The Coming Pandemic Catastrophe
Although all hospital workers are exposed to some risk of infection, the extent of this risk is not distributed equally. Some specialties have always been subject to comparatively high risk. In pandemic flu, primary care and emergency room staff, and particularly respiratory and infectious diseases teams, critical care staff and anaesthesiologists, are likely to be at higher risk than those in unrelated or nonacute specialties.
Nurses tend to spend more time in close contact with patients, and those carrying out aerosol-generating procedures may be at increased risk. The role of essential nonmedical domestic and cleaning staff, as well as catering team members and porters, should not be overlooked. Pandemic flu in humans will follow a mutation in the animal influenza virus reservoir that will facilitate human to human spread.
This may reduce virulence, putting into question the assumption that pandemic flu will be as lethal as SARS. We simply do not know how virulent the virus will be in any pandemic. The and influenza epidemics in the UK were less severe than the — outbreak 1—4 million deaths combined compared with an estimated 20—40 million deaths worldwide.
In the more recent influenza epidemics, deaths were predominantly in the elderly and the young 7. In the SARS epidemics, deaths occurred in adults, but in cases of H5N1 avian flu bird to human transfer children and young adults are the main victims.
It is not clear whether one section of the population will be disproportionately affected in the next flu pandemic. Familial avian flu cases suggest a genetic susceptibility to the virus. Clearly these figures can be revised if the virus proves less virulent and cases can be cared for in the community. It is reasonable to assume that healthcare workers will have the same attack rate as the rest of the population.
This is where pandemic flu diverges most from SARS, as while SARS had a hospital focus, the influenza virus is likely to be widespread in the community. These differences are explained by the shorter incubation time of the influenza virus, the likelihood of transmission earlier in the disease, and a higher transmission rate. Healthcare workers will inevitably be exposed to risk at work but, once the patient is diagnosed, suitable infection control precautions should lead to a considerable reduction in risk.
In contrast, the risk of infection from the sneeze of a passer-by at the market place or on public transport is more difficult to quantify and counteract. According to national plans 2 , schools will close in order to slow the spread of the pandemic in most countries, with consequent childcare problems for staff with nursery or school age children.
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This will put pressure on remaining team members and require diversification of work practices. This diversification will occur at trigger points. Elective surgery and admissions will cease, freeing up surgeons, anaesthesiologists, intensive care unit ICU bed space and equipment e. Meanwhile, essential non-flu services, such as obstetric services, emergency surgery, psychiatry and community services will need to be maintained and an equitable balance struck between flu and non-flu work and acute and tertiary services, in terms of both staff and the allocation of resources.
In high-risk emergency situations, such as in epidemics or bioterrorist attacks, the doctor is subject to a number of competing duties: 1 a duty to patients; 2 a duty to protect oneself from undue risk of harm; 3 a duty to one's family; 4 a duty to colleagues whose workloads and risk of harm will increase in one's absence; and 5 a duty to society. The very nature of being a clinician entails a duty of beneficence to patients.
Hence, morally, doctors have greater obligations to help patients than nonclinicians. The profession as a whole also has an implicit contract with society which has usually subsidised medical training to provide medical help in times of crisis. This raises several questions: what is an acceptable level of risk to the healthcare professional? When does the risk cease to be reasonable, and who should decide 8? Professional organisations offer some guidance. The balance between protecting individual doctors and their families from harm, and ensuring patients are not put at unnecessary risk, is best addressed at local level, taking into account the principle that those who place themselves at additional risk should be supported in doing so and the risks and burdens minimized as far as possible.
For the AMA, the level of risk to be taken is left to the discretion of the individual, but it is noteworthy that the justification for not treating patients is one purely based on beneficence to future patients, not on the physician's other obligations to self or loved ones.
In exchange for their work, doctors receive benefits from society, including high status, public respect and some receive substantial financial reward. As mentioned earlier, some specialities are more exposed to risk than others, and rewards are higher in senior members of the profession, yet junior medics and nurses may be at greater risk of infection than senior staff due to more frequent exposure.argo-karaganda.kz/scripts/jigetehig/1083.php
World health leaders warn the world is dangerously unprepared for a pandemic
The same applies to paramedics and community teams, who will care for sick patients outside the hospital. A court of law could find a nurse negligent if a person suffered harm because they neglected to care for them adequately. The professional guidance above goes against the ethical analysis of one of the authors D. Sokol , who has claimed that physicians' duty of care is not limitless, as purported by the professional governance authorities, but determined by various factors including the physician's speciality hence an ophthalmologist and an infectious disease specialist accept different levels of risk , the burdens and risk of harm to the clinician, the likely benefit of treatment to patients, and the strength of other competing moral obligations brought about by the clinician's multiple roles e.
Noting the emphasis in the literature on triage and resource allocation in a pandemic, Malm et al. While one strategy is to claim that healthcare workers have an absolute duty of care, however perilous the situation, the authors conclude that such an approach, although pleasingly simple, would deter individuals from entering the field. Instead, they propose a contract-based consent: healthcare workers should voluntarily acknowledge the duty to treat during a pandemic and should be remunerated for that responsibility.
While Malm et al. However attractive in the short term, the latter option could lead to chaos when disaster strikes, and undermine the success of the plans. Alexander and Wynia 13 examined the willingness of 1, senior US physicians to treat high-risk patients and their perceived preparedness for a bioterrorism incident.
Willingness to treat was associated with a belief in the professional duty to treat in epidemics, with feeling personally prepared, and being in primary care practice. In a qualitative study of healthcare worker attitudes, Ives et al. Childcare, personal illness, and transport problems were identified as barriers to the ability to work; whereas barriers to the willingness to work were related to perceived risk to family or self, and choosing not to use alternative childcare options.
Obligation to colleagues was also noted as a factor: as Reid 16 has pointed out, the risk refused by one individual is left to be absorbed by someone else, either within the healthcare team, or by society at large. The study was based on the attitudes of a range of healthcare workers in a UK Midlands hospital.
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Social, cultural and religious variations across Europe may influence respondents' beliefs and views on their duty of care to patients. In their aim to benefit patients with minimum harm, doctors and nurses also have a collective responsibility to learn from previous pandemics and emergencies. Yu et al. All these factors are highly relevant to staff education, ward layout, patient location and the therapies selected.
Analysis of transmission rates among hospital staff in the Toronto outbreaks revealed a greater risk of developing SARS in doctors and nurses performing endotracheal intubation and providing NIV, although for NIV use this did not reach significance NIV is an interesting case in point, as recommendations for use in guidelines are currently inconsistent 19 , Benefits, however, should be set against the potential increased risk of droplet dissemination with infection transmitted to healthcare workers and other patients.
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In a pandemic that is relatively mild in normal individuals but produces ventilatory decompensation in those with chronic conditions, the balance tips towards providing NIV; if the pandemic is associated with high mortality, the balance moves away from NIV use unless strict safety measures for healthcare workers are effective. Readers should consult their own local and national guidelines. Park et al. Lessons learnt from severe acute respiratory syndrome SARS outbreak. This highly influential approach revolves around the application and interpretation of four basic moral principles.
In the pandemic context, a Four Principles analysis would yield a number of obligations on the part of the clinician, each falling within one of the aforementioned broad principles, as follows. Also, healthcare workers must be aware that a refusal to treat patients may lead to loss of trust in medical professionals, loss of status and other professional harms. Obligation to respect the autonomous decisions of stakeholders and their evaluations of risks and benefits.
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Of course, these many nonabsolute obligations may conflict with one another, and judgement should then be used to balance the competing duties. One obligation may be trumped by more compelling obligations.
A family member may ask that one of the few ventilators go to their terminally ill relative when many others would derive much greater benefit from ventilation. Here, beneficence to other patients and a justice obligation to use limited resources in the most effective manner may trump respecting the autonomous request of the family member.
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Other stakeholders, such as the hospital, the state and even patients, have reciprocal obligations which can also be categorised under these principles, such as the hospital administration's obligation to minimise risk to its healthcare staff e. Infected patients also have obligations to minimise the risk of infecting others, such as covering their mouth and nose when coughing or sneezing, and observing quarantine advice.
During major catastrophes, the duty of care of the health service changes to a different mode than in normal circumstances. The service may be stretched beyond capacity and hard decisions will have to be made. Who will get vaccinated first? Who will be treated first? Which medical services should be first to shut down? Should clinicians and vital figures in society be prioritised?
How can we avoid social unrest? The answers to these uncomfortable questions should be morally defensible and transparent. Further, they must be deemed acceptable by the various stakeholders, including members of the public who will constitute future patients and relatives. The Canadian consensus-based triage guidelines for intensive care admission are the most widely advocated for case prioritisation The rationale for this triage system is well rehearsed elsewhere 29 — In previous articles, we discussed how communicable diseases and pandemics are or are not addressed in personal and commercial insurance policies.
Like good old-fashioned insurance, catastrophe bonds are a way to transfer risk, often for natural disasters. They usually work like this: investors buy a high-yield bond issued by an insurance company.