitarian theory has several strengths: public policy acceptance, fair resource budgeting, and promotion of the overall good versus the individual good (Mallia, 2014). It does not prioritize individual autonomy. Utilitarianism is the most used theory for the ethical triage of disaster victims (Gluchman, 2016). Its intent is to save as many people as possible based on prioritization.

Patients are triaged and then prioritized based on level of urgency for medical treatment. Nurses assess their patients, consider possible outcomes with rationales, and then justify their actions with a moral compass (Casey, 2017). The Rawls’ Principle aids in the application of utilitarianism, determining the number of patients that can be saved, prioritizing patients based on the amount of time each requires for treatment regardless of sex, age and race (Mallia, 2014). Utilitarianism View of Allocating Resources Utilitarianism-based care begins during disaster preparation, continues through the event itself, and during the immediate recovery period (Gluchman, 2016). Classical utilitarianism uses a cost-benefit analysis approach (Morrison & Furlong). During the time preceding a disaster, planning is done to distribute resources in preparation for unexpected situations and decreasing resources as the disaster progresses (Casey, 2017). Normally, the Emergency Severity Index (ESI) scale is used in emergency departments around the country (Wanger). This scale places patients in five levels based on urgency and need.

In a disaster, the ESI scale is set-aside, and the START method is employed because the resources normally available to a hospital are quickly depleted (Wanger 2015). Level 1 patients are seen first because they require immediate medical attention; these are followed by level 2 patients who require care within 20 minutes. Both level 1 and 2 patients require a lot of resources. Level 3 patients can wait up to an hour and only need three or more resources while level 4 patients only need one resource. Level 5 patients do not require any resources. These systems manage benefits and justice equally. START identifies the level and urgency of care needed by color: black, red, yellow and green. Black is used for dead or expected to die without use of multiple resources. Red tags identify those patients with critical vital signs and an altered mental status who need immediate care but have a good chance of survival (Wanger 2015). Yellow tags identify those patients who are stable for the moment, but who need to be observed for deterioration. Green tags are for people who are able to walk, the “walking wounded” (Wanger 2015).

Legal Implications and Dr. Sulmasy After a natural disaster, there is often an abundance of lawsuits as victims believe they were neglected and desire compensation for their suffering (Faust, K. & Carlosn, S. 2011). Hurricane Katrina resulted in multiple lawsuits brought against hospitals like New Orleans Memorial Hospital. It was said that some patients were given comfort measures that were believed to hasten their death (Wagner, 2015). In his article, “Palliative sedation and the rule of double effect,” Daniel Sulmasy writes that disaster events like Hurricane Katrina can lead to disproportionate palliative sedations of critically ill patients (Buckely et al 2012). The rule of double effect is that a person only intended the good effect and not the bad effect of a decision (Buckely et al 2012). A nurse may have ordered for morphine as a comfort measure for a patient but did not intend to depress their respiratory rate (Buckley et al 2012). In 2014, experts worked together to create what an ideal nurse would look like for in disaster and public health emergencies. The nurse should have the knowledge base, skills, and abilities for an appropriate disaster response; be able to respond directly or indirectly for support; promote disaster preparedness in their community include their families; and, demonstrate commitment to professional preparedness by participating in disaster planning, drills and exercise within and beyond their specialty environment (Veenema, 2015).

Disaster planning should also include community agencies that will be working with hospitals (Casey, 2017). The ideal disaster-prepared nurse is similar to what is expected of a nurse in the ANA scopes and standards and the provision. There are a large number of RN and nursing students that are not prepared for disaster management (Nilsson, J., et al 2016). They are not prepared because they lack experience, their employers do not have an emergency plan, and they have not exercised role-playing disaster scenarios (Nilsson, J., et al 2016). Nursing students are possible volunteers during a disaster. These students have the opportunity to gain real life learning experience during disaster management exercises (Veenema, 2015). In order to improve the number of prepared nurses, they would need to have more training programs and to have universities collaborate on disaster stimulations (Nilsson, J., et al 2016).

Nurses play a key role in disaster response worldwide and the training they receive is mostly the direct response to a specific disaster (Veenema, 2015). Disaster planning should have both likely scenarios and practice, and community agencies that will be working with hospitals (Casey, 2017). The American Association of Colleges of Nursing now requires disaster education as part of their essentials of baccalaureate education (Veenema, 2015). Hospitals should meet the needs of their community and establish expectations for medical care during disaster situations (Knudson 2012). In order for hospital improve disaster prepareness; national, state and local organizations have awarded billions of dollars to hospitals to improve their disaster preparedness (Knudson, 2012). In order to decrease the negligence and malpractice that happens during a disaster, there has been a call to action in healthcare. Policies are needed to outline what is expected of healthcare personnel, employers, and response teams in the emergency response plan (Knudson, 2012).

These policies can help reduce lawsuit like one against New Orleans Memorial Hospitals and healthcare staff. These charges were brought because it was believe patient were given comfort measure that lead to patients death (Wagner, 2015). Negligence and Malpractice If a nurse does not follow standards set forth by the ANA, then negligence and malpractice can take place. First there is negligence, defined as failing to do what a reasonable nurse would do in the same situation (Jacoby, 2017). Over 100 patients died in hospitals because of the lack of preparedness during Hurricane Katrina (Knudson, 2012). For legal action to take place against a nurse, the nurse must violate ANA ethical principles. During a disaster, ANA provisions become more ambiguous due to the application of utilitarian principles. Nurses may have to stay to work in the path of a hurricane and leave their families (Casey 2017). ANA provision 2 states that the nurse’s primary commitment is to their patients. However, provision 5 states that nurses owe the same duties to themselves (Casey 2017).

Provision 3 states that a patient’s safety health and rights should be protected by nurses (Jacoby, 2017). If you must black tag a patient and the patient’s family is there, how and do you tell them that their loved one will only receive comfort measures? Should a nurse tell the family that their loved one will not receive care so that others may live (Mallia, 2014)? Within disaster situations, nurses should know that the top reasons for negligence are the following: failure to follow the standards of care, failure to communicate, and failure to act as a patient’s advocate (Jacoby, 2017). Conclusion It is clear that there is a need for better guidelines of ethical principles with the use of START during disasters. It can cause confusion because it deviates from normal treatment procedures, and this confusion provides opportunity for negligence and malpractice. Healthcare personnel are unclear as to which standards of care they are required to adhere. These problems can be alleviated by better policy, designed to both care for victims and protect responders in disaster situations. Hospital leaders need to establish clear methods of communication to inform their personnel when changing to disaster treatment protocols.