1/22/2009 4:48 PM

**MEETING THE CHALLENGE OF PANDEMIC INFLUENZA:**

**ETHICAL GUIDANCE FOR LEADERS AND HEALTH CARE PROFESSIONALS IN THE
VETERANS HEALTH ADMINISTRATION**

**Prepared by**

**THE PANDEMIC INFLUENZA ETHICS INITIATIVE WORKGROUP**

**OF THE VETERANS HEALTH ADMINISTRATION'S NATIONAL CENTER FOR ETHICS IN
HEALTH CARE**

**\*\*\* 2009**

**[DRAFT -- NOT FOR CIRCULATION OUTSIDE OF VA]{.underline}**

***TABLE OF CONTENTS***

***EXECUTIVE SUMMARY
\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....iii***

***WORKGROUP AND ACKNOWLEDGMENTS
.............................................................\...xi***

**[SECTION 1](#Section1): ETHICAL CHALLENGES IN PANDEMIC INFLUENZA
PREPARATION AND RESPONSE
...*\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...1***

> ***[1.1
> Charge\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...1]{.smallcaps}***
>
> [1.2 Purpose of the Guidance
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....1***]{.smallcaps}
>
> [1.3 How the Guidance Was Developed
> ......................................................\...2]{.smallcaps}
>
> [1.4 Background]{.smallcaps}
> .....................................................................................\...2
>
> *1.4.1 Pandemic Scenarios and Projected Scarcity
> .....................................*2
>
> *1.4.2 The Infectious Nature of Pandemic Influenza: Implications for
> Health*
>
> *Care Institutions*
> ......................................................\...\...\...\...\...\...\.....7
>
> [1.5 Ethical Challenges in Pandemic Influenza Preparation and
> Response.......8]{.smallcaps}
>
> [1.6 Core Ethical Principles
> .......................................................................8]{.smallcaps}
>
> [1.7 The Unique Obligations of VHA Leaders -- More Pronounced in
> Pandemic
> Influenza***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...9***]{.smallcaps}
>
> [1.8 Leadership Decision Process for Pandemic Influenza Planning and
> Response***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...10***]{.smallcaps}
>
> ***1.8.1 Informed and Participatory
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....10***
>
> ***1.8.2
> Values-based\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....10***
>
> ***1.8.3 Beneficial
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....13***
>
> ***1.8.4 Systems-focused
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....13***
>
> ***1.8.5 Reasonable
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...13***
>
> ***1.8.6 Transparent
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...13***
>
> [1.9 The Obligations of VHA Clinicians as Health Care]{.smallcaps}
>
> [Professionals]{.smallcaps}
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...14***
>
> *1.9.1 The Ethical Duty to Provide Care and Non-Abandonment
> **\...\...\...\...\...\...\....14***
>
> *1.9.2 Respect for Persons
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....14***
>
> *1.9.3 Duty to Benefit and Prevent Harm
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....15***
>
> *1.9.4 Fairness
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....16***

**[SECTION 2](#Section2): ETHICAL CHALLENGE \#1:RESPONSIBILITIES---WORK
FORCE CAPACITY AND AN ETHICAL "DUTY TO PROVIDE CARE" UNDER CONDITIONS OF
PANDEMIC
INFLUENZA*...........................................................................................................16***

> [2.1 Risk, Responsibility and Work force Capacity: Lessons from
> Public]{.smallcaps}
>
> [Health Emergencies
> .......................................................................\....17]{.smallcaps}
>
> [2.2 The Ethical Duty to Provide Care: Considerations for Pandemic
> Planning in VHA
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....17***]{.smallcaps}
>
> *2.2.1 Scope and Limits of an Ethical Duty to Provide Care
> **......**...................*18
>
> *2.2.2 Reciprocal Institutional Duties
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....19***
>
> [2.3 Recommended Actions]{.smallcaps}
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....23***
>
> *2.3.1 Stakeholder Participation
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...23***
>
> *2.3.2 The Ethical Duty to Provide Care
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...23***
>
> *2.3.3 Reciprocal Institutional Obligations
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...24***

**[SECTION 3](#Section3): ETHICAL CHALLENGE \#2: RATIONING---TRIAGE AND
THE ALLOCATION OF SCARCE LIFE-SAVING CLINICAL RESOURCES
*...................................................25***

> [3.1 Establishment of Scarce Resource Allocation (SRA) And
> Triage]{.smallcaps}
>
> [Teams
> .................................................................................\...\...\...\...\....26]{.smallcaps}
>
> *3.1.1 SRA Team Procedures
> ............................................................\...*29
>
> *3.1.2 Triage Team Procedures
> .............................................................*29
>
> **[3.2 Protocol for Allocation of Scarce Life-Saving Resources in
> VHA]{.smallcaps}**
>
> **[During an Influenza Pandemic
> *......................................................\.......30*]{.smallcaps}**
>
> *3.2.1 Clinical Assessment
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....31***
>
> ***3.2.1.1 Exclusion
> Criteria.............................................................31***
>
> ***3.2.1.2 Triage Priority
> Categorization..............................................32***
>
> *3.2.2 Reassessment
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....37***
>
> ***3.2.3 Triage Decision Makers
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....37***
>
> *3.2.4 Review and Appeals
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....38***
>
> ***3.2.5 Communication about Triage
> .......................................................39***
>
> *3.2.6 Resuscitation Status for Patients Excluded from Scarce
> Life-Saving Resources
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....39***
>
> *3.2.7 Application of Triage Algorithms to Patients Already Receiving
> Life- Saving Treatments
> **\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....39***

**[SECTION 4](#Section4): ETHICAL CHALLENGE \#2: RATIONING---HOSPICE AND
PALLIATIVE**

**CARE PLANNING AND RESPONSE
.........................................................................41**

> ***[4.1 Why Use Resources to Support Hospice Care During
> Pandemic]{.smallcaps}***
>
> ***[Influenza?
> \...\...\...\...\...\...\..........................................................................42]{.smallcaps}***
>
> [4.2 Recommendations for Hospice and Palliative Care Planning
> ...............\...42]{.smallcaps}
>
> *4.2.1 Education of Veterans and Their Families*
> .......................................43
>
> *4.2.2 Resource
> Enhancement*...............................................................43
>
> *4.2.3 Training*
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...43***
>
> [4.3 Palliative Sedation in Circumstances of Pandemic Influenza
> ***\...\...\...\...\...\...\...44***]{.smallcaps}
>
> [4.4 Euthanasia and Practitioner-Assisted Suicide Are
> Never]{.smallcaps}
>
> [Allowed in VHA
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....44***]{.smallcaps}

**[SECTION 5](#Section5): ETHICAL CHALLENGE \#3: RESTRICTIONS---LIMITING
LIBERTY**

**IN THE INTERESTS OF PUBLIC
HEALTH*...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....46***

> [*5.1 Infectious Disease Reporting*
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....47***]{.smallcaps}
>
> [*5.2 Mandated Preventive Health Measures*
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....47***]{.smallcaps}
>
> *[5.3 Quarantine **And Social Distancing
> \...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....48**]{.smallcaps}*
>
> *[5.4 Isolation]{.smallcaps}*
> ***\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...49***

**[SECTION 6](#Section6):
REFERENCES*\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....51***

***[SECTION 7](#Section7): LIST OF TABLES AND
FIGURE............................................................59***

***[APPENDIX 1](#Appendix1): AN ETHICAL FRAMEWORK FOR DECISION MAKING
REGARDING ALLOCATION OF SCARCE, LIFE-SAVING RESOURCES
.......................................\.....60***

***[APPENDIX 2](#Appendix2): CHECKLIST FOR OPERATIONALIZING THIS
GUIDANCE........................68***

**EXECUTIVE SUMMARY**

***CHARGE***

The *Implementation Plan for the National Strategy for Pandemic
Influenza* (2006) charges Federal agencies to develop guidance for the
allocation of scarce health and medical resources during a pandemic flu
event. As the lead agency, The Department of Health and Human Services
(HHS) produced initial guidance in 2007 (Agency for Health Care Quality
and Research, 2007). This VA guidance document draws on the HHS planning
guide, and other key documents, to provide specific guidance targeted to
the Veterans Health Administration (VHA). This document also fulfils the
charge in VA's Pandemic Influenza Plan (Department of Veterans Affairs,
2006) to develop "criteria and transparent processes for allocation
decisions regarding resources that may not be available in sufficient
quantities during a pandemic" (Department of Veterans Affairs, 2006,
Section \# 2.2.2.3).

This guidance addresses decision processes for allocation of scarce
clinical resources that are potentially life-saving, such as ventilators
and other critical care resources, as well as related questions
concerning the ethical duty to provide care and reciprocal institutional
obligations, hospice and palliative care planning and response, and
limits on individual liberties related to influenza containment.
Guidance regarding allocation of countermeasures such as vaccines and
antivirals is being developed by Federal interagency work groups
(Department of Health and Human Services, 2007).

+----------------------------------------------------------------------+
| **Scope of this Guidance**                                           |
+======================================================================+
| Applies to decision making by VHA leaders and health care            |
| professionals regarding care for veterans in VHA hospitals, clinics, |
| nursing homes, and hospices                                          |
|                                                                      |
| Discusses health care professionals' ethical duty to provide care    |
| and reciprocal institutional responsibilities                        |
|                                                                      |
| Discusses criteria and processes for allocation of scarce            |
| life-saving resources                                                |
|                                                                      |
| Discusses limits on individual liberties related to pandemic         |
| influenza containment                                                |
|                                                                      |
| Discusses ***hospice and palliative care planning and response***    |
|                                                                      |
| Does ***not*** address allocation of countermeasures such as vaccine |
| and antivirals                                                       |
+----------------------------------------------------------------------+

This guidance was prepared by a workgroup of the National Center for
Ethics in Health Care and was reviewed by individuals in VHA facilities
and Central Office. A list of workgroup members and reviewers is
provided in the [front matter](#Frontmatter). The workgroup based its
thinking on the literature and on consultation with experts in the areas
addressed by the guidance. Adaptation of analysis or recommendations
from specific resources is indicated in the text.

***\
***

***BACKGROUND***

In an influenza pandemic, the demand for health care services is
anticipated to exceed the capacity of VHA facilities both to treat
influenza patients and to sustain other health care services.
Projections based on the peak period of a severe 1918-like influenza
pandemic suggest that facilities may have only one ICU bed for every
four to five influenza patients who require it, one ventilator for every
two influenza patients who require it, and one non-ICU bed for every two
influenza patients who require it. Facilities will be stressed by
personnel shortages that result from workers becoming ill or remaining
at home either to care for family or out of fear of infection. Due to
the numbers of infected patients who will seek treatment, VHA
facilities, in conjunction with their communities, will need to isolate
patients and may need to advocate voluntary quarantine consistent with
U.S. Community Mitigation Guidance (Department of Health and Human
Services, February 2007) for potentially exposed patients and staff,
resulting in further shortages in the availability of rooms, beds, and
staff.

**PURPOSE OF THE GUIDANCE**

+----------------------------------------------------------------------+
| ***Ethical Challenges in Pandemic Planning and Response***           |
+======================================================================+
| **RESPONSIBILITIES**: The ethical "duty to provide care." The        |
| obligation of health care workers to accept reasonable risk in the   |
| service of patients and the reciprocal obligation of health care     |
| institutions to minimize risk to health care workers.                |
|                                                                      |
| **RATIONING**: Allocation of scarce resources. The criteria and      |
| processes for decision making regarding the fair and efficient use   |
| of scarce resources.                                                 |
|                                                                      |
| **RESTRICTIONS**: Limits on individual liberty in the interests of   |
| public health. Justifications and procedures for implementing limits |
| on individual liberty to prevent the spread of infection.            |
+----------------------------------------------------------------------+

With resources scarce and the pressing need to contain the spread of the
virus, VHA leaders and health care professionals will ***be faced with
extraordinary ethical challenges centered on responsibilities (defining
the scope and limits of VHA employees' ethical duty to provide care to
patients and reciprocal institutional obligations), rationing
(allocation of scarce resources), and restrictions (limiting individual
liberty in the interests of public health).***

The purpose of this guidance is to provide VHA leaders and health care
professionals with an ethical framework to meet these challenges. This
framework includes information, analysis, recommendations, and criteria
for conducting ethical decision processes and for resolving substantive
ethical dilemmas. In each of these areas, this document summarizes
ethical principles about which there is consensus in clear, actionable
language and communicates national guidance for VHA.

The expectation is that VHA leaders and health care professionals will
use this information both *before* an outbreak of pandemic influenza as
a basis for pandemic influenza planning, tabletop exercises, preparatory
drills, and educational forums and *during* an outbreak as a guide for
decision making.

**CORE ETHICAL PRINCIPLES AND VALUES**

The guidance provides information about the ethical bases for pandemic
planning and response, addressing values and obligations of VHA leaders
and VHA health care professionals.

As a starting point, the guidance is predicated on the fundamental
assumption that decision making in pandemic influenza planning and
response must be based on achieving the greatest good for the greatest
number (the principle of utility or efficiency) *within constraints of
respect for human dignity and fairness* (the principle of justice
applied across groups of people according to specified criteria). One of
the most important roles that VHA leaders will play in pandemic planning
and response will be determining, based on reasoned justification, how
these principles will be balanced in particular decisions.

+----------------------------------------------------------------------+
| ***Ethical Leadership in Pandemic Planning and Response***           |
+======================================================================+
| As **public servants**, VHA leaders are specifically responsible for |
| maintaining the public trust, placing duty above self-interest, and  |
| managing resources responsibly.                                      |
|                                                                      |
| As **health care providers**, VHA leaders have a fiduciary           |
| obligation to meet the health care needs of individual patients in   |
| the context of an equitable, safe, effective, accessible, and caring |
| health care delivery system.                                         |
|                                                                      |
| As **managers**, VHA leaders are responsible for creating a          |
| workplace culture based on integrity, accountability, fairness, and  |
| respect. They must ensure that staff throughout the organization are |
| supported in their adherence to high ethical standards.              |
+----------------------------------------------------------------------+

Ethical leadership in pandemic planning and response is grounded in the
obligations and values that define all aspects of VHA health care based
on leaders' roles as public servants, health care providers, and
managers.

The guidance discusses a [leadership decision-making
process](#Leadershipdecisionprocess) that is:

-   Informed and participatory

-   Values-based

-   Beneficial

-   Systems-focused

-   Reasonable

-   Transparent

In addition to the values that guide pandemic planning and response at
the VHA *leadership* level, the guidance discusses [norms of health care
professionalism](#ObligofHCProfessionals) that are relevant to
*clinical* decision making during a pandemic including:

-   Ethical duty to provide care and non-abandonment

-   Respect for persons

-   Duty to benefit and to prevent harm

-   Fairness

+----------------------------------------------------------------------+
| **Assumptions of this Guidance**                                     |
+======================================================================+
| **Assumption \#1:** Under circumstances of pandemic influenza,       |
| health care leaders and professionals will ***be faced with          |
| extraordinary ethical challenges centered on rationing,              |
| responsibilities, and restrictions.***                               |
|                                                                      |
| **Assumption \#2:** Ethical leadership demands advance planning to   |
| meet the challenges of pandemic influenza.                           |
|                                                                      |
| **Assumption \#3:** Both the principle of utility (achieving the     |
| greatest good for the greatest number), and person-oriented          |
| principles of justice and human dignity should play a central role   |
| in guiding health care decision making during a pandemic.            |
|                                                                      |
| **Assumption \#4:** Specific local pandemic-related policies and     |
| procedures are especially important when practitioners are required  |
| to deviate from normal practice and follow alternate standards of    |
| care. If a practitioner can demonstrate that his or her actions are  |
| in accordance with institutionally promulgated policy, guidance      |
| and/or rules, his or her liability exposure will be diminished.      |
+----------------------------------------------------------------------+

**CHAPTER OVERVIEWS**

**Ethical Challenge \#1: Responsibilities\
**[*Section 2: Work force Capacity and an Ethical "Duty to Provide Care"
Under Conditions of Pandemic Influenza*](#Section2)

VHA employees have an ethical "duty to provide care" (i.e., commitment
to provide care to patients even when assuming personal risk) for
patients under conditions of pandemic flu. This ethical duty is grounded
in fidelity to VHA's public service mission and an ethic of care and
non-abandonment of the veterans we are privileged to serve. The ability
of caregivers to fulfill their "duty to provide care" under conditions
of pandemic influenza is predicated on VHA meeting its reciprocal
obligations. These reciprocal obligations center on addressing workplace
conditions that enable employees to take care of patients, but also
include reciprocity owed those employees who voluntarily assume a
disproportionate risk of illness and even death to fulfill VHA's
mission. Recommendations focus on (1) a fair and consistent
decision-making process used to specify the limits or exceptions to an
employee's duty to provide care, and (2) reciprocal obligations of VHA
to safeguard employees and provide for their welfare, mitigate
occupational risk, support stricken staff and their families, and assist
employees in meeting competing obligations.

**Ethical Challenge \#2: Rationing**

[*Section 3 -- Triage and the Allocation of Scarce Life-Saving Clinical
Resources*](#Section3)

Under conditions of dire scarcity, it is expected that need will
outstrip resources and consequently it will not be possible to provide
everyone the care that they require to survive. This guidance focuses
specifically on "tertiary triage," that is, the allocation of scarce
life-saving clinical resources such as ventilators, ICU beds, and
certain medications used to treat those who are gravely ill from
influenza and other illnesses. The protocol outlined here is intended to
provide a fair, consistent and rational framework for making these
difficult decisions. Specific recommendations focus on (1) establishment
of a Scarce Resource Allocation (SRA) team and a Triage team, and (2) a
**protocol for allocation of scarce life-saving resources.**

**Ethical Challenge \#2: Rationing**

[*Section 4* *-- Hospice and Palliative Care Planning*](#Section4)

VHA is committed to the provision of compassionate and humane care to
the terminally ill veteran and the veteran\'s family. Although a
strictly utilitarian approach to pandemic planning and response might
justify concentrating health care resources (staff, beds, supplies, and
drugs) only toward saving those lives that can be saved, an approach
that balances utility, fairness and human dignity requires that steps
are taken to provide for those who are not expected to survive.
Providing hospice and palliative care is a way of respecting the dignity
of those who will not survive by helping to mitigate their pain and
suffering. It is a way of achieving equity for those who cannot benefit
from more intensive therapies or who could benefit, but due to altered
standards of care will not receive access to life-saving resources. The
provision of hospice and palliative care is also a fulfillment of the
obligation of non-abandonment -- a basic tenet of professionalism and
the minimum requirement of an ethical duty to provide care. Carrying
forward these obligations into circumstances of pandemic influenza
requires specific plans to (1) secure a dedicated stockpile of
appropriate hospice and palliative care supplies (e.g., pain medication,
anxiolytics), (2) identify non-clinical support staff who will assist in
the provision of hospice and palliative care during pandemic, (3)
establish and augment linkages with community-based service
organizations and personnel, and (4) develop educational materials for
patients and family that help them understand how best to take care of
themselves and dying family members when they do not have access to
life-saving hospital care.

**Ethical Challenge \#3: Restrictions**

[*Section 5* *-- Limiting Liberty in the Interests of Public
Health*](#Section5)

In public health crises such as pandemic influenza, a public health
response is likely to include restrictions on the liberty of individuals
in order to control the spread of infection within the population. Such
a public health response poses predictable challenges to VHA health care
professionals' obligation to give priority to the welfare of individual
patients. Although many veterans may voluntarily accede to some
restrictions on their liberty, the usual emphasis on patient autonomy
may cause professionals and their veteran patients to chafe at such
restrictions. However, ethical theories uniformly recognize that
individual liberties may be limited to prevent harm to others; public
health measures are established on this basis. To preserve liberty as
much as possible, the Centers for Disease Control and Prevention's (CDC)
Community Mitigation guidance recommends that quarantine be voluntary
and be applied to household members of the ill only (Department of
Health and Human Services, February 2007). Similarly, this guidance
emphasizes (1) strategies for achieving public health goals through the
least restrictive means possible and (2) effective communication with
staff and veterans during pandemic planning and a pandemic.

**RECOMMENDATIONS**

To ensure ethically informed pandemic influenza preparation and
response, this guidance recommends a number of steps by VHA leadership.

**In advance of a pandemic event, the Under Secretary for Health or
designee should:**

Issue disaster policies outlining special procedures for informed
consent and withdrawal and withholding of scarce resources under altered
standards of care.

Clarify with VACO, VISN, and facility leaders the White House Homeland
Security Council's guidance that "VA\'s priority with respect to
protecting human health is to deliver health care to enrolled veterans
and beneficiaries. VA also has a mission to provide medical surge
capacity for treatment of casualties arising from DOD operations and can
provide other support to the extent the VA\'s mission to serve veterans
is not compromised." (2006, p. 115). The purpose of this clarification
should be to assist Facility Directors in decision making regarding the
provision of humanitarian care during pandemic.

Ensure that the communications response plan targeting employees and
volunteers:

Emphasizes the commendable nature of caring for veterans during pandemic
flu despite the great personal risk of exposure to contagion.

Reinforces VHA reciprocal obligations to support staff members and
volunteers who put themselves at risk. The plan should include
communications concerning:

Providing pay incentives, including overtime and hazardous duty pay.

Provide immunity from personal liability.

Caring for the basic physical needs of staff members and volunteers.

Helping the staff to meet other competing obligations.

Providing safety and protection, including physical plant safety,
vaccines, countermeasures, and personal protective gear.

4)  Seek authority to provide the following reciprocal support to
    employees who place themselves at risk during a pandemic, including,
    as needed, but not limited to:

    a.  Overtime pay (e.g., for Title 38 nurses).

5)  Engage stakeholders, including veterans, VSOs, labor unions,
    employees, the public, and Congress, in a discussion of the ethical
    issues contained in this guidance.

6)  Ensure that national policies governing Time and Attendance and
    Leave are modified for use in emergency response to provide maximal
    flexibility to facilities to arrange work schedules and duty station
    assignments.

7)  Ensure that the resources required to provide hospice and palliative
    care are included in national stockpiles and available for use when
    required.

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3)  Encourage facility leadership to incorporate a process for disaster
    credentialing and granting disaster privileges into their
    credentialing and privileging process and emergency management plan.

**In advance of a pandemic event, VACO and VISN leaders should:**

1)  Determine and communicate the trigger and processes for instituting
    altered standards of care at VHA facilities.

**During a pandemic event, VACO and VISN leaders should:**

Implement protocols for clinical evaluation and allocation of scarce
life-saving resources consistently across all VHA facilities that are
operating under altered standards of care. VACO leadership should ensure
that VISN and facility leadership have timely, accurate, and complete
information regarding the developing pandemic and the Federal
government's response to it.

Clarify with Facility Directors that in the event of severe local
resource scarcity, initiation of the tertiary triage protocol is at the
discretion of the Facility Director, pending VISN approval.

**In advance of a pandemic event, facility leaders should:**

(See [Appendix 2](#Appendix2) for a detailed checklist for facility
leaders.)

1)  Update the facility work force plan to:

    a.  Address the clinical staff duty to care.

    b.  Specify the facility's reciprocal obligations to staff.

    c.  Outline the role of non-clinical staff in clinical duties.

    d.  Detail assignments for volunteers (including Disaster Emergency
        Medical Personnel System (DEMPS volunteers). (VHA HANDBOOK
        0320.03, Disaster Emergency Medical Personnel System (DEMPS)
        Program and Database)

    e.  Detail plans for changes in scope of practice.

    f.  Inform contractors that legal authority does not currently exist
        to protect contract employees under the Federal Tort Claims Act
        and that they should check with their malpractice insurer to
        make sure that their coverage would extend to actions taken
        under an altered scope of practice during a pandemic.

2)  Update the facility patient care response plan to:

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a.  Establish a scarce resource allocation (SRA) team and associated
    data management requirements and operating procedures (covering
    triage protocols and review and appeal mechanisms.)

b.  Describe the processes and resources required for implementing
    hospice and palliative care services during the pandemic (covering
    stockpiling supplies, palliative sedation, coordinating with SRA,
    and staffing and training.)

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3)  Ensure the facility communications plan addresses the ethical issues
    covered in this guidance relevant to:

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a.  Changes made to the work force plan.

b.  The allocation of scarce resources and altered standards of care.

c.  The expectations about mandated public health measures.

d.  The expectations about quarantine, social distancing, and isolation.

e.  Direct communication and education of veterans and their families.

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4)  Ensure appropriate preparation, training, and testing of all of the
    new ethics elements of the facility pandemic flu response plan.

5)  Actively engage stakeholders, including veterans, VSOs, labor
    unions, employees, and the public throughout the pandemic flu
    planning and preparation process.

**During a pandemic event, VHA facility leaders should:**

1)  Be physically present at their facilities and be actively involved
    in supporting both clinical and non-clinical staff in ensuring the
    delivery of care to veterans and the provision of essential services
    to employees.

2)  Activate the SRA team and support its implementation of altered
    standards of care. Ensure that the team has the information and
    authority it needs to make decisions about triage and the allocation
    of scarce resources.

3)  Ensure timely and accurate flow of information between the SRA team
    and top facility management; and the timely and accurate flow of
    information to employees, patients, family members, and the public,
    including the reasoning behind the decisions being made and the
    processes being used to make them.

In addition, VISN and facility leaders should review this entire
guidance document and consider how best to address the principles
discussed and to implement the specific protocols detailed. Facility
managers, supervisors and IntegratedEthics program staff should also
study this document and integrate these ethical principles and protocols
into their pandemic influenza planning. [Appendix 2](#Appendix2)
provides a checklist for facility leaders to ensure that these
principles and protocols are implemented in pandemic preparation and
response.

[]{#Frontmatter .anchor}**WORKGROUP AND ACKNOWLEDGMENTS**

The Development of this Guidance was led by the Pandemic Influenza
Ethics Initiative Workgroup at the National Center for Ethics in Health
Care:

Virginia Ashby Sharpe, PhD

Kenneth A. Berkowitz, MD, FACHE

Ruth Cecire, PhD

Mary Beth Foglia, RN, MA, PhD

Michael Ford, JD

Sherrie Hans, PhD

We thank the following reviewers for their contributions:

Barbara Chanko, RN, MBA, Staff, Ethics Consultation, VHA National Center
for Ethics in Health Care.

Sandro Cinti, MD, Assistant Professor, Infectious Diseases, University
of Michigan Hospitals/VA Ann Arbor Health Systems.

Christine Cody, RNC, MSN, National Program Manager, Hospice and
Palliative Care.

Victoria Davey RN, MPH, Deputy Chief Officer, VA Office of Public Health
and Environmental Hazards.

James Geiling, MD, FACP, FCCM, FCCP, Chief, Medical Service, VA Medical
Center White River Junction, VT and Associate Professor of Medicine
Dartmouth Medical School Hanover, NH.

Rosell Knight, RN, MS, Clinical Executive and Ethics Liaison, VA Office
of Nursing Services.

Ware Kuschner, MD, Director, Pulmonary Rehabilitation and Chair of the
Clinical Bioethics Committee, VA Palo Alto Health Care System.

Robert Pearlman, MD, MPH, Director, Ethics Program Puget Sound Health
Care System; Chief, Ethics Evaluation Service, National Center for
Ethics in Health Care (VHA); Professor of Medicine in the Division of
Gerontology and Geriatric Medicine, University of Washington.

Lewis J. Radonovich, Jr., MD, Director, Occupational Health Services,
Malcom Randall NF/SGVHS, Gainesville, Florida.

Heather Tompkins, Management Analyst in Non-Institutional Care Program,
Hospice and Palliative Care.

William Van Stone, MD, Associate Chief for Psychiatry, VA Office of
Mental Health Services.

Thanks also to Justice Cowan for copy editing services.

[]{#Section1 .anchor}**SECTION 1: ETHICAL CHALLENGES IN PANDEMIC
INFLUENZA PREPAREDNESS AND RESPONSE**

***1.1 [Charge]{.smallcaps}***

The U.S. Homeland Security Council's *Implementation Plan for the
National Strategy for Pandemic Influenza* (2006) has charged the
Department of Health and Human Services (HHS) in coordination with the
Department of Defense (DoD) and the Department of Veterans Affairs (VA),
to "develop guidance for allocating scarce health and medical resources
during a pandemic" (U.S. Homeland Security Council, 2006, \#6.1.2.4.).

In fulfillment of this task, the Agency for Health Care Research and
Quality (AHRQ) has developed a planning guide, *Mass Medical Care with
Scarce Resources* (AHRQ, 2007) to assist communities in their efforts to
plan for and respond to a mass casualty event (AHRQ, 2007, p. iii). AHRQ
has also funded the American College of Chest Physicians (ACCP) to
develop two products: (1) operational guidance for providing mechanical
ventilation outside of traditional ICUs (Rubinson, 2008), and (2) triage
algorithms for initiating, withholding and withdrawal of critical care
resources for emergency mass critical care. (Devereaux, 2008)

This Veterans Health Administration (VHA) guidance document draws on the
Agency for Health Care Research and Quality (AHRQ) planning guide and
other Federal and non-Federal resources to provide guidance informed by
and specifically targeted to VHA. This document fulfils the charge in
VA's Pandemic Influenza Plan to develop "criteria and transparent
processes for allocation decisions regarding resources that may not be
available in sufficient quantities during a pandemic" (Department of
Veterans Affairs, 2006, Section 2.2.2.3).

**[1.2 Purpose Of The Guidance]{.smallcaps}**

The purpose of this guidance is to provide VHA leaders and clinicians
with an ethical framework to meet the challenge of pandemic influenza.
This framework includes information, analysis, recommendations, and
criteria for conducting ethical decision processes as well as for
resolving substantive ethical dilemmas concerning:

-   ***The scope and limits of VHA employees' duty to provide care to
    patients***

-   Allocation of scarce life-saving resources

-   ***Hospice and palliative care planning and response***

-   ***Limitations on individual liberty in the interests of public
    health***

In each of these areas, this document summarizes consensus ethical
principles in clear, actionable language; communicates national guidance
for VHA (where appropriate), and, on issues where no consensus is
apparent, provides a framework for decision making by VHA leaders and
clinicians.

This guidance focuses specifically on decision processes for allocation
of scarce life-saving resources such as ventilators and other critical
care resources as well as related issues. Guidance regarding allocation
of countermeasures such as vaccines and antivirals is being developed by
Federal interagency work groups informed by expert and lay opinion
(Department of Health and Human Services, October 17, 2007).

The expectation is that VHA leaders and health care professionals will
use this information both *before* an outbreak of pandemic influenza as
a basis for tabletop exercises, preparatory drills, and educational
forums and *during* an outbreak as a guide for decision making.

**[1.3 How The Guidance Was Developed]{.smallcaps}**

This guidance was prepared by a workgroup of the National Center for
Ethics in Health Care and was reviewed by individuals in VHA facilities
and in VA Central Office. A list of workgroup members and reviewers is
provided in the [front matter](#Frontmatter). The workgroup developed
the guidance on the basis of literature review and on consultation with
experts in the areas touched on by the guidance. Adaptation of analysis
or recommendations from specific resources is indicated in the text.

***[1.4 Background]{.smallcaps}***

In an influenza pandemic, the demand for health care services is
anticipated to exceed the capacity of VHA facilities both to treat
influenza patients and to sustain other health care services. Facilities
will be stressed by personnel shortages that result from workers
becoming ill or remaining at home either to care for family or out of
fear of infection. Due to the numbers of infected patients who will seek
treatment, VHA facilities, in conjunction with their communities, will
need to isolate patients and may need to advocate voluntary quarantine
as part of U.S. Community Mitigation Guidance (Department of Health and
Human Services, February 2007) for potentially exposed patients and
staff, resulting in further shortages in the availability of rooms,
beds, and staff. Scarcity projections and the need for public health
containment measures highlight the need for ethically informed planning
and decision processes (Schoch-Spana et al., 2007; Hick and O'Laughlin,
2006; Christian et al., 2006; OHPIP, 2006; Kraus et al., 2007).

***1.4.1 Pandemic scenarios and projected scarcity***

In its community planning guide, *Mass Medical Care with Scarce
Resources*, the Agency for Health Care Research and Quality (AHRQ, 2007)
describes prolonged-impact mass casualty events including severe
influenza pandemic. Such events entail a gradual increase in the number
of people affected, rising to a catastrophic number of patients. Unlike
localized disasters such as an earthquake or bombing, pandemic flu, as a
contagious illness, is expected to spread gradually in multiple waves of
community outbreaks across the country.

Table 1 is the HHS projection of the possible impact of moderate and
severe pandemic influenza scenarios for the entire United States
population (300 million).

**Table 1**

**Number of Episodes of Illness, Health Care Utilization, and Death
Associated with Moderate and Severe Pandemic Influenza Scenarios \--
U.S. population, 300 million**

  **Characteristic**                                                                                                                                                                                                                **Moderate (1957/68-like)**   **Severe (1918-like)**
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- ------------------------
  Illness                                                                                                                                                                                                                           90 million (30%)              90 million (30%)
  Outpatient medical care                                                                                                                                                                                                           45 million (50%)              45 million (50%)
  Hospitalization                                                                                                                                                                                                                   865,000                       9,900,000
  ICU care                                                                                                                                                                                                                          128,750                       1,485,000
  Mechanical ventilation                                                                                                                                                                                                            64,875                        745,500
  Deaths                                                                                                                                                                                                                            209,000                       1,903,000
  Note: Estimates are based on extrapolation from past pandemics in the United States. Note that these estimates do not include the potential impact of interventions not available during the 20th century pandemics (HHS 2007).                                 

Based on HHS planning assumptions for both scenarios, the Center for
Biosecurity at the University of Pittsburgh Medical Center has projected
the following average impacts on hospitals for influenza patients alone
(Table 2). In a moderate scenario, influenza patients would require 19%
of non-ICU beds, 46% of ICU beds, and 20% of ventilators. In a severe
scenario, influenza patients would require 191% of non-ICU beds, 461% of
ICU beds, and 198% of ventilators (Toner and Waldhorn, 2006). In other
words, in a severe 1918-like pandemic, "local hospitals can expect to
have only one mechanical respirator for every two influenza patients,
and only one bed for every four to five influenza patients who need them
at the peak of the crisis" (Schoch-Spana et al, 2007).

**Table 2**

**FluSurge Projection of Average Impact on Hospitals**

  **Moderate scenario (1968-like)**                                                                                                                                                                                                                                                                                                                                                                                                             **Severe scenario (1918-like)**
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ---------------------------------
  19% of non-ICU beds                                                                                                                                                                                                                                                                                                                                                                                                                           191% of non-ICU beds
  46% of ICU beds                                                                                                                                                                                                                                                                                                                                                                                                                               461% of ICU beds
  20% of ventilators                                                                                                                                                                                                                                                                                                                                                                                                                            198% of ventilators
  Note: These projections were derived using FluSurge 2.0 with national population statistics, 750,000 non-ICU beds, 90,000 ICU beds, 105,000 ventilators, an 8-week duration, a 25% attack rate, and accepting the other default assumptions (1968 based). For a severe pandemic, the assumed number of hospitalizations was changed from 992,000 to 9.9 million to correspond with the HHS planning assumptions (Toner and Waldhorn, 2006).   

**Using the same HHS planning assumptions, Table 3 estimates impacts on
a population of 540,065 eligible VA enrollees in** Veterans Integrated
Service Network (**VISN) 8, the largest of VHA's health care networks.**

**Table 3**

**Number of Episodes of Illness, Health Care Utilization, and Death
Associated with Moderate and Severe Pandemic Influenza Scenarios -- VISN
8 (540,065 enrollees)**

  **Characteristic**                                                                                                                                                                                                                **Moderate (1957/68-like)**   **Severe (1918-like)**
  --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- ----------------------------- ------------------------
  Illness                                                                                                                                                                                                                           162,020 (30%)                 162,020 (30%)
  Outpatient medical care                                                                                                                                                                                                           81,010 (50%)                  81,010 (50%)
  Hospitalization                                                                                                                                                                                                                   1558                          17,823
  ICU care                                                                                                                                                                                                                          233                           2674
  Mechanical ventilation                                                                                                                                                                                                            167                           1337
  Deaths                                                                                                                                                                                                                            390                           3426
  Note: Estimates are based on extrapolation from past pandemics in the United States. Note that these estimates do not include the potential impact of interventions not available during the 20th century pandemics (HHS 2007).                                 

VISN 8 has also developed more specific projections for a 239 (Table 4)
and a 62 bed (Table 5) hospital, based on a moderate 1968-scale
pandemic. As indicated, the demand for resources is anticipated to
significantly tax or exceed supply in VHA facilities. For a 12-week
outbreak at a 25% attack rate, projections for the 239 bed hospital are
that influenza patients alone would require 47% of non-ICU beds, 84% of
ICU beds, and 37% of ventilators. For the 63 bed hospital, influenza
patients alone would require 90% of non-ICU beds, 227% of ICU beds, and
107% of ventilators.

Although projections are by their nature uncertain, these figures
indicate that even under a moderate scenario such as that used in the
specific VISN 8 projections, the impact on VHA facilities would be
significant as they, like most health care institutions, already run at
or near capacity.

**Table 4**

**239 Bed VA Hospital 1968-Scale Influenza Pandemic (Moderate
Scenario)**

**239 Bed VA Hospital 1968-Scale Influenza Pandemic (Moderate
Scenario)**

![239 bed VA hospital](media/image1.png){width="5.989583333333333in"
height="3.8333333333333335in"}

Radonovich, 2006; derived from FluSurge 2.0.

**Table 5**

**62 Bed VA Hospital 1968-Scale Influenza Pandemic (Moderate Scenario)**

**62 Bed VA Hospital 1968-Scale Influenza Pandemic (Moderate Scenario)**

![62 bed VA hospital](media/image2.png){width="6.0in"
height="3.65625in"}

Radonovich, 2006; derived from FluSurge 2.0.

Focusing on ventilators as a representative resource, Tables 4 and 5
list projected ventilator use in individual hospitals (239 bed and 62
bed, respectively) within VISN 8. The overall availability of
ventilators within a VISN 8 Medical Center as of May 2007 can be found
in Table 6 (Note: There are no ventilators typically used in VISN 8
Nursing Homes). On average, approximately 36.8% of all available
ventilators are in use by current inpatients at any one time. VISN 8 as
a whole would likely be able to absorb the increased demand for
mechanical ventilators related to a moderate outbreak of pandemic
influenza (167 = 32% of the current total ventilators, and 50% of those
not already in use). However, a severe outbreak would result in a
critical shortage of ventilators (1137 = 251% of the current total
ventilators, and 397% of available ventilators).

Due to unequal distribution of ventilators within networks, there may be
local shortages under either scenario. One VISN 8 facility, for example,
reports that it has no ventilators on site, while another has only a
small percentage of its ventilators in use at any point. Also, it should
be noted that these projections are for a single 12-week outbreak, and
do not factor in shortages created by subsequent outbreaks, or the
effect of any carryover patients from a previous outbreak. Finally,
disposable ventilators are designed for use by a single patient and the
supply must be replenished. The number of available disposable
ventilators will be dependent on national supply and demand.

**Table 6**

**Number of Ventilators Available and in Use in VHA Facilities -- VISN
8**

                                                                                  **VISN 8 Medical Centers Combined**
  ------------------------------------------------------------------------------- -------------------------------------
  Total number of ventilators                                                     **523**
  Number of ventilators typically in use by [chronic]{.underline} care patients   **65**
  Number of ventilators typically in use by [acute]{.underline} care patients     **131**

**[1.4.2 The Infectious Nature of Pandemic Influenza: Implications for
Health Care Institutions]{.smallcaps}**

For health care institutions, the infectious nature of a severe pandemic
influenza virus will mean that traditional strategies to divert staff
and resources to an affected area may not be feasible, both because
local areas must preserve resources that will be needed if the pandemic
arrives and because mobilization of staff and supplies can contribute to
the spread of the virus.

According to HHS, as the pandemic progresses, social distancing measures
including travel restrictions, closure of schools and day care centers,
cancellation of public events, voluntary quarantine of household members
of ill persons, and workplace measures to limit workers being in contact
with one another, would likely be imposed. In addition, because pandemic
influenza will, by definition, be a new human viral strain, definite
information about its virulence and modes of transmission may not be
immediately understood, giving rise to fear and uncertainty. In light of
these factors, a large percentage of people would likely choose to stay
home to care for children and to minimize exposure. HHS estimates that
in a severe pandemic, absenteeism attributable to illness, the need to
stay home under voluntary quarantine during the illness of a household
member, and fear of infection may reach 40% during the peak weeks of a
community outbreak (Department of Health and Human Services, February
2007).

Fear and uncertainty about the infectious nature of the viral strain as
well as estimates regarding absenteeism highlight the need for explicit
discussion and institutional planning around health care providers' duty
to provide care and the reciprocal obligations of the institution to
safeguard and support these providers.

**[1.5 Ethical Challenges in Pandemic Influenza Preparation and
Response]{.smallcaps}**

As indicated in the scenarios described in Section 1.4.1, pandemic
influenza is expected to generate demand for clinical services and
health care that significantly exceeds the availability of beds,
critical equipment (e.g., ventilators), medications, and health care
staff. With resources scarce and the pressing need to contain the spread
of the virus, health care leaders and professionals will ***be faced
with extraordinary ethical challenges centered on responsibilities
(defining the scope and limits of VHA employees' duty to provide care to
patients and reciprocal institutional obligations), rationing
(allocation of scarce resources), and restrictions (limiting individual
liberty in the interests of public health) (Wynia, 2007). Table 7
summarizes these challenges.***

***Table 7***

**Ethical Challenges in Pandemic Influenza Preparation and Response**

> **1. RESPONSIBILITIES**: The ethical "duty to provide care." The
> obligation of health care workers to accept some level of risk in the
> service of patients and the reciprocal obligation of health care
> institutions to minimize risk to health care workers.
>
> **2. RATIONING**: Allocation of scarce resources. The criteria and
> processes for decision making regarding the fair and efficient use of
> scarce resources.
>
> **3. RESTRICTIONS**: Limits on individual liberty in the interests of
> public health. Justifications and procedures for implementing
> restrictions on individual liberty to prevent the spread of infection.

**[1.6 Core Ethical Principles]{.smallcaps}**

Decision making in pandemic influenza planning and response must be
based on achieving the greatest good for the greatest number (the
principle of utility or efficiency) *within constraints of respect for
human dignity and fairness* (the principle of justice applied across
groups of people according to specified criteria). This view is echoed
in the CDC's "Ethical Guidelines in Pandemic Influenza" which states
that "a classic utilitarian approach to defining priorities...is not a
morally adequate platform for pandemic influenza planning. We
recommend...an approach to ethical justification, that, like
utilitarianism, evaluates the rightness or wrongness of actions or
policies primarily by their consequences, but...that planning should
take into account other checks...grounded in the ethical principles of
respect for persons, nonmaleficence, and justice" (Kinlaw and Levine et
al., 2007).

One of the most important roles that VHA leaders will play in pandemic
planning and response will be determining, based on reasoned
justification, how these principles will be balanced in particular
decisions. Ethical leadership in this area is grounded in the
obligations and values that define all aspects of VHA health care.

**[1.7 The Unique Obligations of VHA Leaders -- More Pronounced in
Pandemic Influenza]{.smallcaps}**

Leaders in VHA have a unique set of obligations that flows from their
overlapping roles as public servants, providers of health care, and
managers of both health care professionals and other staff. These
obligations are sharpened by VA's commitment to providing health care to
veterans as a public good, a mission born of the nation's gratitude to
those who have served in its armed forces.

-   As public servants, VHA leaders are specifically responsible for
    maintaining the public trust, placing duty above self-interest, and
    managing resources responsibly.

-   As health care providers, VHA leaders have a fiduciary obligation to
    meet the health care needs of individual patients in the context of
    an equitable, safe, effective, accessible, and caring health care
    delivery system.

-   As managers, VHA leaders are responsible for creating a workplace
    culture based on integrity, accountability, fairness, and respect.

To fulfill these roles, VHA leaders not only have an obligation to meet
*their* fundamental ethical obligations, they also must ensure that
staff throughout the organization are supported in their adherence to
high ethical standards.

All of these responsibilities become more pronounced in the context of a
public health crisis such as pandemic influenza. In anticipating and
responding to the uncertainty and upheaval of a pandemic flu, it is
crucial that VHA leaders maintain trust with employees, patients, and
with the public. Most challenging will be the need to provide health
care to individual patients in the context of severe resource shortages,
contagion risk, and the overarching goals of VA pandemic response: "to
stop, slow, or limit the spread of disease, reduce suffering and death,
and sustain the operations of the Department of Veterans Affairs"
(Department of Veterans Affairs, 2006, Section 3. p. 27).

Experts in ethics and public health have pointed out that ethical
considerations must be a central part of pandemic influenza planning and
response (Hodge et al., 2007). This insight is prompted in part by the
Severe Acute Respiratory Syndrome (SARS) experience in Toronto. In that
case, researchers state, "the costs of not addressing the ethical
concerns are severe: loss of public trust, low hospital staff morale,
confusion about roles and responsibilities, stigmatization of vulnerable
communities, and misinformation" (Thompson et al, 2006). In addition,
the SARS experience highlighted that \"where guidance is incomplete,
consequences uncertain, and information constantly changing, where
hour-by-hour decisions involve life and death, *fairness is more
important, rather than less.*\" (Bell et al., 2004).

Because a pandemic influenza crisis will affect entire facilities and
the VHA system as a whole, policies concerning altered standards of care
(e.g., allocation of scarce life-saving resources and other triage
decisions) must be the product of participatory, reasonable, and
transparent decision making at the national and local leadership level.
Decision making at this level not only promotes consistency and
fairness, but also preserves as much as possible the clinician-patient
relationship by shielding clinicians from *ad hoc* allocation decisions.

**[1.8]{.smallcaps}** []{#Leadershipdecisionprocess
.anchor}**[Leadership Decision Process for Pandemic Influenza Planning
and Response]{.smallcaps}**

As with any ethical decision, the process used by VHA leaders to make
decisions for pandemic planning and response should be informed,
participatory, values-based, beneficial, systems-focused, reasonable,
and transparent (Department of Veterans Affairs, 2007).

***1.8.1 Informed and Participatory*.** The more value-laden a decision
is or the more it involves uncertainty about the right course of action,
the more important it is that the decision be well informed. Leaders
must ensure not only that they have collected the full range of facts
that bear on a given decision but also that they understand the
perspectives of those who are (or should be) involved in making the
decision and those who will be affected by it.

Stakeholders (those who stand to benefit or be harmed by institutional
decisions) should participate actively in pandemic influenza planning
(and *post hoc* response evaluation). This includes volunteers,
employees whose duties place them at a disproportionate risk of
infection and their labor union representatives, and veterans whose care
may be affected by public health measures and/or triage protocols, and
VSO's. Stakeholders are more likely to accept leadership decisions if
the decision-making process is perceived to be informed and
participatory.

*To assist VHA leaders in their planning and to ensure that decision
making is both informed and participatory, VHA's National Center for
Ethics has developed an educational packet for health care staff
discussion forums on ethics issues including scarce resource allocation
and the ethical "duty to provide care" in pandemic preparedness. The
packet contains information for forum planners and participants and
includes: explanation as to why staff discussions are important, a
sample discussion agenda, an overview, planning points for setting up a
discussion, PowerPoint slides, scenarios and questions. This material is
available at*

***http://www.ethics.va.gov/ETHICS/activities/pandemic\_influenza\_preparedness.asp***

***1.8.2 Values-based*. Decision making that pays** explicit attention
to strongly held beliefs, ideals, principles, or standards that inform
ethical decisions or actions. Well-made decisions weigh options
carefully in relation to important organizational and social values.
This requires that the values at stake in a decision, such as fairness,
stewardship, or fidelity to mission, be clarified and explicitly
considered

A number of key ethical values have been identified as central to
pandemic influenza planning and response (University of Toronto 2005,
Kinlaw and Levine et al., 2007). They include:

> **Advance Planning and Goal Setting** -- Commitment to developing and
> clearly communicating preparedness goals and procedures in advance of
> a pandemic. One of the basic roles and responsibilities of VHA, and
> all health care institutions, is to promote health and prevent
> disease. Anticipating, planning for, and communicating strategies for
> effectively meeting the demands of pandemic influenza are essential
> for health care institutions to continue to serve this mission. In
> addition, health care institutions and their missions are sustained by
> professionalism and the commitment of staff to patient care. Creating
> and effectively communicating coherent protocols for operations during
> a crisis are essential to preserving staff commitment and
> professionalism. For example, clear work force policies indicating
> expectations and institutional responsibilities during a crisis will
> make it easier for staff to report to work. Uniform triage protocols
> will prevent ad hoc decision making, promote fairness, and enhance
> trust. Isolation protocols that use the least restrictive means will
> limit the spread of the virus while maintaining the value of
> individual liberty. Advance planning, when there is adequate time
> available, also makes it easier to ensure transparency in decision
> making.
>
> **Stewardship** -- Commitment to the responsible management of
> resources. Responsible management of resources in VHA health care
> facilities requires decision making that not only optimizes resource
> use but does so in a way that preserves fairness and human dignity.
> When resources are especially scarce, as is anticipated in a pandemic,
> responsible stewardship depends upon fair decision processes that
> avoid placing clinicians in the untenable position of making *ad hoc*
> and independent allocation decisions for individual patients.
>
> **Fair Process** -- Commitment to:

-   Ensuring that decisions are based on reasons (i.e., evidence and
    > principles) that stakeholders can agree are relevant to meeting
    > health needs in a pandemic influenza crisis.

-   Ensuring that decision makers are impartial, neutral, and
    > accountable.

-   Ensuring consistent application of allocation principles across
    > people and time (treating like cases alike).

-   Ensuring that those affected by decisions have a voice in decision
    > making.

-   Ensuring a practicable process for disputes and appeals.

-   Ensuring opportunities to revisit and revise decisions as new
    > information emerges throughout the crisis.

> **Proportionality** -- Commitment to b**alancing individual liberty
> and community interests** by:

-   Using the least restrictive public health measures necessary to
    > protect the public from harm.

-   Not exceeding what is necessary to address the actual level of risk
    > to or critical needs of the community.

-   Minimizing the negative impacts of public health measures on
    > individuals and communities.

-   Protecting, as much as possible, those who are affected by
    > quarantine or isolation restrictions from stigmatization and
    > unwarranted disclosure of private information.

-   Supporting, as much as possible, those who are affected by
    > quarantine or isolation restrictions with social supports.

> **Reciprocity** -- Institutional commitment to supporting those who
> face a disproportionate burden in serving VHA's health care mission to
> veterans and taking steps to minimize burdens as much as possible.
> Institutional commitment to employees who face a disproportionate
> burden in caring for patients. Just as the VHA mission of service to
> veterans is based on reciprocity to those who bore a disproportionate
> burden in protecting the public good, so too should reciprocity extend
> to support for those who face a disproportionate burden in serving the
> VHA mission in times of pandemic influenza.
>
> **Solidarity** -- The commitment to a common purpose and collaborative
> approaches that set aside self-interest among individuals, health care
> services, and facilities.

*This guidance uses these values as reference points for leadership
decision making in circumstances of pandemic influenza. See Sections
2-5.*

+----------------------------------------------------------------------+
| **Leadership Decision Process**                                      |
+======================================================================+
| -   **Informed and Participatory C**ollect the full range of facts   |
|     that bear on a given decision and understand the perspectives of |
|     those involved in the decision and those who will be affected by |
|     it                                                               |
|                                                                      |
| -   **Values-based Weigh** options carefully in relation to          |
|     important organizational and social values such as fidelity to   |
|     mission, fairness, stewardship, proportionality, and reciprocity |
|                                                                      |
| -   **Beneficial W**eigh the short- and long-term consequences, both |
|     positive and negative, and make sure that the benefits of the    |
|     decision outweigh potential harms                                |
|                                                                      |
| -   **Systems-focused** Examine and address underlying systems       |
|     issues that may cause or contribute to ethical concerns          |
|                                                                      |
| -   **Reasonable Ensure that decisions rest** on a defensible        |
|     decision-making process and sound reasoning                      |
|                                                                      |
| -   **Transparent** When communicating final decisions, explain how  |
|     the decision was made, who was involved in making it and the     |
|     reasoning behind it                                              |
+----------------------------------------------------------------------+

***1.8.3 Beneficial*.** Ethical decision making requires that leaders
weigh the short- and long-term consequences, both positive and negative,
and make sure that the benefits of the decision outweigh potential
harms. Making those determinations involves fairly balancing the
different interests of stakeholders, including veterans, staff, the
organization, and often, the community. Leaders may find it helpful to
consider best-case and worst-case scenarios as a way of thinking about
the impact a decision will have on different parties or different
activities across the organization. Leaders should also recognize that
decisions can result in unintended and unforeseeable consequences as
well as unintended but foreseeable consequences. To the greatest extent
possible, leaders should assess the impact of their decisions
prospectively and after implementation of these decisions in order to
mitigate the effect of any negative consequences. One of the predictable
ethical challenges of any public health crisis involves balancing the
welfare of individuals and the public welfare in order to stop the
spread of disease and optimize resource use.

*This document provides leaders with specific guidance on balancing
these interests in circumstances of pandemic influenza. See Sections
2-5.*

***1.8.4 Systems-focused*.** Ethical decision making should include an
examination of underlying systems issues that may cause or contribute to
ethical concerns. Addressing underlying systems issues can help to
ensure that these concerns do not recur since the underlying cause of
the ethical concern has been removed. Focusing on systems issues can
help to ensure that the decision establishes a precedent that can be
applied to other similar cases.

*This document provides leaders with specific guidance on coordination
to achieve integrated and consistent practices in the event of pandemic
influenza. See Sections 2-5.*

***1.8.5 Reasonable.*** Leaders should consider how their decisions will
be perceived by persons other than those directly involved in the
decision-making process or immediately affected by a given decision
itself. Imagining whether a decision would seem reasonable to a friend
or family member or to a mentor or respected colleague outside the
organization can be a useful exercise. Asking, "Would I be able to
defend this decision to patients, external stakeholders, the media, or
the general public?" can be another test to ensure that decisions have
been considered from all angles and are ethically justifiable. Even
people who disagree with a decision will be more likely to accept it if
they perceive the decision-making process as fair and understand the
rationale behind the decision.

***1.8.6 Transparent*. Practicing ethical decision making requires that
decisions be transparent to those affected by them. Leaders should
explain to the individuals who have a stake in an ethical decision both
the process used to make the decision and the reasons why certain
options were chosen over others. Even people who disagree with a
decision will be more likely to accept it if they perceive the
decision-making process as fair and understand the rationale behind the
decision.**

*This document provides leaders with well reasoned and explicit
justifications for difficult choices that will need to be made in the
event of pandemic influenza. See Sections 2-5.*

[]{#ObligofHCProfessionals .anchor}**[1.9 The Obligations of VHA
Clinicians as Health Care Professionals]{.smallcaps}**

In addition to the values that guide pandemic planning and response at
the VHA leadership level, there are norms of health care professionalism
that are relevant to *clinical* decision making during a pandemic. These
norms stem from the unique nature of the clinician-patient relationship.
Anticipating the significant strain that a pandemic influenza will place
on health care professionals, this document provides guidance on
interpretation and implementation of professional obligations in a
crisis situation and on institutional steps to preserve, as much as
possible, the clinician-patient relationship and its traditional
governing norms.

***1.9.1 The Ethical Duty to Provide Care and Non-Abandonment***

Beyond the general obligation to benefit patients, the ethical duty to
provide care embodies a commitment by health care professionals to
deliver this care even at some personal risk to themselves.
Non-abandonment is the minimum requirement of a duty to provide care.
Ordinarily the obligation of non-abandonment requires clinicians to
ensure that patients in their care are appropriately transferred to a
comparable provider should the circumstances require it. In a pandemic
situation when staff resources are limited, there may be no realistic
option for transfer. Under such circumstances, where health care
professionals are subject to significantly higher personal risk while
caring for patients, fulfilling this obligation will depend on
facilities taking concrete steps to remove barriers to work attendance
including assisting staff with meeting competing role-based obligations
(e.g., family), meeting basic needs while on the job (e.g., food, rest),
mitigating occupational risk (e.g., through provision of personal
protective equipment, antivirals, and vaccines), and clarifying what
stricken staff and their families can expect in terms of institutional
care and support.

*Because the level of risk accompanying a pandemic is significantly
greater than what health care professionals assume under ordinary
circumstances, this document provides specific guidance on the scope and
limits of the ethical duty to provide care as well as reciprocal
institutional obligations to support personnel who place themselves at
risk. See Section 2.*

***1.9.2 Respect for Persons***

The principle of respect for persons **is a key element of**
professional codes of ethics, patients' rights documents, and
philosophical and theological frameworks for health care ethics. The
principle assumes the inherent worth and dignity of human beings and, on
this basis, establishes both the equality of persons and the notion that
persons should be treated as ends in themselves (Purtilo, 2004 p. 2152).
This principle has been expressed most prominently in terms of respect
for patient autonomy.

Patient autonomy will be limited in a number of ways during pandemic
influenza. (Kuschner et al, 2007) In some cases, autonomy will be
limited by absolute scarcity of resources. In others, it will be in
tension with compelling public health goals to limit the spread of
disease and to optimize the use of resources that are scarce:

-   Under circumstances of dire scarcity, fairness and efficiency will
    require the implementation of triage criteria. Only those patients
    who meet stringent inclusion criteria will be eligible for
    life-saving equipment such as ventilators and other critical care
    resources. Patients who do not meet inclusion criteria will be
    triaged to receive palliative care only.

-   Because of resource scarcity, clinicians will not have the ordinary
    array of treatment options to offer and patients will not have the
    ordinary range of options from which to choose. Despite the
    constrained choices patients may have under conditions of pandemic
    influenza, informed consent discussions should occur according to
    clinical standards.

-   In order to prevent the spread of the virus, a patient's freedom of
    movement may be restricted. For example, patients who are exposed to
    the influenza virus may be subject to liberty-limiting restrictions
    such as isolation.

Given these limits on patient choice, a narrow focus on autonomy must,
of necessity, give way to a broader focus on respect for the dignity and
humanity of patients and their families in the crisis situation. This
will entail making it as clear as possible to patients and their
families which goals of care are attainable under these circumstances;
how decisions regarding their care will be made; respecting, as much as
possible, patient preferences; and, in cases in which patient treatment
preferences cannot be met, acknowledging the toll that the curtailment
of options may take on a patient and family.

Where limitations on patient autonomy are required to achieve public
health goals, clinicians must be supported by institutional protocols
that use standard decision procedures and the least restrictive means
possible to achieve those goals. Just as in ordinary circumstances,
institutional policies and procedures regarding resource use or
constraints on patient autonomy are necessary to, as much as possible,
preserve the clinician-patient relationship.

*This document anticipates the ways in which patient autonomy will be
limited during pandemic influenza and provides guidance for VHA leaders
and clinicians regarding justifications for such limits and measures to
minimize burdens on patients. Guidance is also provided regarding
respect for the humanity and dignity of patients through palliative and
supportive care. See Sections 3-5.*

***1.9.3 Duty to Benefit and Prevent Harm***

Expressed in the Hippocratic writings as "to help or at least to do no
harm", the obligation to benefit patients and prevent harm to them is
the oldest and most basic tenet of medical ethics. This elemental
presumption is embodied in professional standards of care. In a
pandemic, ordinary standards of care will need to be adjusted as a
result of resource scarcity and the need to sustain overall health care
operations. For example, lack of resources will limit the range of
beneficial treatments that are available to patients. Similarly,
protocols to optimize resource use will exclude some patients from
receiving life-saving treatments if they do not meet objective triage
criteria. In addition, preventing harm, in particular by preventing the
spread of infection to patients or third parties, may involve limiting
patients' access to their families and loved ones.

Although obligations to benefit and prevent harm may be justifiably
overridden in these circumstances, they can never be erased. Even in
extreme circumstances, clinicians must find ways of minimizing harm to
individual patients and providing whatever benefit is obtainable under
the circumstances.

*This document provides guidance to clinicians who are faced with
providing benefit and minimizing harm under altered standards of care.
See Sections 3 and 4.*

***1.9.4 Fairness***

As an obligation of health care professionals, fairness or justice
requires that clinicians treat patients in a manner that is unbiased,
consistent, and based on the best available clinical evidence and
protocols. *See Section 3.*

[]{#Section2 .anchor}**SECTION 2: RESPONSIBILITIES---WORK FORCE CAPACITY
AND A "DUTY TO CARE" UNDER CONDITIONS OF PANDEMIC INFLUENZA**

Under conditions of pandemic influenza, VHA employees have an obligation
to provide care to patients (i.e., an ethical "duty to provide care")
even at some personal risk to themselves. This duty is grounded in
fidelity to VHA's public service mission as well as an obligation of
care and non-abandonment owed to the veterans VHA is privileged to
serve. The ability of caregivers to fulfill their ethical duty to
provide care to patients under conditions of pandemic influenza is
predicated on facility leaders meeting their reciprocal obligations.
These reciprocal obligations center on addressing workplace conditions
that enable caregivers to take care of patients, but also include
reciprocity owed those employees who voluntarily assume a
disproportionate risk of illness and even death to fulfill VHA's
mission. VHA facility leaders must incorporate into pandemic influenza
planning considerations regarding the scope and limits of a duty to
provide care both on the part of VA employees and the institution
itself.

**[2.1 Risk, Responsibility and Work force Capacity: Lessons from Public
Health Emergencies]{.smallcaps}**

In a sobering assessment of work force availability during pandemic flu,
HHS projects that during the peak period of a severe pandemic,
"absenteeism attributable to illness, the need to care for ill family
members, and fear of infection may reach 40%" (U.S. Department of Health
and Human Service, 2007). In fact, the risk of morbidity and mortality
to frontline health care workers in a pandemic is estimated to be much
higher than the level of risk implicitly accepted by virtue of being a
care provider. The SARS epidemic is instructive. Health care
professionals were disproportionately infected relative to the
population as a whole. For example, in Canada, of 141 probable cases of
SARS, 65% of these diagnoses involved health care professionals. In
Vietnam, nearly all reported deaths from SARS were of doctors and
nurses. In Hong Kong, a quarter of all patients treated for SARS were
health care workers (Emanuel, 2003).

Absenteeism among healthy employees may occur if employees are uncertain
whether they have an obligation to continue to provide care to patients
when that care entails more than minimal risk to the employee. This
uncertainty will be especially pronounced for non-clinicians who are
asked to assume clinical support roles outside of their usual duties.
Professional associations have offered only limited guidance on this
issue. For example, the American Nurses Association asserts that nurses
must take limited personal risks if the benefit to patients outweighs
that risk (ANA, 1994). The American College of Physicians Ethics Manual
(American College of Physicians, 1998) states that "\[t\]raditionally,
the ethical imperative for physicians to provide care has overridden the
risk to the treating physician, even during epidemics". Although an
ethical duty to provide care was conceded by professional associations
in relationship to human immunodeficiency virus/acquired
immunodeficiency syndrome (HIV/AIDS) (Morin et al., 2006), this duty was
based on an assessment that the risk of infection to care providers was
minimal and therefore that the obligation was proportionate to that risk
(Reid, 2005).

**[2.2 The Ethical Duty to Provide Care: Considerations for Pandemic
Planning in VHA]{.smallcaps}**

Continuing to provide care to patients during a public health emergency
depends on the availability of a work force that can respond to the
crisis. Given the known challenges of sustaining an adequate work force
during public health emergencies, it is incumbent on VHA leaders to
incorporate into pandemic influenza planning the following
considerations regarding the scope and limits of an ethical duty to
provide care both on the part of VA employees and the institution itself
through its policies and procedures.

***2.2.1 Scope and Limits of an Ethical Duty to Provide Care***

> Do health care professionals have an ethical duty to provide care
> under conditions of pandemic influenza in spite of the elevated risk
> of morbidity and mortality associated with the discharge of these
> duties? If such an ethical duty exists, is it a limited or unlimited
> duty?

A strong but limited ethical duty to provide care (i.e., ethical
obligation to provide care to patients even at some personal risk)
exists for all VHA employees but especially for professional caregivers
such as doctors, nurses and other allied health care professionals. This
duty to provide care is grounded in a number of ethical tenets. Central
among these are VHA's public service mission to veterans; an ethic of
care that includes non-abandonment of patients, solidarity with one's
colleagues in terms of burden sharing (e.g., work load, risk of
infection), and a "contract" with society that subsidizes clinician
education and allows professionals to regulate themselves on the
condition that professionals will serve the general good.

Although a clear ethical duty to provide care exists, especially for
health care professionals, this duty is not without limit. However,
there is no bright line demarcating when, or even if, the level of
personal risk relieves clinicians from the duty to their patients. In
its 2004 opinion, "Physician Obligation in Disaster Preparedness and
Response" (AMA, 2004), the American Medical Association (AMA) stated
that "National, regional, and local responses to epidemics, terrorist
attacks, and other disasters require extensive involvement of
physicians. Because of their commitment to provide care to the sick and
injured, individual physicians have an obligation to provide urgent
medical care during disasters. This ethical obligation holds even in the
face of greater than usual risks to their own safety, health or life
(AMA, 2004). The AMA also notes that the clinician work force is a
limited resource and as such, the level of risk that clinicians assume
in disaster response may have an effect on the ability of clinicians to
provide care to patients in the future. Institutions play an important
role in mitigating that risk by providing clinicians and other
front-line caregivers with adequate protections.

Strikingly, during the SARS epidemic, most health care professionals
continued to care for patients, in spite of convincing evidence that the
risk to these caregivers exceeded minimal risk (Farrow, 2003). In
circumstances of pandemic influenza, each individual employee will
likely establish their own limits by weighing and balancing their
obligation to patients and colleagues (i.e., if not me, then who?) with
other obligations (e.g., self, family), against the backdrop of
heightened personal risk. Health care workers' willingness to expose
themselves to risk will be significantly affected by their level of
confidence in the protections and support provided to them by the
institution that employs them. (Mackler et al., 2007; Anantham et al,
2008)

> If an ethical duty to provide care exists, does it apply equally to
> all facility employees (e.g., leaders, clinical support staff, other
> support staff such as accountants, housekeepers) or only to
> professional caregivers (e.g., doctors, nurses and allied health
> providers)?

For non-professional health care workers (e.g., nursing assistants, food
service workers, housekeepers, lab technician, therapy aides,
volunteers) or others who indirectly support care delivery (e.g.,
clerks, accountants, health care record management personnel) the duty
to provide care has not been thoroughly debated in the ethics
literature. Unlike doctors or nurses, non-professional health care
workers are not generally obligated by history, tradition or a
particular code of ethics to assume significant personal risk when
caring for patients. These workers, however, may be obligated by virtue
of their employment (Reid, 2005, North Carolina Institute of Medicine,
2007). Further, as public servants, all VHA employees have an ethical
duty not only to assist the VHA in maintaining essential functions under
conditions of pandemic influenza but also to serve the VHA mission of
service to veterans. Importantly, many of these employees (including
non-clinical staff) may be called upon to assume an expanded role in
support of patient care, and should be prepared (to the extent possible)
in advance of pandemic influenza for the assumption of these duties.
Importantly, because the wages of many non-professional health care
workers are low, these workers and their families may be
disproportionately burdened if the worker is stricken by influenza. In
weighing the institution's reciprocal duties towards employees, VHA
leaders must factor this disproportionate burden into their decision
making.

***2.2.3 Reciprocal Institutional Obligations***

> Are there reciprocal institutional duties to be borne by VHA in
> solidarity with "at risk" facility employees?

As a health care institution, VHA has an obligation not to leave
patients without care during a public health emergency. Likewise, VHA's
public service mission to veterans entails that VHA will accord priority
during a pandemic to the delivery of health care to enrolled veterans
and beneficiaries (U.S. Homeland Security Council, 2006, p. 115).
Whereas clinicians meet their obligations directly, through ongoing care
of patients, VHA leaders and managers meet this obligation indirectly
through shaping the overall care delivery system.

Specifically, VHA facility leaders have an obligation (in planning for
and in responding to pandemic influenza) to optimize workplace
conditions in order to *enable* doctors, nurses and other caregivers to
discharge their duty to patients. A minimum floor of *enabling*
obligations to be borne by VHA facilities includes:

-   taking the steps necessary to ensure an adequate work force,

-   providing for employees' and volunteers basic human needs while on
    the job,

-   assuring a safe and secure work environment,

-   mitigating occupational health risks, and

-   attending to those employees (and their families) who succumb to
    pandemic influenza (Department of Veterans Affairs, 2006, Sections
    2.2.3.2 and 2.2.3.8).

The principle of reciprocity obligates facilities to support those
employees and volunteers who assume a disproportionate burden
(heightened risk of morbidity and mortality) in service of the public
good (care of veterans), and to minimize those burdens to the greatest
extent possible (Emanuel, 2003; Joint Center for Bioethics, 2005; North
Carolina Institute of Medicine, 2007).

Fairness demands that these reciprocal obligations be applied across
categories of employees and should not be differentially allocated
without justification. For example, during Hurricane Katrina, solidarity
among employees and between employees and managers was compromised when
a facility provided only physicians, and not nurses and other direct
care providers, with places to sleep and shower (Chaffee, 2006). All of
these employees were working multiple back-to-back shifts in order to
continue to provide care to patients. VHA facility leaders should ensure
that all direct care providers are treated similarly (e.g., provision of
facilities to rest). In order to maintain trust in our health care
system, fairness becomes more, not less important during a public health
crisis (Thompson et al., 2006).

The role of facility leadership will be crucial during a pandemic -- to
show solidarity with care providers, to optimize work place conditions
and to skillfully manage surge capacity in order to ensure a consistent
level of personnel and other resources. The code of ethics for health
care executives requires that leaders act as "moral role models" thereby
meriting the trust, confidence, and respect of health care professionals
and the general public (ACHE, 2003). To merit the trust and confidence
of employees and patients during a pandemic, leaders should be
physically present at their respective facilities and be actively
involved in supporting both clinical and non-clinical staff in ensuring
the delivery of care to veterans and the provision of essential services
to employees. Among the many lessons from Hurricane Katrina is the
importance of developing an effective administrative operation in a
chaotic setting (Curiel, 2006, Sine, 2007), including effective policies
and procedures for the care of staff family members, clear staff recall
procedures, including provisions for communication, compensation, and
rest. (Sine, 2007)

Table 8 summarizes the range of reciprocal obligations cited in the
ethics literature and specifies current VHA authority to fulfill them.

[]{#Table8 .anchor}**Table 8**

**Reciprocal Obligations Cited in the Ethics Literature and Current VHA
Authority**

+-----------------+-----------------+-------------+-----------------+
| **Reciprocal    | **Current VHA   |             |                 |
| Facility        | Authority**     |             |                 |
| Obligations**   |                 |             |                 |
+=================+=================+=============+=================+
| \(A\) Provide   | Help employees  | Yes         | See 38 U.S.C.   |
| practical       | meet multiple   |             | §7809 and VA    |
| assistance to   | role            |             | Pandemic        |
| remove barriers | obligations     |             | Influenza Plan  |
| to work         | including child |             | Appendix B-2,   |
| attendance      | or dependent    |             | TABLE OF LEGAL  |
|                 | care            |             | AUTHORITIES AND |
|                 |                 |             | POLICIES        |
|                 |                 |             | RELEVANT TO     |
|                 |                 |             | EMERGENCIES,    |
|                 |                 |             | Section I,      |
|                 |                 |             | subsection D.   |
+-----------------+-----------------+-------------+-----------------+
|                 | Pet care        |             | No specific     |
|                 |                 |             | authority       |
|                 |                 |             | needed.         |
|                 |                 |             | Discretion of   |
|                 |                 |             | local           |
|                 |                 |             | leadership      |
+-----------------+-----------------+-------------+-----------------+
|                 | Provide         | Yes         | See VA Pandemic |
|                 | employees       |             | Influenza Plan  |
|                 | transportation  |             | Appendix B-2,   |
|                 | assistance to   |             | TABLE OF LEGAL  |
|                 | get to and from |             | AUTHORITIES AND |
|                 | work if needed  |             | POLICIES        |
|                 |                 |             | RELEVANT TO     |
|                 |                 |             | EMERGENCIES,    |
|                 |                 |             | Section V:      |
|                 |                 |             | Home-to Work    |
|                 |                 |             | Transportation  |
|                 |                 |             | of Employees    |
+-----------------+-----------------+-------------+-----------------+
| \(B\) Utilize   | Authorize       | Yes         | See 5 CFR       |
| all available   | hazardous duty  |             | 550.904 and     |
| pay             | pay for Title 5 |             | Office of       |
| flexibilities   | employees       |             | Personnel       |
| for employees†  |                 |             | Management,     |
|                 |                 |             | Frequently      |
|                 |                 |             | Asked Questions |
|                 |                 |             | About Hazardous |
|                 |                 |             | Duty Pay For    |
|                 |                 |             | Federal         |
|                 |                 |             | Employees.      |
|                 |                 |             | Available at    |
|                 |                 |             | http://www.op   |
|                 |                 |             | m.gov/oca/pay/h |
|                 |                 |             | tml/hazduty.asp |
+-----------------+-----------------+-------------+-----------------+
|                 | Authorize       | Yes         | See 5 U.S.C.    |
|                 | overtime pay    |             | §5544 and VA    |
|                 | for wage grades |             | Handbook 5007   |
+-----------------+-----------------+-------------+-----------------+
|                 | Authorize       |             | See 5 U.S.C.    |
|                 | overtime pay    |             | §5542           |
|                 | for general     |             |                 |
|                 | schedule (GS)   |             |                 |
|                 | employees       |             |                 |
+-----------------+-----------------+-------------+-----------------+
|                 | Authorize       | Yes limited | Currently       |
|                 | overtime for    |             | authorized for  |
|                 | certain Title   |             | nurses and      |
|                 | 38 employees    |             | hybrid          |
|                 |                 |             | employees, but  |
|                 |                 |             | not physicians, |
|                 |                 |             | dentists,       |
|                 |                 |             | podiatrists,    |
|                 |                 |             | chiropractors,  |
|                 |                 |             | and             |
|                 |                 |             | optometrists.   |
|                 |                 |             | 38 U.S.C.       |
|                 |                 |             | §§7453 and      |
|                 |                 |             | 7454.           |
+-----------------+-----------------+-------------+-----------------+
|                 | Ensure (to      | Yes         | See VA Pandemic |
|                 | extent          |             | Influenza Plan  |
|                 | possible)       |             | Appendix B-2,   |
|                 | access to       |             | TABLE OF LEGAL  |
|                 | medical         |             | AUTHORITIES AND |
|                 | resources, if   |             | POLICIES        |
|                 | stricken        |             | RELEVANT TO     |
|                 |                 |             | EMERGENCIES,    |
|                 |                 |             | Section I C &   |
|                 |                 |             | D: VA Authority |
|                 |                 |             | to Provide      |
|                 |                 |             | Hospital Care   |
|                 |                 |             | and Medical     |
|                 |                 |             | Services to     |
|                 |                 |             | non-VA          |
|                 |                 |             | Beneficiaries.  |
+-----------------+-----------------+-------------+-----------------+
| \(C\) Minimize  | Provide         | Yes         | Current         |
| legal exposure  | immunity from   |             | authority       |
| of employees    | personal        |             | exists under    |
|                 | liability for   |             | the Federal     |
|                 | non-clinical    |             | Tort Claims     |
|                 | staff providing |             | Act. Recommend  |
|                 | clinical        |             | to Department   |
|                 | support for     |             | of Justice that |
|                 | hospice and     |             | employees'      |
|                 | palliative care |             | actions in      |
|                 |                 |             | providing       |
|                 |                 |             | pandemic        |
|                 |                 |             | treatment       |
|                 |                 |             | support be      |
|                 |                 |             | found within    |
|                 |                 |             | the scope of    |
|                 |                 |             | their           |
|                 |                 |             | employment.     |
|                 |                 |             | NOTE: Legal     |
|                 |                 |             | authority does  |
|                 |                 |             | not currently   |
|                 |                 |             | exist to        |
|                 |                 |             | protect         |
|                 |                 |             | contractors or  |
|                 |                 |             | their employees |
|                 |                 |             | under the       |
|                 |                 |             | Federal Tort    |
|                 |                 |             | Claims Act.     |
|                 |                 |             | Contract        |
|                 |                 |             | employees       |
|                 |                 |             | should check    |
|                 |                 |             | with their      |
|                 |                 |             | malpractice     |
|                 |                 |             | insurer to make |
|                 |                 |             | sure that their |
|                 |                 |             | coverage would  |
|                 |                 |             | extend to       |
|                 |                 |             | actions taken   |
|                 |                 |             | under an        |
|                 |                 |             | altered scope   |
|                 |                 |             | of practice     |
|                 |                 |             | during a        |
|                 |                 |             | pandemic.       |
+-----------------+-----------------+-------------+-----------------+
|                 | Provide         | Yes         | Current         |
|                 | immunity from   |             | authority       |
|                 | personal        |             | exists under    |
|                 | liability for   |             | the Federal     |
|                 | employees       |             | Tort Claims     |
|                 | practicing      |             | Act. Recommend  |
|                 | outside scope   |             | to Department   |
|                 | of practice     |             | of Justice that |
|                 | under altered   |             | employees\'     |
|                 | standards of    |             | actions in      |
|                 | care            |             | providing       |
|                 |                 |             | pandemic        |
|                 |                 |             | treatment       |
|                 |                 |             | support be      |
|                 |                 |             | found to be     |
|                 |                 |             | within the      |
|                 |                 |             | scope of their  |
|                 |                 |             | employment      |
+-----------------+-----------------+-------------+-----------------+
| \(D\) Safeguard | Ensure that     | Yes         | See: VA         |
| employees       | basic human     |             | Pandemic        |
| health and      | needs (e.g.,    |             | Influenza Plan, |
| well-being      | food, water,    |             | §2.2.3.2;       |
| while at work   | rest) are met   |             | §2.2.3.8        |
|                 | while on the    |             |                 |
|                 | job             |             | See 38 U.S.C.   |
|                 |                 |             | 1785 and 7421;  |
|                 | Ensure priority |             | VA Pandemic     |
|                 | access to       |             | Influenza Plan  |
|                 | vaccines,       |             | §§ 3.2.3.4 and  |
|                 | antivirals,     |             | .5.             |
|                 | personal        |             |                 |
|                 | protective      |             |                 |
|                 | equipment and   |             |                 |
|                 | other           |             |                 |
|                 | non-medical     |             |                 |
|                 | counter         |             |                 |
|                 | measures to     |             |                 |
|                 | limit           |             |                 |
|                 | occupational    |             |                 |
|                 | hazards         |             |                 |
|                 |                 |             |                 |
|                 | Provide         |             |                 |
|                 | sufficient      |             |                 |
|                 | security to     |             |                 |
|                 | ensure personal |             |                 |
|                 | safety          |             |                 |
+-----------------+-----------------+-------------+-----------------+
|                 | Provide         | Yes         | See: VA         |
|                 | critical        |             | Pandemic        |
|                 | incident        |             | Influenza Plan, |
|                 | de-briefing and |             | §2.2.3.9        |
|                 | access to       |             |                 |
|                 | mental health   |             |                 |
|                 | and chaplaincy  |             |                 |
|                 | services        |             |                 |
+-----------------+-----------------+-------------+-----------------+
| \(E\) Authorize | Authorize death | Yes         | Federal         |
| income          | benefits to     |             | Employees       |
| replacement to  | ensure income   |             | Compensation    |
| stricken        | replacement     |             | Act. See: VA    |
| employees and   |                 |             | Pandemic        |
| their families  |                 |             | Influenza Plan, |
|                 |                 |             | Section 4:      |
|                 |                 |             | RECOVERING FROM |
|                 |                 |             | PANDEMIC        |
|                 |                 |             | INFLUENZA. VA   |
|                 |                 |             | states that it  |
|                 |                 |             | will assist in  |
|                 |                 |             | providing death |
|                 |                 |             | benefits to     |
|                 |                 |             | surviving       |
|                 |                 |             | family members  |
|                 |                 |             | of staff who    |
|                 |                 |             | die from        |
|                 |                 |             | exposure to     |
|                 |                 |             | pandemic        |
|                 |                 |             | influenza in    |
|                 |                 |             | the course of   |
|                 |                 |             | their duties    |
+-----------------+-----------------+-------------+-----------------+
|                 | Provide         | No          |                 |
|                 | enriched        |             |                 |
|                 | disability      |             |                 |
|                 | benefits        |             |                 |
+-----------------+-----------------+-------------+-----------------+
|                 | Provide         | No          |                 |
|                 | enriched life   |             |                 |
|                 | insurance       |             |                 |
+-----------------+-----------------+-------------+-----------------+

†For additional information, see the Human Resources Flexibilities
Templates & Resources at the VA Office of Human Resource Management
Pandemic Resource Center. Available at
<http://www1.va.gov/ohrm//Worklife/Pandemic/HRTemplates_Resources.htm>

**[2.3 Recommended Actions]{.smallcaps}**

***2.3.1 Stakeholder Participation***

-   Facility leaders should actively engage stakeholders in pandemic
    influenza planning and preparation. Primary stakeholders are those
    employees (e.g., direct care providers, employees who will be asked
    to assume clinical support roles, volunteers) whose duties place
    them at disproportionate risk of occupational exposure during
    pandemic flu. Not only does this type of engagement increase
    employee trust in leaders and in the fairness of decision-making
    processes, but training and discussion about a duty to provide care
    may be one method facility leaders can utilize to promote greater
    commitment and responsibility at the individual level (Wynia, 2007)
    and thereby optimize the available work force. To assist leaders,
    the National Center for Ethics has developed an educational packet
    for staff discussion forums on ethics issues in pandemic
    preparedness. The packet contains information for forum planners and
    participants and includes: an explanation as to why staff
    discussions are important, a sample discussion agenda, an overview,
    planning points for setting up a discussion, PowerPoint slides,
    scenarios and questions. This material is available at
    [http://www.ethics.va.gov/ETHICS/activities/pandemic\_influenza\_preparedness.asp](blocked::http://www.ethics.va.gov/ETHICS/activities/pandemic_influenza_preparedness.asp)

***2.3.2 The Ethical Duty to Provide Care***

-   VHA leaders should communicate to employees and volunteers that
    coming to the aid of those who fall ill during an influenza
    pandemic, or other large disease outbreak, may be one of the most
    important and commendable activities of a lifetime. Veterans have
    entrusted their lives to the VHA employees who serve and support
    them. The need for the collective skills of all staff will never be
    more crucial than during a pandemic.

-   Facility leaders should explicitly articulate employer expectations
    and employee responsibilities in advance of pandemic flu. Leaders
    should unambiguously communicate that [all]{.underline} employees in
    a health care system are "essential" during a health care crisis,
    not only clinicians and clinical support staff. Reinforcing the
    employees' duty to provide care in the context of a public health
    emergency is a crucial component of surge planning.

-   Facility leaders should adopt and implement a fair and consistent
    decision-making process to specify the limits or exceptions to
    employees' duty to provide care. Criteria that have been cited in
    the literature to exempt employees from disaster duty include:

    -   An employee who is a parent and whose spouse/partner is also
        required to work during a disaster/pandemic (e.g., fire/rescue,
        nurse, law enforcement).

    -   An employee who is the sole provider for care of elderly,
        disabled or chronically ill persons.

    -   An employee who is a single parent of young children.

-   Facility leaders should exercise maximal flexibility in scheduling
    and worksite assignments to enable employees to come to work yet
    maintain home responsibilities as well.

-   Facility leaders should avoid coercive strategies (e.g., threats of
    terminating employment) in work force planning on both ethical and
    prudential grounds. Coercive strategies are ethically problematic
    given the exigent circumstances that many employees will be
    grappling with (e.g., more patients than resources, personal risk of
    morbidity or mortality, sick family members), and as a result are
    unlikely to succeed. Incentives, such as hazardous duty pay, are an
    ethically permissible means of motivating employees to continue to
    discharge their workplace responsibilities during conditions of
    pandemic flu and for certain Title 5 and wage grade employees,
    premium pay is required for exposure to hazards. [(See
    Table 8)](#Table8) However lack of incentives such as overtime or
    hazardous duty pay does not eliminate the employees' obligations.

***2.3.3 Reciprocal Institutional Obligations***

> VHA leaders and facility leaders should:

-   Clearly delineate and communicate in advance what employees can and
    cannot expect in terms of reciprocity from VHA. Importantly, VHA
    does not presently have the authority to realize all of the
    reciprocal obligations cited in the literature. Where possible VHA
    leaders may wish to selectively seek authority, for example, to
    provide hazardous duty pay to employees who place themselves at
    inordinate risk in order to provide care to veterans.

-   Openly acknowledge that the risks anticipated to be associated with
    pandemic influenza exceed risks to which employees are normally
    exposed in the course of enacting their duties. VHA leaders should
    clearly delineate how the facility will safeguard employee well
    being (e.g., security, building and infrastructure safety), mitigate
    occupational risk (e.g., availability of protective equipment such
    as masks, gloves, vaccine), and clarify what stricken staff and
    their families can expect in terms of institutional care and
    support.

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-   Ensure that at a minimum, their facility has a plan to affirmatively
    help employees fulfill their duty to provide care by taking concrete
    steps to remove barriers to work attendance including assisting
    staff in meeting competing role-based obligations (e.g., family),
    meeting basic needs (e.g., food, rest), and taking actions to
    safeguard health and well being.

-   Ensure that a work force plan is developed (and communicated) that
    anticipates the degree to which non-clinical support staff,
    designated volunteers and management will be called upon to assume
    roles in support of direct delivery of care to veterans and fallen
    colleagues. Staff should be aware of the range of duties they may be
    called upon to fulfill and the potential liability issues should be
    discussed. An important aspect of facility planning will include
    "cross training" of and the development of "just in time" training
    capabilities (North Carolina Institute of Medicine, 2007) for these
    employees, as well as for clinical employees. Incorporate a process
    for granting disaster privileges into their credentialing and
    privileging process and emergency management plan. (VHA Handbook
    1100.19, Credentialing and Privileging)

-   Ensure that advance planning is rigorous, tested in field conditions
    and includes extensive preparation and training of staff. Disaster
    response depends on a level of operational interdependency and
    horizontal functioning that is uncommon in day-to-day care delivery.
    More typically, institutions function vertically, like silos, both
    before and after disasters. As experts have observed, there is a
    false belief that the onset of a public health emergency will
    suddenly and magically lead to "robust horizontal communication and
    cooperation" (Deputy Editor et al., 2007).

[]{#Section3 .anchor}**SECTION 3: RATIONING---TRIAGE AND THE ALLOCATION
OF SCARCE LIFE-SAVING CLINICAL RESOURCES**

Resource allocation is an aspect of normal operations in the VHA medical
care system. At the policy and administrative level, macro allocation
decisions are made with regard to eligibility and to the distribution of
funds and resources among hospitals and programs. At the clinical level,
clinical criteria are applied to determine appropriate allocation of
drugs, devices, and ICU beds to individual patients. The goal of these
allocation practices is to efficiently and fairly steward limited
resources.

Under ordinary circumstances, triage is a particular clinical strategy
for optimizing the use of resources that are insufficient to meet the
needs of all patients. Triage (also called "secondary triage" in this
context) is routinely used to prioritize patients who present for
emergency treatment. Typically, a triage nurse will assess all incoming
patients on arrival to determine acuity level and appropriate
disposition, (e.g., to registration, waiting room, exam room, urgent
care, or clinics).

In mass casualty events, such as natural or man-made disasters, The
National Disaster Medical System has designated Simple Triage and Rapid
Treatment (START) as the method for initial or "primary field triage",
to sort patients into four care categories: non-salvageable, major
injury, minor injury, and walking wounded. A second-phase field triage
process called Secondary Assessment of Victim Endpoint (SAVE) is used to
sort those in the major and minor injury categories who can derive the
most benefit from scarce treatment resources. Depending on the nature of
the event (e.g., infectious versus non-infectious), the number of
persons seeking medical assistance, and the availability of medical
resources, field triage may entail sending patients to hospitals,
clinics, alternate care sites, or to their homes.

A different level of triage, "tertiary triage" for patients who are in
or who have presented to an acute care facility, is the focus of the
guidance provided in this document. At this level, triage decisions
focus specifically on the allocation of scarce life-saving clinical
resources such as ventilators, ICU beds, and medications used to treat
those who are gravely ill from influenza and other illnesses. Under
conditions of dire scarcity, it is expected that need will outstrip
resources and consequently that it will not be possible to provide
everyone the care that they require to survive. The purpose of the
allocation protocol presented here is to direct scarce resources
[away]{.underline} from patients who are expected to die and who have
non-urgent needs, and to direct resources [towards]{.underline} patients
with treatable emergent illness. The allocation protocol is intended to
provide a fair, consistent and rational basis for making these difficult
decisions.

In what follows, this guidance provides specific proposals for (1)
establishment of a Scarce Resource Allocation (SRA) team and a Triage
team and (2) a **protocol for allocation of scarce life-saving resources
in VHA during an influenza pandemic. (Tabery et al, 2008)**

**[3.1 Establishment of Scarce Resource Allocation (SRA) and Triage
Teams]{.smallcaps}**

The VHA Facility Director or chief of staff should identify, before the
need arises, specific members of a Scarce Resource Allocation (SRA) team
(Kuschner et al., 2007) or comparable structure (See Figure 1) as part
the facility Incident Command structure (ICS) and Emergency Operations.
(VHA Directive 0320 Comprehensive Emergency Management Program) The
team's principal responsibility is to provide a command structure that
formally oversees operations during a crisis period characterized by a
need for rapid and ethically challenging decision making. In a context
of increasing scarcity of resources, the team provides a structure for
addressing the inevitable tensions that arise between clinicians'
professional commitment to individual patients and the simultaneous goal
of maximizing the survivability of the greatest numbers of persons. In
the event of a pandemic (marked by declaration of a public health
emergency), the director or chief of staff should activate the SRA team
to assist in the shift to alternate standards of care and to guide
implementation of triage protocols.

> []{#Figure1 .anchor}**Figure 1**
>
> **Scarce Resource Allocation (SRA) Team and Triage Team Membership and
> Roles** (adapted from Kuschner et al., 2007).
>
> **Scarce Resource Allocation (SRA) Team Membership and Roles**
>
> ***Scarce Resource Allocation Team Leader.*** The SRA team leader
> should have broad-based knowledge of the resources and capabilities of
> the health care organization. The team leader must possess situational
> awareness---- the ability to acquire and act on knowledge as the
> pandemic unfolds in a manner that is consistent with the health care
> organization's mission and ethical tenets. The team leader should be
> an experienced and respected member of the health care organization
> staff with proven leadership skills and a top-to-bottom understanding
> of the health care organization's strengths, reserves, and
> limitations. The team leader should have final responsibility for and
> authority over clinical decisions that involve triage and scarce
> resource allocation. Throughout the public health emergency, the team
> leader should report to the Facility Director and chief of staff or
> designee, as appropriate within the Incident Command structure.
>
> ***Logistics/Management Representative.*** A representative of the
> health care organization's management team should provide guidance on
> the capabilities of the organization with respect to resources,
> personnel, and external support. This person should have knowledge of
> logistics related to the acquisition and distribution of critical
> supplies, security, fiscal matters, internal and external
> communication, control of patient information, and cooperative
> capabilities with other health care organizations. The management
> representative may also report to a larger Emergency Operations
> Committee responsible for directing the organization's overall
> response to pandemic influenza.
>
> ***Ethics Representative.*** A member of the organization's
> IntegratedEthics Program, generally from the Ethics Consultation
> Service, should provide guidance to resolving ethical conflicts,
> disputes, and dilemmas. This person should have knowledge of widely
> accepted ethical principles and the special ethical challenges that
> community medical disasters and public health emergencies present.
> This person should ensure that ethical values are an integral part of
> any decision process.
>
> ***Critical Care Medicine Representative*.** A physician with
> expertise in critical care medicine should provide guidance about the
> management of intensive medical care and proposed implementation of
> altered standards of care.
>
> ***Nursing Representative.*** The Nurse Executive or other designated
> nurse leader should provide information about nurse staffing capacity
> to meet additional health care service needs of patients. Nursing
> judgments must be reflected in the SRA team's decisions to alter
> standards of care that result in the nursing staff performing duties
> that are normally performed by physicians, in the modification of
> nurse--patient ratios, and in decisions to include non-clinical staff
> in clinical support roles.
>
> ***Emergency Department Representative.*** This role should be filled
> by a nurse or physician who is capable of providing real-time
> information about surge capacity and clinical-decision making in the
> emergency department.
>
> ***Infectious Diseases Representative:*** An *infectious diseases
> physician* or infection control specialist should provide regular
> updates regarding the status and impact of the pandemic and the
> management of patients with influenza.
>
> ***Palliative Medicine Representative.*** A physician with experience
> in palliative medicine should provide updates on the demands for
> palliative care and strategies to meet these demands. A qualified
> physician assistant or nurse practitioner may fill this role when a
> qualified physician is not available.
>
> ***Social Work Representative.*** A licensed clinical social worker
> should provide updates on the social service demands imposed on the
> health care organization as a consequence of pandemic influenza.
>
> ***Chaplain Representative*.** A chaplain should provide regular
> updates on the capacity of the health care organization to address the
> special spiritual needs of patients and family members, especially of
> those patients a physician deemed ineligible to receive care that
> would normally be delivered.
>
> ***Patient/Veteran or VSO Representative.*** A representative of the
> veteran community can provide specific insight on veterans issues and
> help to ensure transparency in the functioning of the team.
>
> ***Ad Hoc Representatives from Other Departments*.** Representatives
> from other departments significantly affected by the pandemic may be
> necessary to provide updates on their capacity to meet surge demands
> for care. For example, an engineering representative who can advise on
> available supplies of oxygen and utilities.
>
> **[Triage Team Membership and Roles]{.underline}**
>
> A group functioning under the direction of the SRA team, the Triage
> team, should be designated and is responsible for tertiary triage
> scoring and decisions based on the tertiary triage protocol and
> available resources. Membership of the Triage team includes, at
> minimum, a critical care medicine, nursing, and logistics/management
> representative. **The Triage team will consider regional and local
> circumstances and the resources available, and use the triage protocol
> to determine which patients are eligible for life-saving resources.**
> Although the Triage team functions under the direction of the SRA, the
> Triage team's role within the SRA should, ideally, be limited to
> triage implementation, that is, collecting data, ensuring its
> accuracy, and directing bedside clinicians on triage decisions.

***3.1.1 SRA Team Procedures***

The SRA team should work to acquire the information necessary to
facilitate and oversee informed and ethical triage and scarce resource
allocation decisions. Information should include, but not be limited to,
resources (bed census, staffing, projected needs for care, existing
medical resources, resource gaps, and projected availability of
life-saving and hospice and palliative care resources), and influenza
management (up-to-date treatment options and prognostic factors).

The team should collaborate and make judgments in association with
health care organization leaders and staff to implement appropriate
alternative standards of care that are necessary to address the special
demands that the pandemic imposes on the health care organization or
that could be expected to impose imminently.

During the emergency, the SRA team should meet at least daily.
Alternative meeting options may be appropriate, including telephone
conference calls and videoconferencing. The team should advise and
assist, as required, and make definitive decisions, if necessary, to
resolve uncertainties and disputes that affect the health care
organization's capacity to carry out its dual missions during a public
health emergency. The team should prepare information briefs at least
daily, to the chief executive officer, chief of staff or designee(s)
about the emergency's status and the health care organization's response
so that the information may be communicated to appropriate staff and
stakeholders.

Multiple individuals may fill the position of SRA team leader on a
rotating basis. A team leader should be available 24 hours per day,
seven days per week as should the Triage team members. All other members
of the team should be available throughout business hours and for
extended periods, as necessary and feasible, seven days per week. In
order to allow for illness or absence of SRA team members, there should
be a continuity plan in the staffing of this team.

***3.1.2 Triage Team Procedures***

**The Triage team should meet at least daily to review initial tertiary
triage assessments made by emergency department practitioners, bed
status, the case definition of pandemic, or other activities deemed
appropriate by the SRA team. It will be the responsibility of the Triage
team to insure compliance by the treating team in ordering lab tests
required for SOFA scoring, and to collect data, insure its accuracy, and
direct bedside clinicians on triage decisions. On a defined 48 hour
schedule, the Triage team will consider clinical assessments of all
patients who are receiving or who are candidates for scarce life-saving
resources and make triage decisions based on the allocation protocol,
and on resource availability determined by the SRA team.**

**The Triage team will communicate its triage decisions to the
clinician(s) caring for the patients for implementation of its decision,
and to the SRA team leader for oversight and reporting to the
organizational leadership.**

**The Triage team should develop and maintain a record of triage
decisions and the data upon which the decisions were based. A daily
retrospective of all triage decisions should be conducted as a routine
quality review process.**

[]{#Protocol .anchor}**[3.2 Protocol for Allocation of Scarce
Life-Saving Resources in VHA During an Influenza Pandemic]{.smallcaps}**

VHA has developed this protocol for clinical evaluation and allocation
of scarce life-saving resources, (i.e., critical care resources
including ventilators and hemodynamic support). This protocol is based
on the ethical framework outlined in [Appendix 1](#Appendix1) and on
previously developed pandemic influenza and mass casualty event
protocols including the Ontario Health Plan for Influenza Pandemic
(OHPIP) (Ontario Health Plan for Influenza Pandemic, 2006), draft New
York State Task Force on Life and the Law Report (New York State Task
Force on Life and the Law, 2007), Task Force for Mass Critical Care
guidance (Devereaux, 2008), and on the **Sequential Organ Failure
Assessment (SOFA)** score (Ferreira, et al, 2001).

In the event of an influenza pandemic, the protocol should be used in
affected VISNs throughout VHA to assure patients fair access to
life-saving resources in circumstances when the demand is greater than
the supply and use of those resources must be optimized. Generally, the
protocol will be applied throughout an affected VISN at the discretion
of the VISN Director, but if significant clinical urgency exists at a
particular facility, initiation of the protocol can be at the discretion
of the Facility Director, pending VISN approval. The VISN Director is
encouraged to take into account that his or her decisions regarding
initiation of the tertiary triage protocol should take into
consideration local or regional declarations (e.g., state-wide
declaration of emergency by a governor). The VISN Director must assure
that the protocol is applied consistently and fairly whenever and
wherever it is initiated within the VISN.

The protocol is based on a nested approach to allocation criteria as
described in [Appendix 1](#Appendix1). The overarching criterion is that
of medical success or survivability determined by the application of
established clinical criteria, including SOFA scores. Once a
determination has been made that a patient qualifies for the resource
under the SOFA score, and a patient's priority category has been
determined (red or yellow), within-category priority is established on a
first-come, first-served basis or a random selection/lottery basis,
depending on the feasibility of implementation. *Because the shift to
altered standards is predicated upon conditions of scarcity, it is only
at the point that demand for the life-saving resource overwhelms supply
that the application of pandemic triage algorithms will apply.*

The protocol is based on the assumption that resource allocation will
take local and regional circumstances into consideration. This
"situational awareness" is described in the White House Homeland
Security Council's *Implementation Plan for the National Strategy for
Pandemic Influenza* (2006, p. 115) as follows: "VA\'s priority with
respect to protecting human health is to deliver health care to enrolled
veterans and beneficiaries. VA also has a mission to provide medical
surge capacity for treatment of casualties arising from DOD operations
and can provide other support to the extent the VA\'s mission to serve
veterans is not compromised." The organization's leadership will
maintain situational awareness, communicate information regarding
resource availability, and communicate guidance regarding implementation
of VA priorities to the SRA team, staff and other stakeholders.

Although this protocol has been designed based on consensus and
available literature, it has not been tested or implemented during an
actual pandemic. As part of pandemic influenza planning, this protocol
should be tested in drills and exercises with lessons learned
communicated to the Office of Public Health and Environmental Hazards
and the National Center for Ethics in Health Care so that necessary
modifications can be made in advance of a pandemic. If national,
regional, or local pandemic influenza planners believe that it is
necessary to adjust or modify the protocol based on actual circumstances
during an influenza pandemic (e.g., new knowledge of specific predictors
of outcome for pandemic influenza patients), the goal should be to
maintain a consistent protocol in affected VISNs throughout VHA so that
all patients are assessed according to the same criteria.

***3.2.1 Clinical Assessment***

During an influenza pandemic, clinicians will thoroughly assess all
patients who present for care. Those patients who have clinical
indications for scarce life-saving resources (e.g., critical care
patients who require ventilators or hemodynamic support) will be subject
to the tertiary triage protocol unless they elect not to be candidates
for critical care.

**3.2.1.1 Exclusion Criteria**

Those who have clinical indications for scarce life-saving resources
will be assessed for exclusion criteria to determine the appropriateness
of the initiation or continuation of scarce life-saving treatment. If an
exclusion criterion is present (Table 9), the patient is no longer a
candidate for scarce life-saving resources, including scarce resources
that may be needed for cardiopulmonary resuscitation. Clinicians should
offer palliative and other supportive care to the patient and follow
clinical standards for withdrawal of scarce life-saving resources and
writing of a DNR orders.

Exclusion criteria are intended to identify and exclude patients with a
short life expectancy irrespective of the current acute illness.
Exclusion criteria, drawing upon the work of the New York State Task
Force on Life and the Law, the OHPIP, and the Task Force for Mass
Critical Care and incorporating suggestions from additional VHA
reviewers and critical care experts, are presented below.

**Table 9**

**Exclusion Criteria for Access to Scarce Life-Saving Resources**

+----------------------------------------------------------------------+
| 1\. Confirmed presence of any advanced disease with average life     |
| expectancy of 6 months or less (e.g., advanced cancer or end-stage   |
| organ failure with less than 6 months average survival).             |
|                                                                      |
| 2\. Recent cardiac arrest: unwitnessed arrest, recurrent arrest,     |
| arrest unresponsive to standard measures; trauma-related arrest.     |
|                                                                      |
| 3\. Confirmed severe irreversible cognitive impairment (e.g.,        |
| Persistent Vegetative State (PVS) or advanced dementia).             |
+----------------------------------------------------------------------+

**3.2.1.2 Triage Priority Categorization**

> The threshold for receipt of scarce life-saving resources will vary
> depending on availability of resources.

Because many patients will present to the emergency department for care,
emergency physicians should be prepared to apply the initial assessment
tool for patients who have clinical indications for critical care. For
patients already receiving acute care, the Triage team will conduct the
initial assessment as well as 48 hour reassessment for all patients
eligible for critical care resources.

The Triage team will monitor patients using established criteria for
initial assessment. Patients will be placed in categories based on a
SOFA score (Table 10), and assigned a priority category according to an
algorithm that is a variation of the OHPIP and draft New York State
Protocol (Table 11). Acute care patients already receiving scarce
life-saving resources when triage begins will be categorized by the
Triage team according to the initial assessment to see whether they will
remain eligible for continued use of these resources. Depending on
resource availability, the assigned priority category of the patient
will determine whether or not he/she may receive scarce life-saving
resources. In other words, the threshold for receipt of scarce
life-saving resources will vary depending on availability of resources.
Patients assigned to the same category will be allocated resources on a
first-come, first-served basis or a random selection/lottery basis,
depending on the feasibility of implementation. The Triage team will
provide information to treating clinicians regarding patients' triage
status.

**Table 10**

**Sequential Organ Failure Assessment (SOFA) Score\***

+----------+----------+----------+----------+----------+----------+
| **Va     | **SOFA   |          |          |          |          |
| riable** | Score**  |          |          |          |          |
+==========+==========+==========+==========+==========+==========+
|          | **0**    | **1**    | **2**    | **3**    | **4**    |
+----------+----------+----------+----------+----------+----------+
| P        | \> 400   | 301 --   | 201 --   | 101 --   | [\<]{.un |
| aO2/FiO2 |          | 400      | 300      | 200      | derline} |
| mmHg     |          |          |          |          | 100      |
+----------+----------+----------+----------+----------+----------+
| Pl       | \> 150   | 101 --   | 51 --    | 21 -- 50 | [\<]{.un |
| atelets, |          | 150      | 100      |          | derline} |
| x 103/μL |          |          |          |          | 20       |
| or x     |          |          |          |          |          |
| 106/L    |          |          |          |          |          |
+----------+----------+----------+----------+----------+----------+
| Bi       | \<1.2    | 1.2-1.9  | 2.0-5.9  | 6.0-11.9 | \>12     |
| lirubin, |          |          |          |          |          |
| mg/dL    | (\<20)   | (20 --   | (33 --   | (101 --  | (\> 203) |
| (μmol/L) |          | 32)      | 100)     | 203)     |          |
+----------+----------+----------+----------+----------+----------+
| Hyp      | None     | MABP \<  | Dop      | Dop 6 -- | Dop \>15 |
| otension |          | 70 mmHg  | [\<]{.un | 15 or    | or       |
|          |          |          | derline} |          |          |
|          |          |          | 5        | Epi      | Epi \>   |
|          |          |          |          | [\<]{.un | 0.1 or   |
|          |          |          |          | derline} |          |
|          |          |          |          | 0.1 or   | Norepi   |
|          |          |          |          |          | \> 0.1   |
|          |          |          |          | Norepi   |          |
|          |          |          |          | [\<]{.un |          |
|          |          |          |          | derline} |          |
|          |          |          |          | 0.1      |          |
+----------+----------+----------+----------+----------+----------+
| Glasgow  | 15       | 13 - 14  | 10 - 12  | 6 - 9    | \< 6     |
| Coma     |          |          |          |          |          |
| Score    |          |          |          |          |          |
+----------+----------+----------+----------+----------+----------+
| Cre      | \< 1.2   | 1.2-1.9  | 2.0-3.4  | 3.5-4.9  | \> 5     |
| atinine, |          |          |          |          |          |
| mg/dL    | (\<106)  | (106 --  | (169 -   | (301 --  | (\> 434) |
| (μmol/L) |          | 168)     | 300)     | 433)     |          |
|          |          |          |          |          | [or]{.un |
|          |          |          |          |          | derline} |
|          |          |          |          |          | anuric   |
+----------+----------+----------+----------+----------+----------+
| Note:    |          |          |          |          |          |
| Cl       |          |          |          |          |          |
| inicians |          |          |          |          |          |
| will     |          |          |          |          |          |
| d        |          |          |          |          |          |
| etermine |          |          |          |          |          |
| the      |          |          |          |          |          |
| total    |          |          |          |          |          |
| SOFA     |          |          |          |          |          |
| score    |          |          |          |          |          |
| for each |          |          |          |          |          |
| patient  |          |          |          |          |          |
| by       |          |          |          |          |          |
| summing  |          |          |          |          |          |
| the      |          |          |          |          |          |
| scores   |          |          |          |          |          |
| for each |          |          |          |          |          |
| v        |          |          |          |          |          |
| ariable. |          |          |          |          |          |
| Dopamine |          |          |          |          |          |
| \[Dop\], |          |          |          |          |          |
| epi      |          |          |          |          |          |
| nephrine |          |          |          |          |          |
| \[Epi\], |          |          |          |          |          |
| norepi   |          |          |          |          |          |
| nephrine |          |          |          |          |          |
| \[       |          |          |          |          |          |
| Norepi\] |          |          |          |          |          |
| doses in |          |          |          |          |          |
| ug       |          |          |          |          |          |
| /kg/min. |          |          |          |          |          |
| SI units |          |          |          |          |          |
| are      |          |          |          |          |          |
| noted in |          |          |          |          |          |
| par      |          |          |          |          |          |
| entheses |          |          |          |          |          |
| ( ).     |          |          |          |          |          |
|          |          |          |          |          |          |
| *\       |          |          |          |          |          |
| *Adapted |          |          |          |          |          |
| from:    |          |          |          |          |          |
| Ferreira |          |          |          |          |          |
| et al.,  |          |          |          |          |          |
| 2001.*   |          |          |          |          |          |
| Exp      |          |          |          |          |          |
| lanation |          |          |          |          |          |
| of       |          |          |          |          |          |
| va       |          |          |          |          |          |
| riables: |          |          |          |          |          |
| P        |          |          |          |          |          |
| aO2/FiO2 |          |          |          |          |          |
| i        |          |          |          |          |          |
| ndicates |          |          |          |          |          |
| the      |          |          |          |          |          |
| level of |          |          |          |          |          |
| oxygen   |          |          |          |          |          |
| in the   |          |          |          |          |          |
| p        |          |          |          |          |          |
| atient's |          |          |          |          |          |
| blood.   |          |          |          |          |          |
| P        |          |          |          |          |          |
| latelets |          |          |          |          |          |
| are a    |          |          |          |          |          |
| critical |          |          |          |          |          |
| c        |          |          |          |          |          |
| omponent |          |          |          |          |          |
| of blood |          |          |          |          |          |
| c        |          |          |          |          |          |
| lotting. |          |          |          |          |          |
| B        |          |          |          |          |          |
| ilirubin |          |          |          |          |          |
| is       |          |          |          |          |          |
| measured |          |          |          |          |          |
| by a     |          |          |          |          |          |
| blood    |          |          |          |          |          |
| test and |          |          |          |          |          |
| i        |          |          |          |          |          |
| ndicates |          |          |          |          |          |
| liver    |          |          |          |          |          |
| f        |          |          |          |          |          |
| unction. |          |          |          |          |          |
| Hyp      |          |          |          |          |          |
| otension |          |          |          |          |          |
| i        |          |          |          |          |          |
| ndicates |          |          |          |          |          |
| low      |          |          |          |          |          |
| blood    |          |          |          |          |          |
| p        |          |          |          |          |          |
| ressure; |          |          |          |          |          |
| scores   |          |          |          |          |          |
| of 2, 3, |          |          |          |          |          |
| and 4    |          |          |          |          |          |
| indicate |          |          |          |          |          |
| that     |          |          |          |          |          |
| blood    |          |          |          |          |          |
| pressure |          |          |          |          |          |
| must be  |          |          |          |          |          |
| ma       |          |          |          |          |          |
| intained |          |          |          |          |          |
| by the   |          |          |          |          |          |
| use of   |          |          |          |          |          |
| powerful |          |          |          |          |          |
| med      |          |          |          |          |          |
| ications |          |          |          |          |          |
| that     |          |          |          |          |          |
| require  |          |          |          |          |          |
| ICU      |          |          |          |          |          |
| mon      |          |          |          |          |          |
| itoring, |          |          |          |          |          |
| i        |          |          |          |          |          |
| ncluding |          |          |          |          |          |
| d        |          |          |          |          |          |
| opamine, |          |          |          |          |          |
| epin     |          |          |          |          |          |
| ephrine, |          |          |          |          |          |
| and      |          |          |          |          |          |
| norepin  |          |          |          |          |          |
| ephrine. |          |          |          |          |          |
| The      |          |          |          |          |          |
| Glasgow  |          |          |          |          |          |
| coma     |          |          |          |          |          |
| score is |          |          |          |          |          |
| a        |          |          |          |          |          |
| stan     |          |          |          |          |          |
| dardized |          |          |          |          |          |
| measure  |          |          |          |          |          |
| that     |          |          |          |          |          |
| i        |          |          |          |          |          |
| ndicates |          |          |          |          |          |
| ne       |          |          |          |          |          |
| urologic |          |          |          |          |          |
| f        |          |          |          |          |          |
| unction; |          |          |          |          |          |
| low      |          |          |          |          |          |
| score    |          |          |          |          |          |
| i        |          |          |          |          |          |
| ndicates |          |          |          |          |          |
| poorer   |          |          |          |          |          |
| f        |          |          |          |          |          |
| unction. |          |          |          |          |          |
| Cr       |          |          |          |          |          |
| eatinine |          |          |          |          |          |
| is       |          |          |          |          |          |
| measured |          |          |          |          |          |
| by a     |          |          |          |          |          |
| blood    |          |          |          |          |          |
| test and |          |          |          |          |          |
| i        |          |          |          |          |          |
| ndicates |          |          |          |          |          |
| kidney   |          |          |          |          |          |
| f        |          |          |          |          |          |
| unction. |          |          |          |          |          |
+----------+----------+----------+----------+----------+----------+

**Table 11**

**Adapted OHPIP Triage Tools**

**The triage tools (tables) below will be used to assign patients to
priority categories (i.e., color codes) at initial assessment either by
the emergency department physician or the Triage team, and on an
established 48 hour schedule by the Triage team thereafter. NOTE: There
is a specific triage tool for the initial and the 48 hour assessment
intervals.**

**[Initial and 48 hour Triage Assessments]{.underline} -- Clinical
assessment and calculation of a SOFA score at the designated time
intervals will result in patients being assigned to a color coded
priority category.**

**In conformity with other existing tertiary triage protocols, the
following color coding categories will be used:**

> **Blue -- Patients with very poor expected outcomes even if
> life-saving resources are used.**
>
> **Red -- Patients who require life-saving resources and are most
> likely to recover by receiving those resources.**
>
> **Yellow -- Patients who require life-saving resources and are less
> likely than patients in the Red category to recover by receiving those
> resources.**
>
> **Green -- Patients who do not require life-saving resources to
> recover.**

**[Triage Review]{.underline} -- The threshold for receipt of scarce
life-saving resources will vary depending on the supply of resources and
patient demand. The SRA team will consider regional and local
circumstances, as well as the resources available, and subsequently
determine which priority category or categories are eligible for
life-saving resources. The Triage team will apply this determination to
its triage decisions for individual patients. Note: Patients** within
the same priority category will be supported on a first-come,
first-served basis or a random selection/lottery basis, depending on the
feasibility of implementation.

**\
**

+----------------+----------------+--------------+----------------+
| **Life-Saving  |                |              |                |
| Resources      |                |              |                |
| Triage Tool**  |                |              |                |
|                |                |              |                |
| **for INITIAL  |                |              |                |
| ASSESSMENT**   |                |              |                |
+================+================+==============+================+
| Category       | Initial        | Priority     | Action         |
|                | Criteria       |              |                |
+----------------+----------------+--------------+----------------+
| Blue           | Exclusion      | None         | Do not use     |
|                | Criteria       |              | life-saving    |
|                |                |              | resources      |
|                | or  {#or}      |              |                |
|                | --             |              | Use other      |
|                |                |              | resources      |
|                | SOFA \> 11     |              | including      |
|                |                |              | palliative     |
|                |                |              | measures       |
+----------------+----------------+--------------+----------------+
| Red            | SOFA           | Highest      | Use lifesaving |
|                | [\             |              | resources, as  |
|                | <]{.underline} |              | available      |
|                | 7              |              |                |
|                |                |              |                |
|                | [o             |              |                |
|                | r]{.underline} |              |                |
|                |                |              |                |
|                | Single Organ   |              |                |
|                | Failure        |              |                |
+----------------+----------------+--------------+----------------+
| Yellow         | SOFA 8 - 11    | Intermediate | Use            |
|                |                |              | life-saving    |
|                |                |              | resources, as  |
|                |                |              | available      |
+----------------+----------------+--------------+----------------+
| Green          | No requirement | None         | Use other      |
|                | for            |              | medical        |
|                | life-saving    |              | management     |
|                | resources      |              |                |
|                |                |              | Reassess as    |
|                |                |              | needed         |
+----------------+----------------+--------------+----------------+

This initial assessment tool is to be used to assess patients with
clinical indications for critical care. For patients already admitted to
acute care, this initial assessment tool is to be used only by the
Triage team. For patients presenting to the emergency department, this
initial assessment tool is to be used by the emergency physician.

+----------------+----------------+--------------+----------------+
| **Life-Saving  |                |              |                |
| Resources      |                |              |                |
| Triage Tool**  |                |              |                |
|                |                |              |                |
| **for 48-HOUR  |                |              |                |
| REASSESSMENT** |                |              |                |
+================+================+==============+================+
| Category       | 48 Hour        | Priority     | Action         |
|                | Criteria       |              |                |
+----------------+----------------+--------------+----------------+
| Blue           | Exclusion      | None         | Discontinue    |
|                | Criteria       |              | life-saving    |
|                |                |              | resources      |
|                | [o             |              |                |
|                | r]{.underline} |              | Use other      |
|                |                |              | resources      |
|                | SOFA \> 11     |              | including      |
|                |                |              | palliative     |
|                | [o             |              | measures       |
|                | r]{.underline} |              |                |
|                |                |              |                |
|                | SOFA 8 -- 11   |              |                |
|                | and increasing |              |                |
|                | since last     |              |                |
|                | assessment     |              |                |
+----------------+----------------+--------------+----------------+
| Red            | SOFA 8 -- 11   | Highest      | Continue       |
|                | and decreasing |              | life-saving    |
|                | since last     |              | resources, as  |
|                | assessment     |              | available      |
+----------------+----------------+--------------+----------------+
| Yellow         | SOFA \< 8      | Intermediate | Continue       |
|                |                |              | life-saving    |
|                |                |              | resources, as  |
|                |                |              | available      |
+----------------+----------------+--------------+----------------+
| Green          | No longer      | None         | Discontinue    |
|                | requiring      |              | life-saving    |
|                | life-saving    |              | resources.     |
|                | resources      |              | Reassess as    |
|                |                |              | needed         |
+----------------+----------------+--------------+----------------+

This 48-hour reassessment tool is to be used to reassess patients with
clinical indications for critical care. This reassessment tool is to be
used only by the Triage team.

***3.2.2 Reassessment***

Continued use of the scarce life-saving resources will be reviewed on an
established 48 hour schedule of the Triage team thereafter. Patients who
continue to meet criteria for inclusion will receive the resources until
they either meet an exclusion criterion, or they are reassessed
according to the 48 hour Triage team schedule. Patients assigned to the
same category will be allocated resources on a first-come, first-served
or a random selection/lottery basis, depending on the feasibility of
implementation. Those who no longer meet the criteria after reassessment
will no longer be eligible for access to the scarce life-saving
resources and should be informed of the need for withdrawal of these
treatments.

The 48 hour schedule for reassessment is based on the Sequential Organ
Failure tool (Ferreira et al., 2001) and reflects the expected time
course of beneficial treatment for respiratory failure, sepsis, or other
likely complications of severe influenza. A shorter trial interval does
not reflect the period in which benefit would be expected. A longer
trial interval, by contrast, might entail continued use of scarce
resources by patients who are unlikely to benefit from them, resulting
in inefficient use of the resource in times of scarcity. That being
said, some patients will be admitted for critical care between the
Triage team's scheduled 48 hour reassessment interval. Newly admitted
patients will need to be fit into the 48 hour triage assessment schedule
which will require some rounding of the time interval for the first 48
hour assessment. As a rule of thumb, no patient should receive his or
her first reassessment sooner than 36 hours from the initial assessment.

***3.2.3 Triage Decision Makers***

The clinicians treating a patient should not, ideally, have the
responsibility of deciding whether to institute or remove a patient from
life-saving resources. This is the responsibility of the Triage team
which will assess the patient's condition, note the existence or absence
of exclusion criteria, and, if no exclusion criteria are present, assign
the patient to an appropriate priority category (per Table 10). The
Triage team will make triage decisions based on the allocation protocol
and resource availability as determined by the Scarce Resource
Allocation (SRA) team or comparable structure. The Triage team will
communicate its decision to the treating clinician who will implement a
treatment plan consistent with the Triage team's decision. Because of
staff shortages during pandemic influenza, a clinician may be called to
serve both as a Triage team member and a treating clinician. In such
circumstances, involved professionals should make every effort to act
according to expectations for the role they occupy at any given point in
time.

This approach is consistent with the recommendations of the ACCP Working
Group on Emergency Mass Critical Care, a group of experts that produced
a 2005 guidance document for improving surge capacity in public health
disasters (Rubinson et al., 2005). The use of a Triage team has a number
of advantages: the Triage team will have better access to information
about both regional and local circumstances and the number and nature of
patients awaiting scarce life-saving resources, and can set triage goals
accordingly. Such role sequestration will enhance the capacity for
maintaining professionalism by allowing treating clinicians to fulfill
their obligation to care for their individual patients without facing a
conflict of interest about triage. The use of a Triage team may help
decrease burnout and stress for clinicians providing critical care
during the finite duration of the pandemic. Placing responsibility for
triage with a team that is not involved in a particular patient's care
will help to sustain, post-pandemic, the ordinary obligations that
define the physician-patient relationship. Finally, placing
responsibility with a team that has the best information on the current
balance of need versus supply would help ensure consistency of triage
decision making across a group of patients.

[]{#ReviewandAppeals .anchor}***3.2.4 Review and Appeals***

In order to ensure fairness and accountability for the quality of triage
decisions, the triage process must include mechanisms for review and
appeal.

During a pandemic, a daily retrospective of all triage decisions by the
Triage team would provide a regular mechanism to ensure consistency and
fairness in the application of triage criteria and would present an
opportunity for correcting the guidelines or their implementation as
needed.

In addition to a routine retrospective quality review process, a
real-time appeals process is also needed to ensure process
accountability for triage decisions. The assumption behind such a
process is that the established triage protocol meets conditions of
fairness and efficiency such that any appeal is based on claims of
failure to adhere to established triage processes (e.g., an appeal based
on an error in calculating SOFA score, or based on a challenge to the
timing of reassessment) rather than an appeal for an exception to the
process itself. Ideally, even under conditions of limited staffing,
personnel involved in the appeals process would be different from
personnel on the Triage team. These persons should also be experienced
in conflict mediation and have clinical expertise; drawing upon members
of the ethics consultation service, the patient representative service,
clinicians, and the chaplaincy may be ways to provide a rapid appeals
process even during the period of limited staffing. If feasible, members
of a Scarce Resource Allocation team or comparable command structure
excluding those members of the Triage team could be involved in the
appeals process. Appeals review would consider whether applicable
standards are being followed consistently and correctly in an attempt to
assure fairness and resolve conflict.

***3.2.5 Communication About Triage***

Initiation of protocols for **allocation of scarce life-saving
resources** will require clear communication about goals,
implementation, and options. Even before a patient comes to the
hospital, political leaders, VHA leaders, and health officials will have
to emphasize publicly that pandemic influenza is potentially fatal, that
clinicians and health care organizations are doing all they can with the
available resources, and that everyone will need to adjust to a
different way of providing and receiving health care than is customary.
Patients and families must be notified immediately that use of
life-saving resources represents *a trial of therapy*, which, if it does
not improve the patient's condition sufficiently, will be removed
according to the triage protocol. (New York State Task Force on Life and
the Law, 2007, p. 37). Notification establishes the expectation that
care standards have been altered according to triage algorithms. Even
when the protocol is in effect, patients can refuse any treatments with
the exception of those mandated to maintain the health of the public.
(See Section 5).

Training of staff for pandemic readiness should include guidance on how
to implement this protocol and how to discuss it with patients and
families. Communication should be clear upon hospital admission and ICU
admission, as well as during decision making about withholding or
withdrawal of treatment. Since a pandemic may develop rapidly at any
time, facility leaders should ensure that a communication strategy and
tools explaining the nature of a pandemic, the impact on health care
delivery, the allocation protocol and its implementation, are developed
in advance and tested in tabletop exercises.

[]{#DNR .anchor}***3.2.6 Resuscitation Status for Patients Excluded from
Scarce Life-Saving Resources***

During rationing, patients who are excluded from scarce life-saving
resources based on established criteria will, of necessity, be excluded
from access to scarce resources that may be needed for cardiopulmonary
resuscitation. DNR/DNAR orders that are entered into a patient's record
under these circumstances should be reviewed after the period of
scarcity has ended and altered standards of care are no longer
appropriate*.*

***3.2.7 Application of Triage Algorithms to Patients Already Receiving
Life-Saving Treatments:***

There is general agreement that in circumstances of extreme resource
scarcity, critical care triage algorithms should apply to all patients
receiving care in acute care facilities, regardless of their illness or
their current treatment modalities (OHPIP, 2006, Hick et al, 2006,
Christian et al, 2006). In practice, this means that patients who have a
legitimate expectation of continued use of a life-saving treatment may
have the treatment withdrawn under circumstances of severe resource
scarcity. Although under ordinary circumstances the withdrawal of
life-saving therapies in order to benefit another would be unjustified,
in extreme circumstances, application of established algorithms to
patients similarly situated according to their clinical criteria is
understood to be the fairest way of optimizing scarce resources. In
times of extreme resource scarcity, patients and their families must be
notified that life-saving treatment is initiated as a trial therapy that
may be withdrawn if the patient's response does not meet established
algorithms for continued use.

Among organizations considering resource allocation in a pandemic, there
is, however, debate about whether patients in long-term care settings or
at home and who are chronically dependent on life-saving treatments
(such as ventilators) should be subject to triage algorithms during a
pandemic. A recent draft report by The New York State Task Force on Life
and the Law (2007), for example, supports exempting from triage
protocols those chronic patients (such as patients with quadriplegia or
who are in a persistent vegetative state) who have been dependent on
ventilators (or comparable life-saving treatments) in nursing homes,
long-term care facilities and in their own homes. Whereas the report
accepts the need for triage protocols for withdrawal of life-saving
treatments from patients in acute care settings, it argues that a single
triage protocol for both chronic and acute care patients is
pragmatically and ethically unsound. Sudden and fatal extubation of
long-term ventilator-dependent patients residing in long- term care
facilities or in their own homes, the report argues, is not justifiable
even if the use of those ventilators allows greater numbers of healthier
patients to survive. A policy of withdrawal of life-saving resources
from chronically dependent patients, the report argues, is vulnerable to
the critique of making victims of the disabled and/or making skewed
quality-of-life assessments.

If, however, chronic care patients require transfer to an acute care
setting, the report's recommendation is that they should then be
considered as part of that cohort and be subject to established critical
care triage protocols. In a pandemic, this shift would almost certainly
result in such patients failing to meet triage criteria for continued
life-support. In such circumstances, patients or families contemplating
such transfers must be informed of the likely consequences of a decision
to transfer.

In its working paper, "Equitable Access to Therapeutic and Prophylactic
Measures," the World Health Organization (WHO) Working Group on
Addressing Ethical Issues in Pandemic Influenza Planning (Verweij, 2007)
opposes the exemption of chronic care patients from pandemic triage
protocols. This conclusion is based on an argument that an equitable
sharing of sacrifice requires that triage criteria must be applied
across the board.

The report acknowledges that many physicians and other health care
workers may feel that their duty of non-abandonment means that they
should give priority to patients for whom they have already accepted
responsibility. Though there are good pragmatic reasons for such special
obligations in normal circumstances (for example, they support
relationships of trust), in the context of a pandemic such
considerations are, the report maintains, less appropriate. For example
if very large numbers of people get infected and require care, health
care workers can no longer prioritize patients who are already under
their care. They should, the report contends, give equal attention to
all who need it and aim to save as many patients as possible including
patients already being treated as well as those waiting for treatment.

Although there are viable ethical arguments on both sides of this issue
there is a general consensus that the emotional impact of withdrawing a
life-saving treatment is different from reactions to a treatment
modality being withheld. Even the WHO report acknowledges that the
strategies they recommend may prove very difficult for the public at
large. It recognizes that health care professions and the public may
simply not accept a triage policy, even if rationally justified.
Withdrawing treatments from chronically vulnerable patients may present
even greater emotional hurdles.

Given these considerations, VHA patients chronically dependent on
life-saving resources for their daily maintenance and residing in
long-term care facilities or at home will not be subject to the pandemic
triage protocols. Setting aside the small number of ventilators in
long-term care facilities for use by the chronically ill, who likely
will have severely limited access to ventilators in acute care
facilities, offers an appropriate balance between the duties to care and
to allocate wisely. Should such patients require transfer to acute care,
however, they would, in that context, be subject to established critical
care triage protocols.

[]{#Section4 .anchor}**SECTION 4: RATIONING---HOSPICE AND PALLIATIVE
CARE PLANNING AND RESPONSE**

VHA is committed to the provision of compassionate and humane care to
the terminally ill veteran and to support for the dying veteran\'s
family. One aspect of this commitment is VHA's hospice program, a
coordinated program of palliative and supportive services provided in
both home and inpatient settings for persons in the last phases of
incurable disease so that they may live as fully and as comfortably as
possible. The program emphasizes the management of pain and other
physical symptoms as well as the management of the psychosocial problems
and the spiritual comfort of the patient and the patient\'s family or
significant other. Services are provided by a medically-directed
interdisciplinary team of health care providers and volunteers.
(Veterans Health Administration, Directive 2008-066)

The need for hospice and palliative care services to comfort the dying
and lessen their suffering is expected to increase, possibly
dramatically, during circumstances of pandemic influenza. In what
follows, we offer an ethical justification for the use of resources to
support hospice care during a pandemic, and provide recommendations for
VHA leaders in developing pandemic preparedness plans for hospice and
palliative care resources, training, and education.

**[\*4.1 Why Use Resources to Support Hospice Care During Pandemic
Influenza?]{.smallcaps}**

This guidance is based on the fundamental assumption that decision
making in pandemic influenza planning and response must be based on
achieving the greatest good for the greatest number (the principle of
utility) *within constraints of fairness and human dignity*. (Kinlaw and
Levine, 2007; Wynia, 2005; Gostin and Powers, 2006) Although a strictly
utilitarian approach to pandemic planning and response might justify
concentrating health care resources (staff, beds, supplies, and drugs)
on saving those lives that have a high likelihood of being saved, an
approach that balances utility, fairness and human dignity, as advocated
in this guidance, requires that steps are taken to provide for those who
are not expected to survive. (Rosoff, 2006)

In general, the utilitarian goal of maximizing survivability would
direct health care resources (staff, beds, supplies, and drugs) toward
saving those lives that can be saved. This is especially true in the
acute care setting where life-saving resources are concentrated. One
important planning implication of an ethical approach that seeks to
balance overall good with respect for fairness and human dignity is the
need to secure dedicated hospice and palliative care resources in the
acute care setting for those patients who cannot be discharged to home
or who are excluded from receiving life-saving resources based on triage
protocols. Providing hospice and palliative care is a way of achieving
equity for those who cannot benefit (or who could benefit, but due to
altered standards of care will not receive access to live saving
resources) from more intensive therapies. It is also a way of respecting
the dignity of those who will not survive by helping to mitigate their
pain and suffering. Finally, the provision of hospice and palliative
care is also a fulfillment of the obligation of non-abandonment -- a
basic tenet of professionalism in health care and the minimum
requirement of an ethical duty to provide care. Carrying forward these
obligations into the circumstances of pandemic influenza has
implications for VHA's planning for patients in the acute care setting,
nursing homes, and for ill veterans in the community.

Currently, VHA provides hospice care to veterans in a variety of
settings including VA Community Living Centers, or through partnerships
with community care providers in community nursing homes, or in the home
setting (Veterans Health Administration, Handbook 1140.3). In
circumstances of pandemic influenza, many veterans who are seriously ill
with influenza or other conditions will not make it to a hospital and,
as a result, the number of patients needing hospice and palliative care
outside of the hospital setting may increase. To insure that this group
of patients is supported, VHA leaders need to take steps in advance of a
pandemic to establish and augment collaboration with community-based
service organizations.

**[4.2 Recommendations for Hospice and Palliative Care
Planning]{.smallcaps}**

The following recommendations are drawn from national standards proposed
by the Agency for Healthcare Research and Quality (2007). Taken in
advance of a pandemic, these recommended steps will play an essential
role in VHA's ability to meet its obligation to provide care to all
patients across the treatment continuum. Currently, every VHA facility
has a Palliative Care Consultation team (Veterans Health Administration,
Directive 2008-066). Facility Directors should include this team in the
development and implementation of the following recommendations.

***4.2.1 Education of Veterans and Family***

VACO leaders should:

-   Disseminate educational materials for patients and their family as
    part of existing and ongoing home care education about pandemic
    influenza, that can help them understand how best to take care of
    family members who do not have access to hospital care.

***4.2.2 Resource Enhancement***

Facility Directors should:

-   Establish protocols for a dedicated stockpile of appropriate hospice
    and palliative care supplies (e.g., pain medication, anxiolytics).

-   Develop a plan identifying dedicated space for the provision of
    hospice care. This space may be located in the hospital facility
    itself or at an alternate care site.

-   Incorporate a process for granting disaster privileges into their
    credentialing and privileging process and emergency management plan.
    (VHA Handbook 1100.19, Credentialing and Privileging) Such plans
    should include the identification and training of alternative
    providers to support hospice and palliative care of patients.

-   Develop staffing plans identifying personnel resources, including
    retired health care professionals, volunteers, and support staff,
    that can be called on to provide for differing aspects of hospice
    and palliative care during a pandemic, (e.g., clinical support
    (turning, suctioning), spiritual support, psychological support).

-   Establish a communication network and chain of command that
    regularly updates information about VHA and community-based
    palliative service capacity.

-   Establish and augment linkages with community-based service
    organizations and personnel (e.g., home health, long-term care
    settings, hospice and palliative care providers). (Department of
    Veterans Affairs, Office of Public Affairs, 2008)

***4.2.3 Training***

Facility Directors should:

-   Establish a training program for those identified to provide hospice
    care during pandemic influenza that includes:

    -   Skills required for the provision of clinical, spiritual, and
        psychological support to the dying under circumstances of a
        pandemic.

    -   Appropriate use of personal protective equipment to prevent
        disease transmission to the caregivers providing palliative care
        to patients with influenza.

    -   Pain management training for front line clinicians.

    -   A discussion of the implications of resource scarcity (e.g.,
        implementation of triage protocols for life-saving resources and
        withdrawal of ineligible patients from those resources).

    -   How to talk with patients and families about the implications of
        triage protocols.

[]{#PalliativeSedation .anchor}**[4.3 Palliative Sedation in
Circumstances of Pandemic Influenza]{.smallcaps}**

Palliative sedation involves "sedating a patient to the point of
unconsciousness to relieve one or more symptoms that are intractable and
unrelieved despite aggressive symptom-specific treatments, and
maintaining that condition until the patient dies." (Taylor, 2003) The
intent is to provide symptom relief for a dying patient when all other
efforts have failed. Palliative sedation is distinct from euthanasia or
practitioner-assisted suicide, where a lethal dosage of an agent is
administered to a patient for the purpose of ending the patient's life
(see Section 4.4).

Palliative sedation has been endorsed as a treatment of last resort for
dying patients obtaining care under ordinary circumstances. (National
Ethics Committee, 2007) The appropriateness of this therapy is
contingent on the participation of a health care professional with
appropriate expertise in palliative care. The appropriate administration
of palliative sedation and based on specific criteria, including:

> \(a\) when severe pain or other clinical symptoms (e.g., dyspnea,
> nausea and vomiting, agitated delirium) is/are not ameliorated by
> aggressive symptom-specific interventions that are tolerable to the
> patient;
>
> \(b\) for patients who have entered the final stages of the dying
> process and who have a DNR/DNAR order;
>
> \(c\) with the signed informed consent of the patient, or surrogate if
> the patient lacks decision-making capacity, as required by VA policy
> for treatments or procedures involving general anesthesia.

During the pandemic planning process, each VHA facility should:

-   Determine the availability of palliative sedation expertise under
    conditions of resource scarcity and whether providers with this
    expertise will be assigned to palliative or acute care. On the basis
    of these determinations, each facility should determine whether they
    have the capacity to offer palliative sedation during pandemic.
    Palliative sedation should not be considered an appropriate therapy
    during these circumstances unless there will be sufficient expertise
    and resources available to provide it.

**[4.4 Euthanasia and Practitioner-Assisted Suicide Are Never Allowed in
VHA]{.smallcaps}**

The practice of euthanasia -- the direct administration of a lethal
dosage of an agent to a patient with the intent to mercifully end the
patient's life -- is prohibited within VHA. (42 USC 14402)
Physician/practitioner-assisted suicide (PAS) -- intentionally providing
the necessary means to facilitate death (e.g., a prescription for
barbiturates for the purpose of enabling the patient to perform a
life-ending act) -- is similarly prohibited. This prohibition applies
equally to VA practitioners in states that have laws permitting PAS.

[]{#Section5 .anchor}**SECTION 5: RESTRICTIONS---LIMITING LIBERTY IN THE
INTERESTS OF PUBLIC HEALTH**

In responding to pandemic influenza, VHA will implement public health
strategies for detection and containment of the virus, and treatment of
those who fall ill. These strategies, which may entail limitations on
individual liberty, pose predictable challenges to VHA health care
professionals' obligation to give priority to the welfare of individual
patients. Although many veterans will voluntarily accede to some
restrictions on their liberty, the emphasis on patient autonomy in the
last 50 years of American medical ethics may cause professionals and
their veteran patients to chafe at such restrictions. However, ethical
theories uniformly recognize that individual liberties may be limited to
prevent harm to others and public health measures are established on
this basis. To preserve liberty as much as possible, the CDC's Community
Mitigation guidance recommends that quarantine would be voluntary and
would be applied to household members of the ill only. (Department of
Health and Human Services, February 2007) Similarly, this VA guidance
emphasizes that, inevitably, balancing these values depends on
strategies and safeguards that preserve each without undermining either.
This section provides an overview of these challenges, guidance for
achieving public health goals through the least restrictive means
possible, and recommendations for VHA leaders in communicating with
staff and veterans.

In public health crises such as pandemic influenza, there are four
primary ways in which restrictions on the liberty of individuals may be
necessary to control the spread of infection within the population. They
are: infectious disease reporting, mandated preventive health measures,
quarantine and social distancing, and isolation.

> **Quarantine** is the separation of potentially exposed persons from
> those who have not been exposed. **Social distancing** is the
> cancellation of public gatherings in order to lessen contacts that
> could result in disease transmission. **Isolation** is the separation
> of ill persons from others.

As with any public health practice that may impose restrictions on
individuals, transparent decision making and the provision of clear
information in advance of a pandemic (CDC, 2007) is the best way to
ensure that veterans will be aware of and understand the need for these
restrictions and the role that their clinicians must play. Likewise,
transparent decision making and clear information and guidance to health
care professionals will help them to understand and appropriately
implement their responsibilities regarding public health measures.
Patients and health care professionals alike must understand that
physicians have no discretion over public health orders (Lo and Katz,
2005).

**[5.1 Infectious disease reporting]{.smallcaps}**

Infectious disease reporting is a longstanding public health strategy to
enable effective disease surveillance. Because they are privy to
patients' communicable disease status, health care professionals are
understood to have legal and ethical obligations to report certain
information to public health authorities. Nonetheless, many clinicians
may be unaware of this obligation or uncomfortable playing a role that
could undermine their advocacy for individual patients. Patients too may
be unaware that their information must, under certain circumstances, be
provided to public health authorities.

In anticipation of a pandemic, VHA leaders should, in accordance with
VHA Handbook 1605.1 Privacy and Release of Information, Section 27:

-   Communicate expectations regarding health care professionals' role
    in communicable disease reporting during a flu pandemic.

-   Explain the value of reporting in safeguarding the public health.

-   Ensure that protected health information is appropriately
    communicated so that patient information goes only to those who need
    it to reduce risk associated with spread of infection.

**[5.2 Mandated preventive health measures]{.smallcaps}**

Because medical countermeasures such as vaccines and antivirals are
expected to be in short supply before and during a pandemic, it is
unlikely that patient populations will be mandated to receive them.
Rather, the reverse ethical problem is anticipated: how should these
scarce resources be fairly and efficiently allocated when not all can
receive them?

Since health care workers have a much greater risk of exposure to a
pandemic influenza virus due to their role in patient care and in
sustaining health care operations, they are the likely candidates for
mandated preventive health measures. Indeed, providing such protection
is necessary from both an ethical and a practical perspective.
Ethically, health care institutions have an obligation to minimize the
risk to staff who bear a disproportionate burden in caring for patients
(See Section 2). In addition, because health care workers can themselves
be a vector for transmission, countermeasures are an important means for
fulfilling the obligation to prevent harm to patients. From a practical
point of view, staff will be more likely to come to work and be better
able to help others if they feel that they are protected.

In general, health care workers understand and welcome access to
protective measures when they are regarded as necessary and effective.
They also recognize that they have an ethical obligation to prevent harm
to patients by protecting against the spread of infection.

In addition to operational steps outlined in the VA Pandemic Influenza
Plan, in anticipation of a pandemic, VHA Facility Directors should
educate staff about:

-   The possible need for mandatory preventive health measures.

-   The rationale for giving priority to health care workers in access
    to preventive measures.

**[5.3 Quarantine and Social Distancing]{.smallcaps}**

The CDC defines quarantine as "separation and restriction of movement of
persons who, while not yet ill, have been exposed to an infectious agent
and therefore may become infectious" (CDC, 2005). Under the 10^th^
Amendment to the U.S. Constitution, states have authority to enact laws
and regulations to promote health, safety, welfare of citizens.
Quarantine is one such state action that has been used as a tool to
manage some infectious disease outbreaks. State quarantine orders would
be implemented under the authority of state and local public health
agencies.

Federal quarantine authority is available to the Secretary of Health and
Human Services (Department of Health and Human Services), the Surgeon
General, and the President. In April 2005, President Bush issued an
executive order to include influenza viruses with pandemic potential as
a quarantinable disease (EO 13375, April 1, 2005).

In circumstances of pandemic influenza, VHA facilities may be called
upon to implement involuntary quarantine orders issued under the
authority of state and local public health authorities, or the Federal
government. Whereas the ability of a state to "compel" a Federal
facility to comply with a quarantine order may be legally in question,
VA Regional Counsel has been instructed by General Counsel that they
should initially look to state law to involuntarily hold a patient. (VA
Office of General Counsel, 2004) VHA implementation of involuntary
quarantine may be an ethically appropriate response to the public health
crisis in support of community/regional pandemic mitigation efforts but,
as discussed below, only when it is implemented in a transparent and
least restrictive way.

Experts on public health law and ethics observe that there has been "no
large-scale human quarantine implemented within U.S. borders during the
past 8 decades" (Barbera et al., 2001, p. 2712). As a result, it has
been necessary to reexamine quarantine as a modern means of infection
control in light of past actions and current scientific, legal and
ethical considerations.

In light of these conditions, mandatory quarantine should be understood
as a last resort. Unlike in the past, there is now greater recognition
that deprivation of individual liberties to serve a public good must be
legal, necessary, proportionate, by the least restrictive means
available, and guided by due process considerations (Gostin and Berkman,
2006). Experts agree that mandatory quarantine would be justifiable only
under circumstances where the following conditions are met (Barbera et
al., 2001, p. 2714-15; Kinlaw and Levine et al., 2007):

-   The imposition of quarantine must "have a reasonable scientific
    chance of substantially diminishing the spread of disease,"

-   The disease must be one which has been determined to pose a "serious
    risk of widespread human-to-human transmission," and must confer a
    high risk of "serious illness or death."

-   The quarantine must have a reasonable chance of containing diseases.

-   The quarantine must be equitably applied with clear explanations why
    particular communities are being restricted.

-   There must be sufficient material and human resources to "enforce
    the confinement of large groups of persons, perhaps against their
    will,"

-   Those who are quarantined must be detained "in safe and hygienic
    locations" with "adequate food and other necessities" provided.

-   Those who are quarantined must have access to "competent medical
    care."

-   Public education and support are essential to high rates of
    compliance with voluntary quarantine (Rothstein et al., 2003).

In lieu of mandatory quarantine, public health authorities now recommend
voluntary quarantine in circumstances of a pandemic (Department of
Health and Human Services, February 2007).

In addition to operational steps outlined in the VA Pandemic Influenza
Plan, in anticipation of a pandemic, VHA leaders should develop
communications materials that:

-   Clearly communicate to veterans and staff why quarantine measures
    and social distancing are vital to control transmission of influenza
    for public safety and solidarity.

-   Clearly communicate barriers and challenges presented by quarantine
    and social distancing, including the closure of day care centers
    used by VHA staff, the impact on staff ability to report to work,
    and the cancellation of group activities and therapies.

> When a quarantine order is issued by public health authorities,
> research has found that frequent communication by a single, or a very
> limited number of credible spokesperson(s) throughout an epidemic is
> essential to improving public understanding of and maintaining public
> support for quarantine, isolation, and other public health measures
> (Rothstein et al., 2003). This approach is reflected in the VA
> Pandemic Influenza Plan and has been presented in three workshops on
> VA Pandemic Influenza Emergency Communication.

**[5.4 Isolation]{.smallcaps}**

Quarantine applies to healthy people who have been potentially exposed
to a contagious disease. Isolation, by contrast, refers to the
"separation of persons who have a specific infectious illness from those
who are healthy and the restriction of their movement to stop the spread
of that illness" (CDC, 2005). Although isolation restrictions may be one
aspect of a formal quarantine, in some cases, isolation as a containment
strategy will be necessary before quarantine. Given their knowledge of a
patient's infection status, health care professionals in particular may
be called upon to implement these restrictions.

As Wynia and Gostin (2004, p.1098) observe, "using professional powers
to hold patients involuntarily poses a fundamental ethical challenge for
physicians, because it entails overriding an individual patient's wishes
in deference to the community's needs". Whether supported by the
utilitarian rationale of overall public benefit, the public health
principle of preventing harm to third parties, or the paternalistic
rationale of clinical benefit to the individual who suffers involuntary
isolation and treatment, such restrictions must not be imposed without
adequate justification and safeguards.

As in the imposition of formal quarantine, the legal authority to compel
isolation is historically derived from a state's inherent "police
power". According to the VA's Office of General Counsel (OGC), in the
event that a VHA practitioner seeks to involuntarily isolate a VHA
patient, the authority to do so will likely be determined, at least
initially, by applicable state law. Because these laws vary greatly from
state to state, VA Regional Counsel has been advised by OGC to review
applicable state laws to identify the process for initiating such
measures within the state or states where their facilities are located
(VA, Office of General Counsel, 2004). Federal legal authority for
involuntary isolation comes from declaration of emergency under the
Stafford Act or the HHS Assistant Secretary may .

Isolation decisions by VA leaders and recommendations by facility
Infection Control Committees should be informed by the following ethical
considerations (Barbera et al., 2001, p. 2714-15):

-   The imposition of isolation must "have a reasonable scientific
    chance of substantially diminishing the spread of disease."

-   The disease must be one which has been determined to pose a "serious
    risk of widespread human-to-human transmission", and must confer a
    high risk of "serious illness or death."

-   There must be sufficient material and human resources to enforce the
    isolation of persons, perhaps against their will.

-   Those who are subject to isolation must be confined "in safe and
    hygienic locations" with "adequate food and other necessities"
    provided.

-   Those who are subject to isolation must have access to competent
    medical care.

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[]{#Section7 .anchor}**SECTION 7: LIST OF TABLES AND FIGURE**

**Table 1**: **Number of Episodes of Illness, Health Care Utilization,
and**

**Death Associated with Moderate and Severe Pandemic Influenza Scenarios
--**

**U.S. population, 300
million\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....3**

**Table 2**:**FluSurge Projection of Average Impact on
Hospitals..............................................4**

**Table 3**: **Number of Episodes of Illness, Health Care Utilization,
and Death Associated**

**with Moderate and Severe Pandemic Influenza Scenarios -- VISN 8
(540,065 enrollees)..........4**

**Table 4**: 239 Bed VA Hospital 1968-Scale Influenza Pandemic (Moderate
Scenario)...............5

**Table 5**: 62 Bed VA Hospital 1968-Scale Influenza Pandemic (Moderate
Scenario)............\.....6

**Table 6**: **Number of Ventilators Available and in Use in VHA
Facilities -- VISN 8..................\...7**

***Table 7:*** Ethical Challenges in Pandemic Influenza Preparation and
Response.....................8

**Table 8**: Reciprocal Obligations Cited in the Ethics Literature and
Current VHA Authority......21

**Table 9**: **Exclusion Criteria for Access to Scarce Life-Saving
Resources\...\...\...\...\...\...\...\...\...\...\.....32**

**Table 10: Sequential Organ Failure Assessment (SOFA)
Score\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...33**

**Table 11: Adapted OHPIP Triage
Tools\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....34-36**

**Figure 1**: Scarce Resource Allocation (SRA) Team and Triage Team
Membership

and
Roles**\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\....27**

**Appendix 1**

**Table A-1A**: Consequentialist Criteria for Allocating Scarce
Life-Saving

Medical
Resources**\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\.....62**

**Table A-1B**: Person-Centered Criteria for Allocating Scarce
Life-Saving

Medical Resources
**\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...63**

**Table A-1C**: Evaluating Consequentialist Rationing
Criteria**\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...65**

**Table A-1D**: Evaluating Person-Centered Rationing
Criteria**\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...\...66**

[]{#Appendix1 .anchor}**APPENDIX 1: AN ETHICAL FRAMEWORK FOR DECISION
MAKING REGARDING ALLOCATION OF SCARCE, LIFE-SAVING RESOURCES**

**Background Ethical Assumptions About the Goal(s) to be Achieved
Through Triage**

The California Department of Health Services (California Department of
Health Services, 2006) has developed an ethical framework for decision
making regarding scarce resource allocation specifically for pandemic
influenza vaccine. The framework, based on foundational work by Gerald
Winslow in his book, *Triage and Justice*, is used to assess the
feasibility (ethical, legal, political, and practical) of patient
selection criteria. This framework as well as analysis by others
(Kilner, 1990; Verweij, 2006, Kinlaw and Levine et al., 2007) was used
as a guide for identifying the ethical bases for allocation of scarce,
life-saving medical resources under circumstances of pandemic influenza
in VHA. We include this framework as a way of demonstrating transparency
regarding the basis for the **protocol for allocation of scarce
life-saving resources presented in [Section 3](#Section3).**

**NOTE: This ethical framework might be used as a tool to make decisions
not addressed in this guidance, for example, non life-saving resource
allocation decisions or life-saving resource allocation decisions in
non-pandemic mass casualty events.**

1.  **Consequentialist and Person-Centered Approaches to the Allocation
    of Scarce Life-Saving Resources**

There are two widely accepted theoretical approaches to allocation of
scarce resources: consequentialist and person centered (Kilner, 1990;
Winslow, 1982; Gostin and Powers, 2006; Roberts 2006; Vawter et al.,
2007;Verweij, 2006; Kinlaw and Levine et al., 2007; Vawter et al.,
2008). A consequentialist approach aims to create the greatest good for
the greatest number and regards individuals as instrumental to that
overall goal. Such an approach can be the basis for public health
decision making that focuses on the best interest of the population as a
whole. A person-centered approach, by contrast, is based on the equal
worth of all humans and focuses on allocation strategies that emphasize
equitable treatment of people as a way of respecting their inherent
worth.

Consequentialist and person-centered approaches are often in tension,
yet both are understood to be necessary in public health decision
making. For example, triaging to save the greatest number of lives (a
consequentialist objective) will inevitably depend on a principle of
fairness (a person-centered approach) for deciding between individuals
when there are still insufficient resources to treat all who meet the
inclusion criteria. Likewise, a person-centered approach would endorse
the efficient use of the limited resources (a consequentialist
objective) in order to increase the probability of saving more lives.
Similarly, a public health policy of mandatory quarantine to contain
disease outbreak (a consequentialist goal) is understood to be tolerable
to the extent that it uses the least restrictive means (a
person-centered approach) to achieve that end. In addition, from a
practical point of view, public health measures will be more readily
accepted if they are developed through processes that are fair,
reasonable, and open.

Tables A-1A and A-1B provide a variety of commonly used allocation
criteria and strategies that stem from each approach. Tables A-1A and
A-1B make no judgment about whether a particular strategy is
appropriate, legal, ethical, or feasible. This section only describes
how particular strategies for allocation of scarce life-saving resources
could be applicable to an outbreak of pandemic influenza. One important
caveat to keep in mind when assessing these strategies is that *they are
being applied only to the allocation of scarce life-saving resources*.
In other words, these allocation criteria apply specifically to very ill
patients in the tertiary care setting, not to selection for
countermeasures such as vaccines or antivirals. Although there will be
overlap in these criteria, an allocation framework for countermeasures
is outside the scope of this guidance.

**Table A-1A**

**Consequentialist Criteria for Allocating Scarce Life-Saving Medical
Resources**

+----------------------+----------------------+----------------------+
| **CONSEQUENTIALIST   |                      |                      |
| CRITERIA FOR         |                      |                      |
| ALLOCATING**         |                      |                      |
|                      |                      |                      |
| **SCARCE LIFE-SAVING |                      |                      |
| MEDICAL RESOURCES**  |                      |                      |
+======================+======================+======================+
| **Consequentialist   | **Definition**       | **Description**      |
| Criteria**           |                      |                      |
+----------------------+----------------------+----------------------+
| Medical success/     | Priority is given to | Allocate resource by |
|                      | those for whom       | probability of       |
| Survivability        | treatment has the    | successful           |
|                      | highest probability  | treatment. Those who |
|                      | of medical           | will probably live   |
|                      | success/survival.    | even without         |
|                      |                      | treatment and those  |
|                      |                      | who will probably    |
|                      |                      | die even if treated  |
|                      |                      | are left aside in    |
|                      |                      | order to treat those |
|                      |                      | for whom the         |
|                      |                      | specific resource    |
|                      |                      | has the highest      |
|                      |                      | probability of       |
|                      |                      | preventing severe    |
|                      |                      | illness and/or       |
|                      |                      | death. Further       |
|                      |                      | selection within     |
|                      |                      | this category can be |
|                      |                      | made on the basis of |
|                      |                      | length of benefit    |
|                      |                      | and/or quality of    |
|                      |                      | benefit.             |
+----------------------+----------------------+----------------------+
| Immediate usefulness | Priority is given to | Allocate the         |
|                      | the individuals who  | resource to those    |
|                      | are most useful      | who perform a role   |
|                      | under the immediate  | essential to the     |
|                      | circumstance.        | immediate emergency. |
|                      |                      | Individuals will be  |
|                      |                      | identified according |
|                      |                      | to essential role,   |
|                      |                      | indispensability,    |
|                      |                      | and ability to       |
|                      |                      | perform role, if     |
|                      |                      | treated.             |
+----------------------+----------------------+----------------------+
| Conservation of      | Priority is given to | Allocate the         |
| resources            | those who can        | resource in the      |
|                      | benefit by           | smallest effective   |
|                      | proportionately      | increments to        |
|                      | smaller amounts of   | benefit the most.    |
|                      | the resource or      | Conservation         |
|                      | shorter              | benefits those       |
|                      | length-of-use time.  | individuals who      |
|                      |                      | require a smaller    |
|                      |                      | portion of the       |
|                      |                      | available resource   |
|                      |                      | or shorter           |
|                      |                      | length-of-use time.  |
+----------------------+----------------------+----------------------+
| Parental/Caretaker   | Priority is given to | Allocate the         |
| role                 | those who have a     | resource to those    |
|                      | caretaking role for  | who provide primary  |
|                      | dependents.          | home care for        |
|                      |                      | children, elderly,   |
|                      |                      | and the unwell.      |
|                      |                      |                      |
|                      |                      | This principle is    |
|                      |                      | based on the idea    |
|                      |                      | that providing the   |
|                      |                      | resource to          |
|                      |                      | caregivers will      |
|                      |                      | benefit both the     |
|                      |                      | caregiver and the    |
|                      |                      | dependents.          |
+----------------------+----------------------+----------------------+
| Social worth/Moral   | Priority is given to | Allocate the         |
| worth                | those who are        | resource to those    |
|                      | believed to have the | who are most         |
|                      | greatest "social" or | socially or morally  |
|                      | "moral" worth.       | worthy.              |
+----------------------+----------------------+----------------------+

**Table A-1B**

**Person-Centered Criteria for Allocating Scarce Life-Saving Medical
Resources**

+----------------------+----------------------+----------------------+
| **PERSON-CENTERED    |                      |                      |
| CRITERIA FOR         |                      |                      |
| ALLOCATING**         |                      |                      |
|                      |                      |                      |
| **SCARCE LIFE-SAVING |                      |                      |
| MEDICAL RESOURCES**  |                      |                      |
+======================+======================+======================+
| **Person-Centered    | **Definition**       | **Description**      |
| Criteria**           |                      |                      |
+----------------------+----------------------+----------------------+
| Medical need/rule of | Priority is given to | Allocate resources   |
| rescue               | those with the       | according to         |
|                      | greatest medical     | greatest medical     |
|                      | need.                | need. This strategy  |
|                      |                      | assumes that the     |
|                      |                      | medically worse-off  |
|                      |                      | should be given      |
|                      |                      | priority and favors  |
|                      |                      | those individuals    |
|                      |                      | who are most at risk |
|                      |                      | for severe illness   |
|                      |                      | and/or death. This   |
|                      |                      | strategy does not    |
|                      |                      | necessarily consider |
|                      |                      | need relative to     |
|                      |                      | probability of       |
|                      |                      | survival.            |
+----------------------+----------------------+----------------------+
| General need         | Priority is given to | Priority allocation  |
|                      | those with the       | of resources to      |
|                      | greatest general     | those with minimal   |
|                      | need or              | access to medical    |
|                      | helplessness.        | care.                |
|                      | "General need" may   |                      |
|                      | include a range of   |                      |
|                      | characteristics      |                      |
|                      | including: lack of   |                      |
|                      | political power,     |                      |
|                      | social status,       |                      |
|                      | intelligence,        |                      |
|                      | physical strength,   |                      |
|                      | or financial power.  |                      |
|                      | This is relevant     |                      |
|                      | because having these |                      |
|                      | characteristics/     |                      |
|                      |                      |                      |
|                      | conditions often     |                      |
|                      | limits one's access  |                      |
|                      | to medical           |                      |
|                      | resources.           |                      |
+----------------------+----------------------+----------------------+
| Fair innings         | Priority is given to | Where probability of |
|                      | those who have had   | benefit from         |
|                      | less opportunity for | treatment is on par  |
|                      | a full lifespan.     | and age difference   |
|                      |                      | is great, priority   |
|                      |                      | allocation to the    |
|                      |                      | 20-year old over the |
|                      |                      | 60-year old.         |
+----------------------+----------------------+----------------------+
| First -come, first   | Priority is given to | This strategy, which |
| -served              | those who arrive     | depends on the       |
|                      | first, that is, who  | establishment of a   |
|                      | have been waiting    | waiting list or      |
|                      | longest.             | queue, gives         |
|                      |                      | priority to those    |
|                      |                      | individuals who      |
|                      |                      | arrived first in the |
|                      |                      | queue to receive a   |
|                      |                      | needed resource.     |
+----------------------+----------------------+----------------------+
| Lottery              | Priority is given to | This strategy would  |
|                      | those selected by    | give all who require |
|                      | chance through a     | a particular         |
|                      | lottery.             | resource an equal    |
|                      |                      | chance of being      |
|                      |                      | selected.            |
+----------------------+----------------------+----------------------+

**Evaluating the Allocation Criteria**

In order to determine whether these ten allocation criteria are
reasonable, they were evaluated on the basis of five types of test:
meets intervention goals, ethics, legality, political feasibility, and
practicality of implementation:

> **1. Does the criterion meet the VHA intervention goals?** (Each
> criterion must achieve at least one of these goals to be included for
> further analysis.)

-   to stop, slow, or limit the spread of disease,

-   to reduce suffering and death,

-   to sustain operations.

1.  **2. Does the criterion meet moral intuitions regarding important
    > values such as: fair process, proportionality (balance between
    > individual liberty and community interests), and stewardship?**
    > (Each criterion must be consistent with at least two of these
    > values to be included for further analysis.)

> **3. Is the criterion legal?**
>
> Does the criterion conform to statute and regulation governing VA and
> is it a legitimate exercise of public health authority?

1.  **4. Is the criterion politically feasible?**

> Is the criterion likely to be accepted by VHA stakeholders including
> veterans, VHA employees, Congress, and the public?
>
> **5. Can the criterion be practically implemented given the emergency
> circumstances?**
>
> Will it be practical to implement the criterion? For example, can the
> relevant group be easily identified?

All of the criteria were evaluated on a point scale. Each was allocated
between zero and two points for each test, with zero points indicating
that the criterion did not pass a given test and two points indicating
that the criterion is completely acceptable on a given test. One point
in a test indicates that either there are some reservations about the
criterion or that the acceptability of the criterion is uncertain.

In order to be considered reasonable for scarce life-saving resource
allocation, each criterion was required to pass all of the tests; in
other words, each criterion must have received one or two points on each
test. Because VA's intervention goals for pandemic influenza are central
to any allocation criterion, any criterion that received zero points on
the first test was not considered for subsequent tests.

1.  On this basis, seven of the ten criteria were determined to be
    reasonable bases for scarce life-saving resource allocation. These
    criteria passed all five of the tests, though with varying final
    scores. Table A-1C and A-1D below summarize the results of these
    tests. The total score is then used to rank reasonableness.

**Table A-1C**

**Evaluating Consequentialist Rationing Criteria**

+-------+-------+-------+-------+-------+-------+-------+-------+
| **    |       |       |       |       |       |       |       |
| TABLE |       |       |       |       |       |       |       |
| 2A:   |       |       |       |       |       |       |       |
| EVALU |       |       |       |       |       |       |       |
| ATING |       |       |       |       |       |       |       |
| RATI  |       |       |       |       |       |       |       |
| ONING |       |       |       |       |       |       |       |
| CRITE |       |       |       |       |       |       |       |
| RIA** |       |       |       |       |       |       |       |
+=======+=======+=======+=======+=======+=======+=======+=======+
| **C   |       |       |       |       |       |       |       |
| onseq |       |       |       |       |       |       |       |
| uenti |       |       |       |       |       |       |       |
| alist |       |       |       |       |       |       |       |
| St    |       |       |       |       |       |       |       |
| rateg |       |       |       |       |       |       |       |
| ies** |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **C   | *     | *     | *     | *     | *     | **    | *     |
| RITER | *Test | *Test | *Test | *Test | *Test | Final | *Pass |
| ION** | 1:**  | 2:**  | 3:**  | 4:**  | 5:**  | Sc    | or    |
|       |       |       |       |       |       | ore** | F     |
|       | **L   | **Et  | **Le  | **P   | **Fea |       | ail** |
|       | imits | hical | gal** | oliti | sible |       |       |
|       | sp    | val   |       | cally | to    |       |       |
|       | read, | ues** |       | feasi | i     |       |       |
|       | re    |       |       | ble** | mplem |       |       |
|       | duces |       |       |       | ent** |       |       |
|       | d     |       |       |       |       |       |       |
|       | eath, |       |       |       |       |       |       |
|       | suffe |       |       |       |       |       |       |
|       | ring, |       |       |       |       |       |       |
|       | sus   |       |       |       |       |       |       |
|       | tains |       |       |       |       |       |       |
|       | ope   |       |       |       |       |       |       |
|       | ratio |       |       |       |       |       |       |
|       | ns.** |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **    | 2     | 2     | 1 -   | 2     | 2     | 9     | **P   |
| Survi |       |       | legal |       |       |       | ass** |
| vabil |       |       | con   |       |       |       |       |
| ity** |       |       | cerns |       |       |       |       |
|       |       |       | re.   |       |       |       |       |
| All   |       |       | withd |       |       |       |       |
| ocate |       |       | rawal |       |       |       |       |
| res   |       |       | of    |       |       |       |       |
| ource |       |       | l     |       |       |       |       |
| by    |       |       | ife-s |       |       |       |       |
| p     |       |       | aving |       |       |       |       |
| robab |       |       | trea  |       |       |       |       |
| ility |       |       | tment |       |       |       |       |
| of    |       |       |       |       |       |       |       |
| succe |       |       |       |       |       |       |       |
| ssful |       |       |       |       |       |       |       |
| treat |       |       |       |       |       |       |       |
| ment. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| *     | 1     | 1 -   | 2     | 1 -   | 1 -   | 6     | **P   |
| *Imme |       | may   |       | who   | re.   |       | ass** |
| diate |       | chal  |       | de    | l     |       |       |
| us    |       | lenge |       | fines | ife-s |       | re.   |
| efuln |       | trust |       | "     | aving |       | l     |
| ess** |       | and   |       | essen | resou |       | ife-s |
| All   |       | e     |       | tial" | rces, |       | aving |
| ocate |       | quity |       | to    | "     |       | resou |
| the   |       | if    |       | imme  | essen |       | rces, |
| res   |       | perc  |       | diate | tial" |       | Fail  |
| ource |       | eived |       | emerg | pe    |       | if    |
| to    |       | to be |       | ency? | rsons |       | "     |
| those |       | ap    |       |       | may   |       | essen |
| who   |       | plied |       |       | al    |       | tial" |
| pe    |       | too   |       |       | ready |       | pe    |
| rform |       | br    |       |       | be    |       | rsons |
| a     |       | oadly |       |       | too   |       | al    |
| role  |       |       |       |       | ill   |       | ready |
| esse  |       |       |       |       | to    |       | too   |
| ntial |       |       |       |       | serve |       | ill   |
| to    |       |       |       |       | role  |       | to    |
| the   |       |       |       |       |       |       | serve |
| imme  |       |       |       |       |       |       | role  |
| diate |       |       |       |       |       |       |       |
| emerg |       |       |       |       |       |       |       |
| ency. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **Co  | 2     | 2/1   | 2     | 2     | 1 may | 8/9   | **P   |
| nserv |       |       |       |       | not   |       | ass** |
| ation |       | Arbi  |       |       | a     |       |       |
| of    |       | trary |       |       | lways |       |       |
| r     |       | rel   |       |       | be    |       |       |
| esour |       | ative |       |       | easy  |       |       |
| ces** |       | to    |       |       | to    |       |       |
| All   |       | surv  |       |       | pr    |       |       |
| ocate |       | ivabi |       |       | edict |       |       |
| the   |       | lity. |       |       |       |       |       |
| res   |       | Not a |       |       |       |       |       |
| ource |       | suffi |       |       |       |       |       |
| in    |       | cient |       |       |       |       |       |
| the   |       | in    |       |       |       |       |       |
| sma   |       | itial |       |       |       |       |       |
| llest |       | crite |       |       |       |       |       |
| effe  |       | rion. |       |       |       |       |       |
| ctive |       |       |       |       |       |       |       |
| i     |       |       |       |       |       |       |       |
| ncrem |       |       |       |       |       |       |       |
| ents. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **Par | 1     | 1 -   | 2     | 1     | 0     | 5     | **F   |
| ental |       | may   |       |       |       |       | ail** |
| /Care |       | chal  |       |       |       |       |       |
| taker |       | lenge |       |       |       |       |       |
| r     |       | trust |       |       |       |       |       |
| ole** |       | and   |       |       |       |       |       |
| All   |       | e     |       |       |       |       |       |
| ocate |       | quity |       |       |       |       |       |
| the   |       | if    |       |       |       |       |       |
| res   |       | perc  |       |       |       |       |       |
| ource |       | eived |       |       |       |       |       |
| to    |       | to be |       |       |       |       |       |
| those |       | ap    |       |       |       |       |       |
| with  |       | plied |       |       |       |       |       |
| depe  |       | too   |       |       |       |       |       |
| ndent |       | br    |       |       |       |       |       |
| care  |       | oadly |       |       |       |       |       |
| taker |       |       |       |       |       |       |       |
| role. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **S   | 0     | 0 --  | 0     | 0     | 0     | 0     | **F   |
| ocial |       | reinf |       |       |       |       | ail** |
| w     |       | orces |       |       |       |       |       |
| orth/ |       | bias  |       |       |       |       |       |
| Moral |       | and   |       |       |       |       |       |
| wor   |       | discr |       |       |       |       |       |
| th**. |       | imina |       |       |       |       |       |
| All   |       | tion- |       |       |       |       |       |
| ocate |       | not   |       |       |       |       |       |
| res   |       | consi |       |       |       |       |       |
| ource |       | stent |       |       |       |       |       |
| to    |       | with  |       |       |       |       |       |
| those |       | equal |       |       |       |       |       |
| who   |       | moral |       |       |       |       |       |
| are   |       | worth |       |       |       |       |       |
| perc  |       |       |       |       |       |       |       |
| eived |       |       |       |       |       |       |       |
| wo    |       |       |       |       |       |       |       |
| rthy. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+

**Table A-1D**

**Evaluating Person-Centered Rationing Criteria**

+-------+-------+-------+-------+-------+-------+-------+-------+
| **    |       |       |       |       |       |       |       |
| EVALU |       |       |       |       |       |       |       |
| ATING |       |       |       |       |       |       |       |
| RATI  |       |       |       |       |       |       |       |
| ONING |       |       |       |       |       |       |       |
| ST    |       |       |       |       |       |       |       |
| RATEG |       |       |       |       |       |       |       |
| IES** |       |       |       |       |       |       |       |
+=======+=======+=======+=======+=======+=======+=======+=======+
| **    |       |       |       |       |       |       |       |
| Perso |       |       |       |       |       |       |       |
| n-Cen |       |       |       |       |       |       |       |
| tered |       |       |       |       |       |       |       |
| St    |       |       |       |       |       |       |       |
| rateg |       |       |       |       |       |       |       |
| ies** |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **    | *     | *     | *     | *     | *     | **    | *     |
| Strat | *Test | *Test | *Test | *Test | *Test | Final | *Pass |
| egy** | 1:**  | 2:**  | 3:**  | 4:**  | 5:**  | Sc    | or    |
|       |       |       |       |       |       | ore** | F     |
|       | **L   | **Et  | **Le  | **P   | **Fea |       | ail** |
|       | imits | hical | gal** | oliti | sible |       |       |
|       | sp    | val   |       | cally | to    |       |       |
|       | read, | ues** |       | feasi | i     |       |       |
|       | re    |       |       | ble** | mplem |       |       |
|       | duces |       |       |       | ent** |       |       |
|       | d     |       |       |       |       |       |       |
|       | eath, |       |       |       |       |       |       |
|       | suffe |       |       |       |       |       |       |
|       | ring, |       |       |       |       |       |       |
|       | sus   |       |       |       |       |       |       |
|       | tains |       |       |       |       |       |       |
|       | ope   |       |       |       |       |       |       |
|       | ratio |       |       |       |       |       |       |
|       | ns.** |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| *     | 1     | 1     | 2     | 2     | 1     | 7     | **P   |
| *Rule |       |       |       |       |       |       | ass** |
| of    |       | p     |       |       |       |       |       |
| res   |       | roble |       |       |       |       |       |
| cue** |       | matic |       |       |       |       |       |
| All   |       | re:   |       |       |       |       |       |
| ocate |       | s     |       |       |       |       |       |
| acco  |       | tewar |       |       |       |       |       |
| rding |       | dship |       |       |       |       |       |
| to    |       | if    |       |       |       |       |       |
| crit  |       | not   |       |       |       |       |       |
| erion |       | tied  |       |       |       |       |       |
| of    |       | to    |       |       |       |       |       |
| me    |       | likel |       |       |       |       |       |
| dical |       | ihood |       |       |       |       |       |
| need. |       | of    |       |       |       |       |       |
|       |       | suc   |       |       |       |       |       |
|       |       | cess. |       |       |       |       |       |
|       |       | U     |       |       |       |       |       |
|       |       | nfair |       |       |       |       |       |
|       |       | pri   |       |       |       |       |       |
|       |       | ority |       |       |       |       |       |
|       |       | to    |       |       |       |       |       |
|       |       | ident |       |       |       |       |       |
|       |       | ified |       |       |       |       |       |
|       |       | i     |       |       |       |       |       |
|       |       | ndivi |       |       |       |       |       |
|       |       | duals |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| **Ge  | 1     | 1     | ? -   | 1     | 0 -   | 3+    | **F   |
| neral |       |       | may   |       | diff  |       | ail** |
| n     |       |       | not   |       | icult |       |       |
| eed** |       |       | be    |       | to    |       |       |
|       |       |       | consi |       | ide   |       |       |
| Pri   |       |       | stent |       | ntify |       |       |
| ority |       |       | with  |       | this  |       |       |
| alloc |       |       | VHA   |       | class |       |       |
| ation |       |       | e     |       | of    |       |       |
| to    |       |       | ligib |       | p     |       |       |
| those |       |       | ility |       | eople |       |       |
| with  |       |       | prior |       |       |       |       |
| li    |       |       | ities |       |       |       |       |
| mited |       |       |       |       |       |       |       |
| a     |       |       |       |       |       |       |       |
| ccess |       |       |       |       |       |       |       |
| to    |       |       |       |       |       |       |       |
| me    |       |       |       |       |       |       |       |
| dical |       |       |       |       |       |       |       |
| care. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| *     | 2     | 2     | 1     | 1     | 1     | 6     | **P   |
| *Fair |       |       |       | -may  |       |       | ass** |
| inni  |       |       |       | be    |       |       |       |
| ngs** |       |       |       | seen  |       |       |       |
|       |       |       |       | as    |       |       |       |
| Pri   |       |       |       | disc  |       |       |       |
| ority |       |       |       | rimin |       |       |       |
| alloc |       |       |       | ating |       |       |       |
| ation |       |       |       | ag    |       |       |       |
| to    |       |       |       | ainst |       |       |       |
| those |       |       |       | el    |       |       |       |
| who   |       |       |       | derly |       |       |       |
| have  |       |       |       | and   |       |       |       |
| had   |       |       |       | thus  |       |       |       |
| less  |       |       |       | large |       |       |       |
| o     |       |       |       | % of  |       |       |       |
| pport |       |       |       | VHA   |       |       |       |
| unity |       |       |       | popul |       |       |       |
| for a |       |       |       | ation |       |       |       |
| full  |       |       |       |       |       |       |       |
| life  |       |       |       |       |       |       |       |
| span. |       |       |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| All   | 1     | 0/1 - | 2     | 2     | 2     | 7/8   | *     |
| ocate |       | p     |       |       |       |       | *Fail |
| on a  |       | roble |       |       |       |       | as a  |
| **f   |       | matic |       |       |       |       | f     |
| irst- |       | re.   |       |       |       |       | irst- |
| come, |       | fai   |       |       |       |       | order |
| firs  |       | rness |       |       |       |       | cr    |
| t-ser |       | -     |       |       |       |       | iteri |
| ved** |       | f     |       |       |       |       | on.** |
| b     |       | avors |       |       |       |       |       |
| asis. |       | those |       |       |       |       | **P   |
|       |       | who   |       |       |       |       | ass** |
|       |       | have  |       |       |       |       |       |
|       |       | ac    |       |       |       |       | **as  |
|       |       | cess. |       |       |       |       | s     |
|       |       | Arbi  |       |       |       |       | econd |
|       |       | trary |       |       |       |       | order |
|       |       | rel   |       |       |       |       | c     |
|       |       | ative |       |       |       |       | riter |
|       |       | to    |       |       |       |       | ion** |
|       |       | surv  |       |       |       |       |       |
|       |       | ivabi |       |       |       |       |       |
|       |       | lity. |       |       |       |       |       |
|       |       | Not a |       |       |       |       |       |
|       |       | suffi |       |       |       |       |       |
|       |       | cient |       |       |       |       |       |
|       |       | in    |       |       |       |       |       |
|       |       | itial |       |       |       |       |       |
|       |       | crite |       |       |       |       |       |
|       |       | rion. |       |       |       |       |       |
|       |       | Legit |       |       |       |       |       |
|       |       | imate |       |       |       |       |       |
|       |       | 2nd-  |       |       |       |       |       |
|       |       | order |       |       |       |       |       |
|       |       | crite |       |       |       |       |       |
|       |       | rion. |       |       |       |       |       |
+-------+-------+-------+-------+-------+-------+-------+-------+
| All   | 1     | 1 -   | 1     | 1     | 0/1   | 4     | *     |
| ocate |       | sup   |       |       |       |       | *Fail |
| via   |       | ports |       |       | depe  |       | as a  |
| **    |       | fair  |       |       | nding |       | f     |
| lotte |       | ness, |       |       | on    |       | irst- |
| ry**. |       | arbi  |       |       | cir   |       | order |
|       |       | trary |       |       | cumst |       | cr    |
|       |       | rel   |       |       | ances |       | iteri |
|       |       | ative |       |       |       |       | on.** |
|       |       | to    |       |       |       |       |       |
|       |       | surv  |       |       |       |       | **P   |
|       |       | ivabi |       |       |       |       | ass** |
|       |       | lity. |       |       |       |       |       |
|       |       | Legit |       |       |       |       | **as  |
|       |       | imate |       |       |       |       | s     |
|       |       | 2nd-  |       |       |       |       | econd |
|       |       | order |       |       |       |       | order |
|       |       | crite |       |       |       |       | c     |
|       |       | rion. |       |       |       |       | riter |
|       |       |       |       |       |       |       | ion** |
+-------+-------+-------+-------+-------+-------+-------+-------+

The results of this evaluation support a "nested approach" to allocation
criteria. That is, the reasonableness of most of the above criteria
depends on meeting an initial screen for probability of success (the
medical success/survivability criterion) -- which received the highest
overall score. So, for example, the use of smallest effective increments
or first-come, first-served in the allocation of scarce life-saving
resources only makes sense from an efficiency standpoint if it is
determined that those selected for the resource can use it successfully.
Likewise first-come first served is inadequate from the perspective of
fairness -- as it favors those who have means of access and disfavors
those who do not. As such, first-come, first-served is insufficient as
an initial criterion but may be justifiable as a second order criterion,
once an initial criterion (the medical success/survivability criterion)
has been met. One of the problems with the "medical need/rule of rescue"
criterion is that it does not necessarily consider need relative to
probability of survival. Likewise, one would only consider giving
priority for a ventilator to those who provide an "essential service"
immediately relevant to a pandemic if that treatment would be successful
in allowing them to immediately function in that role.

[]{#Appendix2 .anchor}**APPENDIX 2: *CHECKLIST FOR OPERATIONALIZING THIS
GUIDANCE***

**In advance of a pandemic event, VHA facility leaders should**:

-   Actively engage stakeholders in pandemic influenza planning and
    preparation by encouraging them to read and understand this
    guidance, including them in planning and decision-making groups as
    appropriate, and/or soliciting input through forums, discussions, or
    call for comments and opinions (in facility publications, by email,
    public notices, web postings, etc.). Stakeholders include all those
    who will be affected, including employees, veterans, VSOs, labor
    unions, volunteers, and others.

-   Update the facility work force plan (Department of Veterans Affairs,
    2006, Sections 3.4.3.1, 3.2.3.4, 3.2.3.6) to delineate the following
    specific points:

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-   The values and ethical principles governing VHA personnel, including
    the duty to provide care to veterans and the institution's
    reciprocal obligation to support and care for the employee during a
    pandemic flu event. [(Section 2)](#Section2)

-   The employer's expectations of employees' responsibilities during a
    pandemic influenza event. [(Section 2)](#Section2)

-   That legal authority does not currently exist to protect contract
    employees under the Federal Tort Claims Act and that contract
    employees should check with their malpractice insurer to make sure
    that their coverage would extend to actions taken under an altered
    scope of practice during a pandemic.

-   A fair and consistent decision-making process that will be used to
    specify the limits or exceptions to an employee's duty to provide
    care. (Who may be excused from service, why, and how?)
    [(Section 2)](#Section2)

-   The ways in which the facility will:

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-   Safeguard employees (e.g., security, building and infrastructure
    safety).

-   Mitigate occupational risk (e.g., protective equipment and
    vaccines).

-   Clarify for stricken staff and their families available
    institutional care and support for those who become ill from
    influenza.

-   Assist employees in meeting competing obligations (e.g., family
    care).

-   Provide for employee's welfare (e.g., basic needs such as food,
    sleep, clean clothes, and the availability of showers).

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-   The strategies that may be used to encourage and support staff to
    come to work (e.g., overtime pay, hazardous duty pay, etc.) while
    also articulating that coercive strategies (e.g., threats of
    termination) should be avoided. [(Table 8)](\l)

-   The ways in which non-clinical staff will be expected to participate
    in the facility's clinical response -- in particular the use of
    non-clinical staff in the provision of palliative care -- and how
    training will be provided to them.

-   How emergency scopes of practice will be established and the legal
    framework under the FTCA for personal immunity from liability.

-   Incorporation of a process for disaster credentialing and granting
    disaster privileges into the credentialing and privileging process
    and emergency management plan. (VHA Handbook 1100.19, Credentialing
    and Privileging and VHA Directive 2006-067, Credentialing of Health
    Care Professionals)

-   Update the facility patient care response plan to establish in
    > advance of a pandemic:

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-   A [scarce resource allocation (SRA) team](#Figure1).

-   A continuity plan for the SRA team to allow for illness and absence
    of members.

-   A process whereby data required for the SRA team to oversee triage
    and resource allocation decision making will be gathered and shared.

-   Operating procedures governing the SRA team. Those procedures will:

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-   Describe the processes and criteria used to initiate the use of and
    withdrawal of scarce life-saving resources consistent with the
    [protocols](#Protocol) described in this guidance.

-   Mandate appropriate Do Not Resuscitate [(DNR/DNAR) protocols](#DNR)
    during the pandemic.

-   Specify a mechanism for [review and appeal](#ReviewandAppeals) to
    ensure fairness and accountability for the quality of triage
    decisions.

-   Require that the triage algorithms for life-saving resources are
    applied to all critical care patients, regardless of their illness
    or their current treatment modalities. However, the plan should also
    specify that the triage algorithms will NOT be applied to patients
    housed in VHA long-term care beds and/or facilities (e.g., patients
    chronically dependent on life-sustaining resources like ventilators
    in long-term care facilities will not fall under the triage
    protocols until and unless such patients require transfer to an
    acute care setting).

-   Guidance regarding the implementation of involuntary isolation for
    > contagious medical conditions. Such guidance should be informed
    > both by state and federal law with the assistance of Regional
    > Counsel, and by the ethical principles outlined in [Section
    > 5.4](#Section5).

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-   The need for [hospice and palliative care](#Section4) and describe
    > the processes and resources required to implement such care,
    > including:

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-   Establishment of protocols for stockpiling appropriate hospice and
    palliative care supplies (e.g., pain medication, anxiolytics).

-   Description of the ways in which non-clinical staff will help
    support the provision of hospice and palliative care and the
    training to be completed by non-clinical staff who will act in this
    role.

-   Clarification of whether [palliative sedation](#PalliativeSedation)
    will be offered at this facility during a pandemic flu event.

-   Clarification of responsibility for identifying community resources
    for hospice and palliative care and assignment of responsibility for
    building relationships with such programs in advance of a pandemic.

-   Inclusion of information about hospice and palliative care in the
    data collection and communication activities of the SRA team,
    facility leadership, and staff.

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-   Ensure that the communications plan (Department of Veterans Affairs,
    2006, Appendix D-3):

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-   Addresses the work force plan prepared for pandemic flu. Leaders
    should particularly focus on the values message that coming to the
    aid of those who fall ill during an influenza pandemic may be one of
    the most important and commendable actions that staff undertake in
    their VHA careers.

-   Openly acknowledges the risks associated with providing care during
    a pandemic.

-   Describes the altered standards of care expected during a pandemic.

-   Addresses how decisions about triage and altered standards of care
    will be communicated to employees and veterans during a pandemic. At
    a minimum this will include the preparation of patient and staff
    education materials in advance of a pandemic flu event to be used
    during the event to describe to veterans and their family members
    what triage means, how it will work, what care may or may not be
    available to them, and the ethical principles behind these
    protocols.

-   Provides a means to effectively and efficiently share information
    about the availability of palliative care options in the community.

-   Includes education materials for patients and their families on how
    best to take care of themselves and dying family members when they
    do not have access to life-saving hospital care. (Department of
    Veterans Affairs, 2006, Appendix E-6)

-   Communicates expectations regarding the duty to provide hospice and
    palliative support to dying patients who do not have access to
    life-saving hospital care.

-   Communicates expectations regarding health care professionals' role
    in communicable disease reporting in accordance with VHA Handbook
    1605.1 Privacy and Release of Information, Section 27.

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-   Explains the value of reporting to safeguarding the public health.

-   Explains that protected health information is appropriately
    communicated so that patient information goes only to those who need
    it to reduce risk.

-   Communicates expectations about [mandatory preventive health
    measures](#Section5).

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-   Explains the rationale for requiring health care workers to be
    vaccinated against pandemic influenza or to take antivirals.

-   Explains the rationale for giving priority access to health care
    workers for preventive measures.

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-   Communicates expectations about [quarantine, social distancing, and
    > isolation](#Section5).

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-   Clearly communicates to veterans and staff why quarantine measures
    and social distancing are vital to control transmission of
    influenza, to guarantee public safety and to promote solidarity.

-   Clearly communicates barriers and challenges presented by quarantine
    and social distancing including the closure of day care centers used
    by VHA staff, the impact on staff's ability to report to work, the
    cancellation of group activities and therapies as well as medical
    care/treatments not essential during a pandemic (e.g., routine eye
    exams, dental visits, audiology, etc.).

-   Clearly communicates to veterans and staff why isolation measures
    are important, including the need to prevent the transmission of the
    virus, and the values of public safety and solidarity.

-   Clearly communicates barriers and challenges presented by isolation,
    including stigma and the psychological toll on patients who are
    separated from loved ones.

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-   Ensure extensive preparation and training of staff in the
    application of this guidance, the facility work force plan, the
    facility patient care plan, and the communications response plan
    including the use of the triage protocol and how to discuss its use
    with patients and their families.

-   Conduct rigorous, repeated tests of the pandemic influenza response
    plan that include the ethical principles and protocols described in
    this guidance. Report "after action" findings to the Office of
    Public Health and Environmental Hazards and the National Center for
    Ethics in Health Care.

**During a pandemic event, VHA facility leaders should:**

-   Be physically present at their facilities and be actively involved
    in supporting both clinical and non-clinical staff in ensuring the
    delivery of care to veterans and the provision of essential services
    to employees.

-   Activate the SRA team and support its implementation of altered
    standards of care. Ensure that the team has the information and
    authority it needs to make decisions about triage and the allocation
    of scarce resources.

-   Ensure timely and accurate flow of information between the SRA team
    and top facility management; and the timely and accurate flow of
    information to employees, patients, family members, and the public,
    including the reasoning behind the decisions being made and the
    processes being used to make them.