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ANA - Crisis Standard of Care

Crisis Standard of Care COVID-19 Pandemic

In a pandemic, nurses can find themselves operating in environments demanding a balance between time- limited crisis standards of care and longstanding professional standards of care. This guidance applies to decisions about care made during extreme circumstances such as those resulting from emergencies, disasters or pandemics like COVID-19. Changes in the standard of care can occur in circumstances when available resources are limited or when a clinician is practicing in an unusual setting or with unfamiliar patient care needs. In a pandemic, nurses can find themselves operating in crisis standards of care environments. In such situations, a utilitarian framework usually guides practice decisions and actions with special emphasis on transparency, protection of the public, proportional restriction of individual liberty, and fair stewardship of resources (Code of Ethics for Nurses with Interpretive Statements). The Hastings Center (Ethical Framework for Health Care Institutions and Guidelines for Institutional Ethics Services Responding to the Novel Coronavirus Pandemic) describes the changing ethical framework in pandemics as a shift from “patient-centered practice” which is the “focus of clinical ethics under normal conditions” to “public-focused” considerations of care “to promote equality of person and equity in distribution of risks and benefits in society.” The ANA Code of Ethics (2015) obligates professional nurses to respect the dignity of every person in their care while also upholding the public good and collective human rights.

There is a tension between the patient-centered approach to providing the maximum individual good for each patient and the public-focused approach to fair resource allocation during crisis conditions. A public health approach to ethics can provide guidance in balancing the tension between the needs of the individual and those of the group. “Public health emergencies require clinicians to change their practice, including in some situations, acting to prioritize the community above the individual in fairly allocating scarce resources.” (Berlinger, et al., 2020)

This guidance offers answers to frequent challenges nurses and their colleagues address during crisis situations.

Guidance to Registered Nurses:

  • Professional nurses have a duty to care during crises like pandemics. Their employers and supervisors have a corresponding duty to reduce risks to nurses' safety, plan for competing priorities like childcare, and address moral distress and other injuries to personal and professional integrity such crisis events can cause.

  • No crisis changes the professional standards of practice, Code of Ethics, accountability for clinical competence or values of the registered nurse. However, the specific balance of professional standards and crisis standards of care will be based on the reality of the specific situation, such as the presence or absence of necessary equipment, medications or colleagues.

  • Decision-making during extreme conditions can shift ethical standards to a utilitarian framework in which the clinical goal is the greatest good for the greatest number of individuals, but that shift must not disproportionately burden those who already suffer healthcare disparities and social injustice. Sacrifices in desired care must be fairly shared. This means that care decisions are not about “the best that can be done” under normal conditions. They are necessarily constrained by the specific conditions during the crisis.

o ANY move to crisis standards of care MUST be done within the institution’s response structure and ideally in collaboration with other healthcare professionals, policymakers and the community.

  • Registered nurses may be asked to delegate care to others, such as students, staff displaced from another institution, or volunteers. This will require a rapid assessment of the skills of the others available to assist in patient care. Nurses must continue to emphasize patient safety and appropriate delegation.

  • An increased reliance on a nurse’s own or the collective accumulated competence may be needed, as the usual range of colleagues, experts or support services may not be available.

Guidance to institutions:

  • Institutions and healthcare systems, have a duty to safeguard employees with policies and practices that are evidence-based, transparently decided and have clear accountabilities.

  • In a healthcare system characterized by structural racism, income inequality and healthcare disparities, a "first come first served" approach may compound existing injustice. Healthcare systems must counter these impacts with efforts to protect at-risk populations.

  • A range of contingencies must be planned for by accountable decisionmakers as demand for care increases and resources, such as staff and materiel, become scarce.

  • Essential decisions about allocation of resources must be made at systems and community levels. The individual registered nurse should remain focused on patients and is responsible for giving the best possible care with available resources.

  • Decisions at the system level must be:

o Fair – Decision-making standards should be recognized as fair by all those affected by them.

o Equitable – The process used to make decisions about scarce resources should be transparent, consistent, proportional to the scale of the emergency and degree of scarce resources, and accountable for appropriate protections and the just allocation of available resources.

Conclusion: The response of the entire health workforce will make the difference in morbidity and mortality, the degree of suffering, and the rate at which recover occurs in the community. Being ready to adapt and provide essential care under crisis conditions is a professional responsibility.

Definition: Crisis Standards of Care – a substantial change in usual healthcare operations and the level of care it is possible to deliver, which is made necessary by a pervasive (e.g. pandemic influenza) or catastrophic (e.g. earthquake, hurricane) disaster. This change in the level of care delivered is justified by specific circumstances and is formally declared by a state government, in recognition that crisis operations will be in effect for a sustained period. The formal declaration that crisis standards of care are in operation enables specific legal/regulatory powers and protections for healthcare providers in the necessary tasks of allocating and using scarce medical resources and implementing alternat care facility operations. (IOM Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations, 2012)

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