title: Should palliative care be a necessity or a luxury during an overwhelming health catastrophe?
abstract: In the event of a widespread health catastrophe in which either or both human and material resources were in critically short supply, rationing must take place, especially if the scarcity will last for some time. There are several tested allocation methods that are routinely used during emergencies. These include triage procedures employed by emergency departments and the military on the battlefield. The goal is to save the lives of as many as possible. When it is not possible to save all, or even most, who come for care, what should be done, if anything, with those whose fate is death? The central tenet and goal of medicine is the relief of suffering. If we take this seriously as an axiom of practice, then healthcare providers and the institutions in which they work are duty-bound to provide comfort and relief to all, especially the dying. There are several ways this can be done. One is to prepare by training sufficient individuals to provide what might be called emergency palliative care. These people do not all have to be doctors but could (and should) include people from a range of backgrounds including nursing, allied health, pastoral care, and social work. For them to be able to do their jobs effectively, some basic supplies should be stockpiled so the pain and suffering associated with untreated illness and injury can be relieved. However, what happens when there is a shortage of, say, opiates, so that relief of air hunger and pain cannot be eased? Then critical decisions must be made. Alternative sources of symptom relief not considered under ordinary circumstances might be used. However, it is possible to imagine a situation when all resources are in critically short supply. Those remaining resources, logically and morally, should be allocated to persons who can survive. In this scenario, what can be offered to the suffering dying? This might depend on the attitude of personnel caring for patients. In desperate circumstances, it is possible the proscription against active euthanasia could be justifiably overridden by concern for ongoing, relentless, and unmitigated suffering. Any justification that could be made for such action would be undermined by arbitrary or capricious administration. Thus, preparation for a catastrophic healthcare emergency should take into account all conceivable outcomes.
authors.affiliation: Duke University Hospital, Durham, North Carolina, USA. rosof001@mc.duke.edu
authors.forename: Philip M
authors.initials: PM
authors.lastname: Rosoff
mesh_terms: D004189:Disaster Planning / Q000458:organization & administration* / Q000592:standards / Q000639:trends; D004190:Disasters; D004638:Emergency Treatment / Q000941:ethics*; D005065:Euthanasia / Q000941:ethics*; D015276:Health Care Rationing / Q000941:ethics*; D006295:Health Resources / Q000600:supply & distribution; D006301:Health Services Needs and Demand; D006801:Humans; D054527:Mass Casualty Incidents; D009726:Nurses; D010146:Pain / Q000188:drug therapy / Q000209:etiology; D059408:Pain Management; D010166:Palliative Care / Q000941:ethics* / Q000458:organization & administration; D010327:Pastoral Care; D012947:Social Work; D013315:Stress, Psychological / Q000209:etiology / Q000517:prevention & control / Q000628:therapy*; D013727:Terminal Care / Q000941:ethics; D014218:Triage / Q000941:ethics; D000078329:Workforce