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Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement Online Only Articles |

Ethical ConsiderationsEthical Considerations: Care of the Critically Ill and Injured During Pandemics and Disasters: CHEST Consensus Statement FREE TO VIEW

Lee Daugherty Biddison, MD, MPH; Kenneth A. Berkowitz, MD, FCCP; Brooke Courtney, JD, MPH; COL Marla J. De Jong, PhD, RN [USAF]; Asha V. Devereaux, MD, MPH, FCCP; Niranjan Kissoon, MBBS, FRCPC; Beth E. Roxland, JD, MBioethics; Charles L. Sprung, MD; Jeffrey R. Dichter, MD; Michael D. Christian, MD, FRCPC, FCCP; Tia Powell, MD; on behalf of the Task Force for Mass Critical Care
Author and Funding Information

From Johns Hopkins School of Medicine (Dr Daugherty Biddison), Baltimore, MD; the Veterans Health Administration (Dr Berkowitz), New York University School of Medicine, New York, NY; the Office of Counterterrorism and Emerging Threats (Ms Courtney), Office of the Commissioner, US Food and Drug Administration, Silver Spring, MD; US Air Force School of Aerospace Medicine (Dr De Jong), Wright-Patterson AFB, OH; Sharp Hospital (Dr Devereaux), Coronado, CA; BC Children’s Hospital and Sunny Hill Health Centre (Dr Kissoon), University of British Columbia, Vancouver, BC, Canada; NYU School of Law (Ms Roxland), NYU Langone Medical Center, New York, NY; Hadassah Hebrew University Medical Center (Dr Sprung), Jerusalem, Israel; Allina Health (Dr Dichter), Minneapolis, MN; Aurora Health (Dr Dichter), Milwaukee, WI; Royal Canadian Medical Service (Dr Christian), Canadian Armed Forces and Mount Sinai Hospital, Toronto, ON, Canada; and Montefiore Medical Center (Dr Powell), Albert Einstein College of Medicine, New York, NY.

CORRESPONDENCE TO: Lee Daugherty Biddison, MD, MPH, Johns Hopkins School of Medicine, 1830 E Monument St, Room 549, Baltimore, MD 21287; e-mail: edaughe2@jhmi.edu


Ms Roxland is currently at the Office of the Chief Medical Officer, Johnson & Johnson (New Brunswick, NJ).

FUNDING/SUPPORT: This publication was supported by the Cooperative Agreement Number 1U90TP00591-01 from the Centers of Disease Control and Prevention, and through a research sub award agreement through the Department of Health and Human Services [Grant 1 - HFPEP070013-01-00] from the Office of Preparedness of Emergency Operations. In addition, this publication was supported by a grant from the University of California–Davis.

COI grids reflecting the conflicts of interest that were current as of the date of the conference and voting are posted in the online supplementary materials.

DISCLAIMER: American College of Chest Physicians guidelines and consensus statements are intended for general information only, are not medical advice, and do not replace professional care and physician advice, which always should be sought for any medical condition. The complete disclaimer for this consensus statement can be accessed at http://dx.doi.org/10.1378/chest.1464S1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(4_suppl):e145S-e155S. doi:10.1378/chest.14-0742
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BACKGROUND:  Mass critical care entails time-sensitive decisions and changes in the standard of care that it is possible to deliver. These circumstances increase provider uncertainty as well as patients’ vulnerability and may, therefore, jeopardize disciplined, ethical decision-making. Planning for pandemics and disasters should incorporate ethics guidance to support providers who may otherwise make ad hoc patient care decisions that overstep ethical boundaries. This article provides consensus-developed suggestions about ethical challenges in caring for the critically ill or injured during pandemics or disasters. The suggestions in this article are important for all of those involved in any pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS:  We adapted the American College of Chest Physicians (CHEST) Guidelines Oversight Committee’s methodology to develop suggestions. Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions. The detailed literature reviews produced 144 articles. Based on their expertise within this domain, panel members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. The literature in this field is not suitable to support evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS:  We report the suggestions that focus on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns.

CONCLUSIONS:  Ethics issues permeate virtually all aspects of pandemic and disaster response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. Our suggestions reflect the consensus of the Task Force. We recognize, however, that some suggestions, including those related to end-of-life care, may be controversial. We highlight the need for additional research and dialogue in articulating values to guide health-care decisions during disasters.

Triage and Allocation

1. We suggest resources not be held in reserve once a mass disaster protocol is in effect.

2. We suggest disaster and pandemic policies reflect the broad consensus that there is no ethical difference between withholding and withdrawing care and that education regarding such policies be incorporated into training.

3. We suggest triage systems based even on limited evidence are ethically preferable to those based on clinical judgment alone.

4. We suggest critical care resources be allocated based on specific triage criteria, irrespective of whether the need for resources is related to the current disaster/pandemic or an unrelated critical illness or injury.

5. We suggest it may be ethically permissible to use exclusion criteria for critical care resources, since the advantages of objectivity, equity, and transparency generally outweigh potential disadvantages.

6. We suggest protocols permitting the exclusion of patients from critical care during a mass disaster based on a high level of ongoing resource consumption may be ethically permissible.

7. We suggest it is ethically permissible to identify certain resource intensive therapies, procedures or diagnostic tests that should be limited or excluded during crisis standards of care.

8. We suggest policies permitting the withdrawal of critical care treatment to reallocate to someone else based on higher likelihood of benefit may be ethically permissible.

9. We suggest patients who do not qualify under a mass critical care (MCC) protocol for critical care receive do not resuscitate (DNR) orders.

10. We suggest specific groups, eg, health-care workers or first responders, not receive enhanced access to scarce critical care resources when crisis standards of care are in effect.

11. We suggest age of entry for adult critical care units be adjusted down during MCC emergencies that effect substantial numbers of children.

12. We suggest active life-ending procedures are not ethically permissible, even during disasters or pandemics.

Responding to Ethical Concerns of Patients and Families

13. We suggest hospitals communicate the definition of crisis standards of care clearly to patients and families both on admission to the hospital and when triage decisions are communicated.

14. We suggest patients triaged to palliative care be notified of their right to discuss concerns and receive support from hospital personnel, including palliative care, social work, or ethics.

15. We suggest hospitals include ethics resources in planning for MCC and should anticipate a need for ethics consultative services during the event.

Responsibilities to Providers

16. We suggest hospitals make plans to assist with moral distress in providers involved in providing MCC.

17. We suggest critical care clinicians who are unable to accept implementation of crisis standards of care be transferred into support or non-clinical roles during disaster response, if possible, but not be absolved of their obligation to participate in the response.

18. We suggest hospitals plan to protect worker safety and encourage providers/workers to create personal/family disaster preparedness plans.

Conduct of Research

19. We suggest researchers collaborate on a national guidance document that develops standards for obtaining institutional review board (IRB) approval in advance of disasters, and offers ethically, clinically, and legally acceptable mechanisms for research in the disaster context.

20. We suggest research conducted during disasters and pandemics focus specifically on improving treatment, safety, and outcomes.

International Disaster Response

21. We suggest international disaster responders coordinate efforts with local officials and clinicians to focus on interventions that will provide sustainable benefits to the population after the disaster.

22. We suggest international disaster responders have an ethical obligation to familiarize themselves with the predominant cultural and religious practices of the affected population.

23. We suggest international disaster responders demonstrate culturally and religiously appropriate respect for the dead within the disaster context by coordinating responses with local institutions.

The field of health-care ethics has evolved over decades, primarily to ensure the safety and protect the rights of vulnerable populations. Pandemics and disasters create both a surge in the numbers affected and an environment in which disciplined, ethical decision-making may be at risk. Ethics guidance is crucial in helping providers balance competing substantive and process-oriented ethical principles, including the duties to honor autonomy, justice, and beneficence and the requirements to steward resources, and promote consistency, fairness, transparency, proportionality, and accountability.

The 2008 consensus document from the American College of Chest Physicians (CHEST) Task Force was an important example of incorporating ethics commentary in public health disaster/pandemic guidance and included a discussion related to triage and allocation of scarce resources.1 Pandemic and disaster planning guidance documents now routinely include sections that articulate the underlying ethical principles of the plan.2,3 This guidance also often documents efforts to engage communities’ relevant values-based choices in disaster planning. The Institute of Medicine has supported numerous projects related to disaster planning that included both expert ethics consensus and community engagement efforts designed to elicit relevant values.4-6 Our focus has been to clarify and expand on current ethics guidance for disasters, with specific attention to the provision of care to critically ill or injured patients.

Although some may question whether there is time to consider ethical issues during a pandemic or disaster, we argue that time constraints are precisely the reason that planners need to incorporate ethics guidance in their plans in advance of the event. Failure to do so places the front-line worker in the untenable position of making weighty, life-altering decisions without the opportunity to consult others or fully consider the ethical consequences of various decisions. As an example, overwhelmed clinicians may make ad hoc decisions regarding evacuation based on do not resuscitate (DNR) status, unsupported by any institutional policy.7,8 There is, therefore, an obligation to provide ethics guidance for the benefit of both patients and those providing care under austere circumstances. Such guidance, supported by data (when possible), expert opinion, and community values, may help minimize inconsistency in decision-making and therefore unfair treatment of patients. It may also help engender trust and alleviate moral distress and burn-out in providers.

Although ethical issues permeate virtually all aspects of disaster response, we focus here on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. The suggestions in this article are important for all of those involved in a disaster or pandemic with multiple critically ill patients, including front-line clinicians, hospital administrators, and public health or government officials. Although it is important for all providers to be familiar with the ethical aspects of disaster and pandemic response, Table 1 provides an overview of the suggestions most of interest to each of the above groups.

Table Graphic Jump Location
TABLE 1 ]  Primary Target Audiences for Suggestions

We followed the CHEST Guidelines Oversight Committee’s methodology to develop suggestions (see the “Methodology” article by Ornelas et al9 in this consensus statement). Twenty-four key questions were developed, and literature searches were conducted to identify evidence for suggestions (e-Appendix 1 for key questions list and corresponding search terms and results). Searches were limited from 2002 to 2012, and only English-language papers were included. The detailed literature reviews produced 144 articles. Two separate evaluators reviewed each abstract and selected those that were relevant for group review. Based on their expertise within this domain, group members also supplemented the literature search with governmental publications, interdisciplinary workgroup consensus documents, and other information not retrieved through PubMed. Because few scientific studies are available to enable evidence-based recommendations, our suggestions are based upon careful review of the literature, including governmental, advisory group commentary, and expert opinion. Consensus was then developed using a modified Delphi process.

Triage/Allocation

1. We suggest resources not be held in reserve once a mass disaster protocol is in effect.

Once a triage/allocation protocol is in effect, patients who require and meet criteria for resources should be provided care in accordance with the protocols in effect at the time. Government agencies and health-care institutions should stockpile resources that are essential during or after a mass casualty event (eg, ventilators, antibiotics, vaccines, ICU beds).10 Although these stocks are scarce and may be in short supply, once a mass casualty event has occurred, withholding resources in anticipation that a similar patient might require them in the future is not permissible.

2. We suggest disaster and pandemic policies reflect the broad consensus that there is no ethical difference between withholding and withdrawing care and that education regarding such policies be incorporated into training.

Most ethicists find no moral difference between withholding and withdrawing life-sustaining treatments.11 Nonetheless, some health-care professionals report that withholding and withdrawing do not feel equivalent.11 These feelings represent an opportunity for education of health-care professionals rather than a position upon which policy should be based. Nevertheless, even with appropriate education, policymakers must be aware of the emotional strain and moral distress that withdrawal of treatment may cause for providers.

Under usual circumstances, providers should be sensitive to religious and/or cultural beliefs and should not withdraw life-prolonging treatments if the patient or their surrogate refuses withdrawal.12 This accommodation may not be possible during disasters or pandemics. Although providers or decision makers may conclude that under a crisis situation patients who are deemed to have an irreversible, nonsurvivable illness should have therapies, including ventilators, withdrawn so that these resources may be used to help others, they should recognize that some groups may object.12 In some countries, including Israel, laws may prevent withdrawing a ventilator either at all13 or unilaterally. Policies should be clearly communicated in advance to community members to help mitigate potential conflicts.

3. We suggest triage systems based even on limited evidence are ethically preferable to those based on clinical judgment alone.

The likelihood of medical benefit is the most ethically sound basis for triage.10,14 However, considerable debate exists about how best to estimate the relative medical benefit for individual patients. Decisions about survival or ICU benefit based on clinical judgment alone are subjective and prone to inconsistent application by individual providers or across groups of providers. A system that relies on clinical judgment alone is challenging ethically because it will not provide consistent decisions and, therefore, procedural justice for a large group of patients.

Critical care triage based on scoring systems is more objective, but there are no scoring systems to date that are universally reliable for estimating prognosis for individual patients, either during ordinary ICU triage15 or during pandemics and mass disasters.16 The Sequential Organ Failure Assessment score, previously recommended for use during pandemics or disasters,3,17,18 has been criticized and may not be adequate in determining prognosis for individual patients in all circumstances.19,20

Therefore, both the use of clinical judgment alone and scoring systems raise ethical problems. Currently, the most ethically appropriate method is to prospectively define patients who meet ICU inclusion and exclusion criteria and then consistently apply a prospectively developed, objective protocol.3,21 It may be difficult to attain this standard for some patients, including in pediatrics, since adequately validated, objective measurement tools are lacking. In such cases, the triage team will have no option but to assess prognosis and allocate access to critical care based on clinical judgment. Alternatively, when there is insufficient evidence upon which to formulate objective clinical criteria, after applying inclusion and exclusion criteria, allocating available critical care resources among patients of equivalent prognosis by a fair and random process (eg, a first-come, first-served system or lottery) might be ethically justifiable21,22 but logistically challenging to implement (see the “Triage” article by Christian et al23 in this consensus statement). Regardless of the system used, procedural justice must be assured by applying the system consistently and fairly to all acute care patients.

4. We suggest critical care resources be allocated based on specific triage criteria, irrespective of whether the need for resources is related to the current disaster/pandemic or an unrelated critical illness or injury.

When mass critical care (MCC) protocols are in place, exclusion, inclusion, and triage criteria should be applied consistently to all patients under consideration for receiving critical care. We recommend that inclusion/exclusion criteria (see the “Triage” article by Christian et al23 in this consensus statement) be the same regardless of whether the patient’s need for critical care arises from disaster/pandemic or unrelated conditions (eg, traffic accident).21

5. We suggest it may be ethically permissible to use exclusion criteria for critical care resources, since the advantages of objectivity, equity, and transparency generally outweigh potential disadvantages.

Exclusion criteria that are developed prospectively by a multidisciplinary group of experts, in alignment with community values, are more likely to be objective, transparent, and equitably applied. However, they are unlikely to have been validated for patients in pandemic or disaster situations, and hence whether they can accurately predict which patients have the lowest potential to survive with intensive care is unknown. Nevertheless, prospectively defined criteria applied equitably are a more ethically acceptable decision-making approach than clinical judgment alone, despite potential disadvantages.

6. We suggest protocols permitting the exclusion of patients from critical care during a mass disaster based on a high level of ongoing resource consumption may be ethically permissible.

Protocols for MCC must be based on the goal of achieving the greatest good for the greatest number of people (the principle of utility), within constraints of respect for human dignity and fairness. Protocols that permit withdrawal of critical care based on a patient’s disproportionately high level of critical care resource use may be ethically permissible when MCC protocols are in effect, since these protocols support the goal of achieving the greatest good for the greatest number of people.

7. We suggest it is ethically permissible to identify certain resource intensive therapies, procedures or diagnostic tests that should be limited or excluded during crisis standards of care.

MCC protocols should only be in use when resources across a broad geographic area are constrained (see the ”Triage” article by Christian et al23 and the “Surge Capacity Principles” article by Hick et al24 in this consensus statement). Interventions that have been prospectively identified to represent disproportionate resource use (stuff, staff, or space) and impact the ability to respond to the event under the MCC protocol should not be used during disasters.18,21 Limiting access to specific resources must be done carefully to ensure that patients with conditions widely known to be resource-intensive (eg, those on dialysis) are not unfairly penalized in relation to other patients who may require equal amounts of resources but with less probability of benefit (eg, those requiring extracorporeal membrane oxygenation). Careful advance review by experts to select excluded interventions is essential to assuring substantive and procedural justice.

8. We suggest policies permitting the withdrawal of critical care treatment to reallocate to someone else based on higher likelihood of benefit may be ethically permissible.

Withdrawal protocols must demand that the likelihood of survival of the original patient is reliably predicted to be low, or use of the critical care resources is reliably predicted to be disproportionately high/prolonged, and the likelihood of survival of the second patient is reliably predicted to be significantly higher without disproportionate resource use. Importantly, however, to ensure both procedural justice and a fair opportunity for the first patient to benefit from any trial of therapy, treatment should only be withdrawn from one patient in favor of another in the context of carefully developed and implemented protocols that include time trials of life support as well as other considerations.10

9. We suggest patients who do not qualify under a MCC protocol for critical care receive DNR orders.

Resuscitation from cardiopulmonary arrest in the acute care setting is a critical care intervention. Patients who are not eligible for critical care according to the protocol in effect should not have resuscitation attempts and should have clear DNR orders. All other treatments and procedures for which the patient is eligible should be offered regardless of DNR status. The application of DNR status irrespective of patient/surrogate preferences should apply only when the MCC protocol is in place.

10. We suggest specific groups, eg, health-care workers or first responders, not receive enhanced access to scarce critical care resources when crisis standards of care are in effect.

There may be instances in which a designated group should be prioritized for non-critical care resources, such as vaccines, that allow them to continue with their professional responsibilities.25-28 However, it is unlikely that workers who become critically ill during a pandemic or disaster will recover in sufficient time to allow them to return to work and carry out professional responsibilities. Thus, the goal of returning workers to the job is not a justification for enhanced access to critical care. Furthermore, it would be impossible to fairly decide which specific groups would receive enhanced access, since many groups might be affected by working during the crisis.

11. We suggest age of entry for adult critical care units be adjusted down during MCC emergencies that effect substantial numbers of children.

Adjusting entry age corrects for the baseline lower number of ICU beds available to children.22 Adult ICUs that accept children need to provide appropriately trained clinicians. Children tend to have higher survival rates than adults in some disasters, so adjusting age for adult ICU assignment aligns with the goal of maximizing survival.

12. We suggest active life-ending procedures are not ethically permissible, even during disasters or pandemics.

We recommend that policies explicitly state that measures to hasten the death of patients (euthanasia) are not acceptable, even in disasters or pandemics. Clinicians have an obligation to understand and abide by the significant ethical differences between withdrawing treatment, providing appropriate end-of-life comfort care (both ethically permissible under appropriate circumstances), and actively hastening death, which is not permissible.11,29,30

Responding to Ethical Concerns of Patients and Families

13. We suggest hospitals communicate the definition of crisis standards of care clearly to patients and families both on admission to the hospital and when triage decisions are communicated.

When clinicians follow MCC protocols, patients and families have the right, based on procedural justice, to expect that those with similar needs for critical care resources will be treated in similar ways.31 Critical care clinicians should communicate to patients and family members both prognosis and treatment decisions, as well as the basis for making any recommendation.32 Hospitals should ensure a smooth transition to palliative care. Patients/families should receive clear communication regarding the ethical and procedural triage process that prompted this transition.33,34

14. We suggest patients triaged to palliative care be notified of their right to discuss concerns and receive support from hospital personnel, including palliative care, social work, or ethics.

Most patients and family members will be distressed when faced with treatment limitations due to the disaster or pandemic. Although preprinted information may help patients and families comprehend the constraints of a crisis situation, additional support resources should be made available for them.35

15. We suggest hospitals include ethics resources in planning for MCC and should anticipate a need for ethics consultative services during the event.

As much as possible, we recommend that access to ethics consultation resources be included in planning for disasters. Timely ethics consultation via e-mail has been used in disasters to address clinical questions and support mutual trust and transparency.36,37 Normal ethics consultation practices, like all other standards of care, should resume as soon as resources allow.

Ethical Responsibilities to Providers

16. We suggest hospitals make plans to assist with moral distress in providers involved in providing MCC.

Timely communication from hospital leadership regarding the nature of triage during disasters and pandemics may help minimize moral distress. The scope and nature of support for moral distress will vary based on the type and duration of the event and institutional resources.33,38

17. We suggest critical care clinicians who are unable to accept implementation of crisis standards of care be transferred into support or non-clinical roles during disaster response, if possible, but not be absolved of their obligation to participate in the response.

Critical care clinicians should be educated in advance about hospitals’ expectations regarding MCC and should have the opportunity to voice concerns about the shift to crisis standards of care prior to an incident.39-41

18. We suggest hospitals plan to protect worker safety and encourage providers/workers to create personal/family disaster preparedness plans.

Hospitals have clear obligations, both legally and ethically, to protect the safety of workers. Although it is impossible to completely eliminate the risk of providing health care, hospitals should make efforts to supply personal protective equipment and a safe working environment. Hospitals may need additional security precautions to protect the safety of the health-care providers making triage decisions or informing families about them. Health-care systems should educate workers regarding establishment of personal/family preparedness plans. Systems should consider developing services to facilitate worker availability, such as emergency child care.

Conduct of Research

19. We suggest researchers collaborate on a national guidance document that develops standards for obtaining IRB approval in advance of disasters, and offers ethically, clinically, and legally acceptable mechanisms for research in the disaster context.

Research during disasters and pandemics is sorely lacking and is needed to provide evidence about the impact of these events; to study the effectiveness of clinical interventions; and to shape risk assessment, education, policy, and ongoing disaster/pandemic preparedness.42 It could be considered unethical to refrain from conducting such research, given the lack of empirical evidence for disaster/pandemic operations. Research goals, however, must be balanced with the primary responsibility to ensure continued clinical care and the need to respect and protect the interests, privacy, safety, preferences, and autonomy of those affected by the disaster/pandemic.

A disaster or pandemic is no justification for circumventing the ethical conduct of research. As with all research, an institutional review board (IRB) should approve disaster/pandemic research studies. There is a need for national guidance that addresses standards for obtaining IRB approval in advance of disasters/pandemics, including increased efficiency in real-time IRB review of disaster/pandemic-related research protocols. Such guidance should offer ethically, clinically, and legally acceptable mechanisms for data collection and review in the disaster context. Research guidance should address circumstances, if any, in which individual consent might be waived, and should incorporate protections for privacy and risk-minimization strategies.43-48

20. We suggest research conducted during disasters and pandemics focus specifically on improving treatment, safety, and outcomes.

The delivery of clinical care must always be the priority in a disaster, as in any clinical context. Well-designed protocols for research during disasters and pandemics will minimize impediments to the delivery of care and risks to patients and providers, and should address topics that cannot be studied under normal circumstances.49-52 Although the priority is to study the efficacy and safety of disaster/pandemic responses, researchers have additional responsibilities, including to design studies with scientific and technical merit, recruit subjects fairly, address consent to participate, monitor the safety of subjects and researchers, demonstrate sensitivity to the local culture, and avoid inducing additional stress on the population.49,53

International Disaster Response

Please see also the “Resource-Poor Settings” articles by Geiling et al54,55 in this consensus statement.

21. We suggest international disaster responders coordinate efforts with local officials and clinicians to focus on interventions that will provide sustainable benefits to the population after the disaster.

The determination of which benefits are sustainable should not be based solely on technology available to provide this care during the short-term crisis response but also on whether resources to sustain the gains will be available postdisaster. Initiatives must also be sensitive to the need to maintain ongoing care at local institutions. Key to a successful international response is effective coordination with host providers to transition care responsibilities back to local resources once the acute need for international support has resolved.56

22. We suggest international disaster responders have an ethical obligation to familiarize themselves with the predominant cultural and religious practices of the affected population.

Ethical treatment of survivors entails a blend of knowledge about culture, religious beliefs, and human rights.57,58 Despite good intentions, humanitarian assistance has made errors based on religious or cultural insensitivity (eg, an overemphasis on an individualistic orientation that is alien to the local culture).36,59,60

23. We suggest international disaster responders demonstrate culturally and religiously appropriate respect for the dead within the disaster context by coordinating responses with local institutions.

Responders to international mass casualties must strike a balance between safety in disposal of bodies and sensitivity to local customs and religious beliefs. Providers should attempt to honor religious and cultural rites around death in disasters as much as possible.

New evidence-based triage tools that predict survival, resource consumption, and quality-of-life outcomes with a high degree of accuracy for individual patients in specific circumstances would add significantly to current efforts to fairly allocate scarce critical care resources during public health disasters. All current tools fall short of this goal, despite major efforts on the part of many researchers. Pediatric research in developing triage tools lags significantly behind even that available for adult patients. Additionally, specific guidance regarding modifications in IRB protocol review and research processes during disasters and pandemics is needed.

Ethics issues permeate virtually all aspects of disaster and pandemic response. We have addressed some of the most pressing issues, focusing on five essential domains: triage and allocation, ethical concerns of patients and families, ethical responsibilities to providers, conduct of research, and international concerns. We have not covered areas and issues conclusively addressed in prior documents but instead have focused on questions for which debate, controversy, or inadequate information remain. Triage and allocation of scarce critical care resources remain persistently controversial issues in public health emergencies. Research and international concerns have received minimal attention in previous guidance documents. We argue that in these areas there are best practices regarding ethical policies that may be adopted, and we suggest that additional research and reflection on these key ethical issues is warranted.

Author contributions: L. D. B. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., N. K., B. E. R., C. L. S., J. R. D., M. D. C., and T. P. contributed to the development of PICO questions; L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., B. E. R., C. L. S., and T. P. conducted the literature review; L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., N. K., B. E. R., C. L. S., J. R. D., M. D. C., and T. P. contributed to development of expert opinion suggestion; L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., N. K., B. E. R., C. L. S., J. R. D., M. D. C., and T. P. contributed to the conception and design, or acquisition of data, or analysis and interpretation of data from the Delphi process; L. D. B., K. A. B., B. C., M. J. D. J., A. V. D., B. E. R., C. L. S., and T. P. developed and drafted the manuscript; and A. V. D., N. K., J. R. D., and M. D. C. revised the manuscript critically for important intellectual content.

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts: COL DeJong received grant funding to attend Flight Nurse and Aeromedical Evacuation Technician courses. Ms Roxland had no conflicts at the time the manuscripts were being drafted through the date of actual submission to CHEST, but is now employed as Bioethics & Strategy Leader in the Office of the Chief Medical Officer at Johnson & Johnson. The remaining authors report no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Endorsements: This consensus statement is endorsed by the American Association of Critical-Care Nurses, American Association for Respiratory Care, American College of Surgeons Committee on Trauma, International Society of Nephrology, Society for Academic Emergency Medicine, Society of Critical Care Medicine, Society of Hospital Medicine, World Federation of Pediatric Intensive and Critical Care Societies, World Federation of Societies of Intensive and Critical Care Medicine.

Role of sponsors: The American College of Chest Physicians was solely responsible for the development of these guidelines. The remaining supporters played no role in the development process. External supporting organizations cannot recommend panelists or topics, nor are they allowed prepublication access to the manuscripts and recommendations. Further details on the Conflict of Interest Policy are available online at http://chestnet.org.

Other contributions: The authors thank the following for their exceptional professionalism and dedication: Alicia Livinski, MA, MPH, for her assistance with the relevant literature searches, and research assistants Kelly Walters, BA; Jennifer Norris, BA; and Jamal Bracken, BA. The opinions expressed in this manuscript are solely those of the author (K. A. B.) and do not represent the position or policy of the US Government or the Veterans Administration. The opinions expressed within this manuscript are solely those of the author (B. C.) and do not represent the official position or policy of the US Food and Drug Administration. The opinions or assertions contained herein are the private views of the author (M. J. D. J.) and are not to be construed as official or as reflecting the views of the Department of Defense or the Departments of the Air Force, Navy, Army, or Public Health. The opinions expressed within this manuscript are solely those of the author (M. D. C.) and do not represent the official position or policy of the Royal Canadian Medical Service, Canadian Armed Forces, or the Department of National Defence.

Additional information: The e-Appendix can be found in the Supplemental Materials section of the online article.

Collaborators: Executive Committee: Michael D. Christian, MD, FRCPC, FCCP; Asha V. Devereaux, MD, MPH, FCCP, co-chair; Jeffrey R. Dichter, MD, co-chair; Niranjan Kissoon, MBBS, FRCPC; Lewis Rubinson, MD, PhD; Panelists: Dennis Amundson, DO, FCCP; Michael R. Anderson, MD; Robert Balk, MD, FCCP; Wanda D. Barfield, MD, MPH; Martha Bartz, MSN, RN, CCRN; Josh Benditt, MD; William Beninati, MD; Kenneth A. Berkowitz, MD, FCCP; Lee Daugherty Biddison, MD, MPH; Dana Braner, MD; Richard D Branson, MSc, RRT; Frederick M. Burkle Jr, MD, MPH, DTM; Bruce A. Cairns, MD; Brendan G. Carr, MD; Brooke Courtney, JD, MPH; Lisa D. DeDecker, RN, MS; COL Marla J. De Jong, PhD, RN [USAF]; Guillermo Dominguez-Cherit, MD; David Dries, MD; Sharon Einav, MD; Brian L. Erstad, PharmD; Mill Etienne, MD; Daniel B. Fagbuyi, MD; Ray Fang, MD; Henry Feldman, MD; Hernando Garzon, MD; James Geiling, MD, MPH, FCCP; Charles D. Gomersall, MBBS; Colin K. Grissom, MD, FCCP; Dan Hanfling, MD; John L. Hick, MD; James G. Hodge Jr, JD, LLM; Nathaniel Hupert, MD; David Ingbar, MD, FCCP; Robert K. Kanter, MD; Mary A. King, MD, MPH, FCCP; Robert N. Kuhnley, RRT; James Lawler, MD; Sharon Leung, MD; Deborah A. Levy, PhD, MPH; Matthew L. Lim, MD; Alicia Livinski, MA, MPH; Valerie Luyckx, MD; David Marcozzi, MD; Justine Medina, RN, MS; David A. Miramontes, MD; Ryan Mutter, PhD; Alexander S. Niven, MD, FCCP; Matthew S. Penn, JD, MLIS; Paul E. Pepe, MD, MPH; Tia Powell, MD; David Prezant, MD, FCCP; Mary Jane Reed, MD, FCCP; Preston Rich, MD; Dario Rodriquez, Jr, MSc, RRT; Beth E. Roxland, JD, MBioethics; Babak Sarani, MD; Umair A. Shah, MD, MPH; Peter Skippen, MBBS; Charles L. Sprung, MD; Italo Subbarao, DO, MBA; Daniel Talmor, MD; Eric S. Toner, MD; Pritish K. Tosh, MD; Jeffrey S. Upperman, MD; Timothy M. Uyeki, MD, MPH, MPP; Leonard J. Weireter Jr, MD; T. Eoin West, MD, MPH, FCCP; John Wilgis, RRT, MBA; ACCP Staff: Joe Ornelas, MS; Deborah McBride; David Reid; Content Experts: Amado Baez, MD; Marie Baldisseri, MD; James S. Blumenstock, MA; Art Cooper, MD; Tim Ellender, MD; Clare Helminiak, MD, MPH; Edgar Jimenez, MD; Steve Krug, MD; Joe Lamana, MD; Henry Masur, MD; L. Rudo Mathivha, MBChB; Michael T. Osterholm, PhD, MPH; H. Neal Reynolds, MD; Christian Sandrock, MD, FCCP; Armand Sprecher, MD, MPH; Andrew Tillyard, MD; Douglas White, MD; Robert Wise, MD; Kevin Yeskey, MD.

DNR

do not resuscitate

IRB

Institutional Review Board

MCC

mass critical care

Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L; Task Force for Mass Critical Care. Summary of suggestions from the Task Force for Mass Critical Care summit, January 26-27, 2007. Chest. 2008;133(5_suppl):1S-7S. [CrossRef] [PubMed]
 
Devereaux AV, Dichter JR, Christian MD, et al; Task Force for Mass Critical Care. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5_suppl):51S-66S. [CrossRef] [PubMed]
 
Pape JW, Rouzier V, Ford H, Joseph P, Johnson WD Jr, Fitzgerald DW. The GHESKIO field hospital and clinics after the earthquake in Haiti—dispatch 3 from Port-au-Prince. N Engl J Med. 2010;362(10):e34. [CrossRef] [PubMed]
 
Ethical considerations. World Health Organization website. http://www.who.int/csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf?ua=1. Accessed August 11, 2014.
 
Stand on guard for thee. University of Toronto Joint Centre for Bioethics website. http://jointcentreforbioethics.ca/people/documents/upshur_stand_guard.pdf. Accessed August 11, 2014.
 
Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: the National Academies; 2014. [PubMed] [PubMed]
 
Fink S. The deadly choices at memorial. New York Times. August 30, 2009. http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=all&_r=0. Accessed August 11, 2014.
 
Kirsch TD, Moon MR. A piece of my mind. The line. JAMA. 2010;303(10):921-922. [CrossRef] [PubMed]
 
Ornelas J, Dichter JR, Devereaux AV, Kissoon N, Livinski A, Christian MD; on behalf of the Task Force for Mass Critical Care. Methodology: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):35S-41S. [CrossRef] [PubMed]
 
Sprung CL, Danis M, Iapichino G, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med. 2013;39(11):1916-1924. [CrossRef] [PubMed]
 
Truog RD, Campbell ML, Curtis JR, et al; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36(3):953-963. [CrossRef] [PubMed]
 
Sprung CL, Maia P, Bulow HH, et al; Ethicus Study Group. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33(10):1732-1739. [CrossRef] [PubMed]
 
Steinberg A, Sprung CL. The dying patient: new Israeli legislation. Intensive Care Med. 2006;32(8):1234-1237. [CrossRef] [PubMed]
 
Society of Critical Care Medicine Ethics Committee. Consensus statement on the triage of critically ill patients. JAMA. 1994;271(15):1200-1203. [CrossRef] [PubMed]
 
Sprung CL, Baras M, Iapichino G, et al. The Eldicus prospective, observational study of triage decision making in European intensive care units: part I—European Intensive Care Admission Triage Scores. Crit Care Med. 2012;40(1):125-131. [CrossRef] [PubMed]
 
Challen K, Goodacre SW, Wilson R, et al. Evaluation of triage methods used to select patients with suspected pandemic influenza for hospital admission. Emerg Med J. 2012;29(5):383-388. [CrossRef] [PubMed]
 
Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175(11):1377-1381. [CrossRef] [PubMed]
 
Rubinson L, Hick JL, Hanfling DG, et al; Task Force for Mass Critical Care. Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5_suppl):18S-31S. [CrossRef] [PubMed]
 
Shahpori R, Stelfox HT, Doig CJ, Boiteau PJ, Zygun DA. Sequential Organ Failure Assessment in H1N1 pandemic planning. Crit Care Med. 2011;39(4):827-832. [CrossRef] [PubMed]
 
Khan Z, Hulme J, Sherwood N. An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemic. Anaesthesia. 2009;64(12):1283-1288. [CrossRef] [PubMed]
 
Sprung CL, Zimmerman JL, Christian MD, et al; European Society of Intensive Care Medicine Task Force for Intensive Care Unit Triage during an Influenza Epidemic or Mass Disaster. Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(3):428-443. [CrossRef] [PubMed]
 
Antommaria AH, Powell T, Miller JE, Christian MD; Task Force for Pediatric Emergency Mass Critical Care. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(suppl 6):S163-S168. [CrossRef] [PubMed]
 
Christian MD, Sprung CL, King MA, et al; on behalf of the Task Force for Mass Critical Care. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e61S-e74S. [CrossRef] [PubMed]
 
Hick JL, Einav S, Hanfling D, et al; on behalf of the Task Force for Mass Critical Care. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e1S-e16S. [CrossRef] [PubMed]
 
Powell T, Christ KC, Birkhead GS. Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep. 2008;2(1):20-26. [CrossRef] [PubMed]
 
Straetemans M, Buchholz U, Reiter S, Haas W, Krause G. Prioritization strategies for pandemic influenza vaccine in 27 countries of the European Union and the Global Health Security Action Group: a review. BMC Public Health. 2007;7:236. [CrossRef] [PubMed]
 
Talbot TR, Bradley SE, Cosgrove SE, Ruef C, Siegel JD, Weber DJ. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. Infect Control Hosp Epidemiol. 2005;26(11):882-890. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention (CDC). Experiences with obtaining influenza vaccination among persons in priority groups during a vaccine shortage—United States, October-November, 2004. MMWR Morb Mortal Wkly Rep. 2004;53(49):1153-1155. [PubMed]
 
Altevogt BM; Institute of Medicine; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. Washington, DC: National Academies Press; 2009. [PubMed] [PubMed]
 
Hanfling D; Institute of Medicine; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Crisis standards of care: a systems framework for catastrophic disaster response. Washington, DC: The National Academies Press; 2012. [PubMed] [PubMed]
 
Tillyard A. Reorganising the pandemic triage processes to ethically maximise individuals’ best interests. Intensive Care Med. 2010;36(11):1966-1971. [CrossRef] [PubMed]
 
Lin JY, Anderson-Shaw L. Rationing of resources: ethical issues in disasters and epidemic situations. Prehosp Disaster Med. 2009;24(3):215-221. [PubMed]
 
Emmerich N. Anti-theory in action? Planning for pandemics, triage and ICU or: how not to bite a bullet. Med Health Care Philos. 2011;14(1):91-100. [CrossRef] [PubMed]
 
Docter SP, Street J, Braunack-Mayer AJ, van der Wilt GJ. Public perceptions of pandemic influenza resource allocation: a deliberative forum using grid/group analysis. J Public Health Policy. 2011;32(3):350-366. [CrossRef] [PubMed]
 
Taylor-Clark KA, Viswanath K, Blendon RJ. Communication inequalities during Public Health disasters: Katrina’s wake. Health Commun. 2010;25(3):221-229. [CrossRef] [PubMed]
 
Etienne M, Powell C, Amundson D. Healthcare ethics: the experience after the Haitian earthquake. Am J Disaster Med. 2010;5(3):141-147. [PubMed]
 
Holt GR. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg. 2008;139(2):181-186. [CrossRef] [PubMed]
 
Mitchell JT. Collateral damage in disaster workers. Int J Emerg Ment Health. 2011;13(2):121-125. [PubMed]
 
Wessells MG. Do no harm: toward contextually appropriate psychosocial support in international emergencies. Am Psychol. 2009;64(8):842-854. [CrossRef] [PubMed]
 
Pahlman I, Tohmo H, Gylling H. Pandemic influenza: human rights, ethics and duty to treat. Acta Anaesthesiol Scand. 2010;54(1):9-15. [CrossRef] [PubMed]
 
Klopfenstein ML. Pandemic influenza and the duty to treat: the importance of solidarity and loyalty. Am J Bioeth. 2008;8(8):41-43. [CrossRef] [PubMed]
 
Lurie N, Manolio T, Patterson AP, Collins F, Frieden T. Research as a part of public health emergency response. N Engl J Med. 2013;368(13):1251-1255. [CrossRef] [PubMed]
 
Vaslef SN, Cairns CB, Falletta JM. Ethical and regulatory challenges associated with the exception from informed consent requirements for emergency research: from experimental design to institutional review board approval. Arch Surg. 2006;141(10):1019-1023. [CrossRef] [PubMed]
 
Perlman D. Public health practice vs research: implications for preparedness and disaster research review by State Health Department IRBs. Disaster Med Public Health Prep. 2008;2(3):185-191. [CrossRef] [PubMed]
 
Fleischman AR, Wood EB. Ethical issues in research involving victims of terror. J Urban Health. 2002;79(3):315-321. [CrossRef] [PubMed]
 
Daugherty EL, White DB. Conducting clinical research during disasters. Virtual Mentor. 2010;12(9):701-705. [CrossRef] [PubMed]
 
Chung B, Jones L, Campbell LX, Glover H, Gelberg L, Chen DT. National recommendations for enhancing the conduct of ethical health research with human participants in post-disaster situations. Ethn Dis. 2008;18(3):378-383. [PubMed]
 
Macklin R, Cowan E. Conducting research in disease outbreaks. PLoS Negl Trop Dis. 2009;3(4):e335. [CrossRef] [PubMed]
 
Sumathipala A, Jafarey A, De Castro L, et al. Ethical issues in post-disaster clinical interventions and research: a developing world perspective. Key findings from a drafting and consensus generation meeting of the Working Group on Disaster Research and Ethics (WGDRE). Asian Bioethical Review. 2010;2(2):124-142.
 
Cook D, Burns K, Finfer S, et al. Clinical research ethics for critically ill patients: a pandemic proposal. Crit Care Med. 2010;38(suppl 4):e138-e142. [CrossRef] [PubMed]
 
Fowler RA, Webb SA, Rowan KM, et al. Early observational research and registries during the 2009-2010 influenza A pandemic. Crit Care Med. 2010;38(suppl 4):e120-e132. [CrossRef] [PubMed]
 
Mfutso-Bengo J, Masiye F, Muula A. Ethical challenges in conducting research in humanitarian crisis situations. Malawi Med J. 2008;20(2):46-49. [PubMed]
 
O’Mathúna DP. Conducting research in the aftermath of disasters: ethical considerations. J Evid Based Med. 2010;3(2):65-75. [CrossRef] [PubMed]
 
Geiling J, Burkle FM Jr, Amundson D, et al; on behalf of the Task Force for Mass Critical Care. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e156S-e167S. [CrossRef] [PubMed]
 
Geiling J, Burkle FM Jr, West TE, et al; on behalf of the Task Force for Mass Critical Care. Resource-poor settings: response, recovery, and research: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e168S-e177S. [CrossRef] [PubMed]
 
Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010;362(11):e38. [CrossRef] [PubMed]
 
Varghese SB. Cultural, ethical, and spiritual implications of natural disasters from the survivors’ perspective. Crit Care Nurs Clin North Am. 2010;22(4):515-522. [CrossRef] [PubMed]
 
Bennett B, Carney T. Law, ethics and pandemic preparedness: the importance of cross-jurisdictional and cross-cultural perspectives. Aust N Z J Public Health. 2010;34(2):106-112. [CrossRef] [PubMed]
 
Richards P. Ritual dynamics in humanitarian assistance. Disasters. 2010;34(suppl 2):S138-S146. [CrossRef] [PubMed]
 
Welling DR, Ryan JM, Burris DG, Rich NM. Seven sins of humanitarian medicine. World J Surg. 2010;34(3):466-470. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Primary Target Audiences for Suggestions

References

Devereaux A, Christian MD, Dichter JR, Geiling JA, Rubinson L; Task Force for Mass Critical Care. Summary of suggestions from the Task Force for Mass Critical Care summit, January 26-27, 2007. Chest. 2008;133(5_suppl):1S-7S. [CrossRef] [PubMed]
 
Devereaux AV, Dichter JR, Christian MD, et al; Task Force for Mass Critical Care. Definitive care for the critically ill during a disaster: a framework for allocation of scarce resources in mass critical care: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5_suppl):51S-66S. [CrossRef] [PubMed]
 
Pape JW, Rouzier V, Ford H, Joseph P, Johnson WD Jr, Fitzgerald DW. The GHESKIO field hospital and clinics after the earthquake in Haiti—dispatch 3 from Port-au-Prince. N Engl J Med. 2010;362(10):e34. [CrossRef] [PubMed]
 
Ethical considerations. World Health Organization website. http://www.who.int/csr/resources/publications/WHO_CDS_EPR_GIP_2007_2c.pdf?ua=1. Accessed August 11, 2014.
 
Stand on guard for thee. University of Toronto Joint Centre for Bioethics website. http://jointcentreforbioethics.ca/people/documents/upshur_stand_guard.pdf. Accessed August 11, 2014.
 
Institute of Medicine. Crisis Standards of Care: A Systems Framework for Catastrophic Disaster Response. Washington, DC: the National Academies; 2014. [PubMed] [PubMed]
 
Fink S. The deadly choices at memorial. New York Times. August 30, 2009. http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=all&_r=0. Accessed August 11, 2014.
 
Kirsch TD, Moon MR. A piece of my mind. The line. JAMA. 2010;303(10):921-922. [CrossRef] [PubMed]
 
Ornelas J, Dichter JR, Devereaux AV, Kissoon N, Livinski A, Christian MD; on behalf of the Task Force for Mass Critical Care. Methodology: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):35S-41S. [CrossRef] [PubMed]
 
Sprung CL, Danis M, Iapichino G, et al. Triage of intensive care patients: identifying agreement and controversy. Intensive Care Med. 2013;39(11):1916-1924. [CrossRef] [PubMed]
 
Truog RD, Campbell ML, Curtis JR, et al; American Academy of Critical Care Medicine. Recommendations for end-of-life care in the intensive care unit: a consensus statement by the American College [corrected] of Critical Care Medicine. Crit Care Med. 2008;36(3):953-963. [CrossRef] [PubMed]
 
Sprung CL, Maia P, Bulow HH, et al; Ethicus Study Group. The importance of religious affiliation and culture on end-of-life decisions in European intensive care units. Intensive Care Med. 2007;33(10):1732-1739. [CrossRef] [PubMed]
 
Steinberg A, Sprung CL. The dying patient: new Israeli legislation. Intensive Care Med. 2006;32(8):1234-1237. [CrossRef] [PubMed]
 
Society of Critical Care Medicine Ethics Committee. Consensus statement on the triage of critically ill patients. JAMA. 1994;271(15):1200-1203. [CrossRef] [PubMed]
 
Sprung CL, Baras M, Iapichino G, et al. The Eldicus prospective, observational study of triage decision making in European intensive care units: part I—European Intensive Care Admission Triage Scores. Crit Care Med. 2012;40(1):125-131. [CrossRef] [PubMed]
 
Challen K, Goodacre SW, Wilson R, et al. Evaluation of triage methods used to select patients with suspected pandemic influenza for hospital admission. Emerg Med J. 2012;29(5):383-388. [CrossRef] [PubMed]
 
Christian MD, Hawryluck L, Wax RS, et al. Development of a triage protocol for critical care during an influenza pandemic. CMAJ. 2006;175(11):1377-1381. [CrossRef] [PubMed]
 
Rubinson L, Hick JL, Hanfling DG, et al; Task Force for Mass Critical Care. Definitive care for the critically ill during a disaster: a framework for optimizing critical care surge capacity: from a Task Force for Mass Critical Care summit meeting, January 26-27, 2007, Chicago, IL. Chest. 2008;133(5_suppl):18S-31S. [CrossRef] [PubMed]
 
Shahpori R, Stelfox HT, Doig CJ, Boiteau PJ, Zygun DA. Sequential Organ Failure Assessment in H1N1 pandemic planning. Crit Care Med. 2011;39(4):827-832. [CrossRef] [PubMed]
 
Khan Z, Hulme J, Sherwood N. An assessment of the validity of SOFA score based triage in H1N1 critically ill patients during an influenza pandemic. Anaesthesia. 2009;64(12):1283-1288. [CrossRef] [PubMed]
 
Sprung CL, Zimmerman JL, Christian MD, et al; European Society of Intensive Care Medicine Task Force for Intensive Care Unit Triage during an Influenza Epidemic or Mass Disaster. Recommendations for intensive care unit and hospital preparations for an influenza epidemic or mass disaster: summary report of the European Society of Intensive Care Medicine’s Task Force for intensive care unit triage during an influenza epidemic or mass disaster. Intensive Care Med. 2010;36(3):428-443. [CrossRef] [PubMed]
 
Antommaria AH, Powell T, Miller JE, Christian MD; Task Force for Pediatric Emergency Mass Critical Care. Ethical issues in pediatric emergency mass critical care. Pediatr Crit Care Med. 2011;12(suppl 6):S163-S168. [CrossRef] [PubMed]
 
Christian MD, Sprung CL, King MA, et al; on behalf of the Task Force for Mass Critical Care. Triage: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e61S-e74S. [CrossRef] [PubMed]
 
Hick JL, Einav S, Hanfling D, et al; on behalf of the Task Force for Mass Critical Care. Surge capacity principles: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e1S-e16S. [CrossRef] [PubMed]
 
Powell T, Christ KC, Birkhead GS. Allocation of ventilators in a public health disaster. Disaster Med Public Health Prep. 2008;2(1):20-26. [CrossRef] [PubMed]
 
Straetemans M, Buchholz U, Reiter S, Haas W, Krause G. Prioritization strategies for pandemic influenza vaccine in 27 countries of the European Union and the Global Health Security Action Group: a review. BMC Public Health. 2007;7:236. [CrossRef] [PubMed]
 
Talbot TR, Bradley SE, Cosgrove SE, Ruef C, Siegel JD, Weber DJ. Influenza vaccination of healthcare workers and vaccine allocation for healthcare workers during vaccine shortages. Infect Control Hosp Epidemiol. 2005;26(11):882-890. [CrossRef] [PubMed]
 
Centers for Disease Control and Prevention (CDC). Experiences with obtaining influenza vaccination among persons in priority groups during a vaccine shortage—United States, October-November, 2004. MMWR Morb Mortal Wkly Rep. 2004;53(49):1153-1155. [PubMed]
 
Altevogt BM; Institute of Medicine; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Guidance for establishing crisis standards of care for use in disaster situations: a letter report. Washington, DC: National Academies Press; 2009. [PubMed] [PubMed]
 
Hanfling D; Institute of Medicine; Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations. Crisis standards of care: a systems framework for catastrophic disaster response. Washington, DC: The National Academies Press; 2012. [PubMed] [PubMed]
 
Tillyard A. Reorganising the pandemic triage processes to ethically maximise individuals’ best interests. Intensive Care Med. 2010;36(11):1966-1971. [CrossRef] [PubMed]
 
Lin JY, Anderson-Shaw L. Rationing of resources: ethical issues in disasters and epidemic situations. Prehosp Disaster Med. 2009;24(3):215-221. [PubMed]
 
Emmerich N. Anti-theory in action? Planning for pandemics, triage and ICU or: how not to bite a bullet. Med Health Care Philos. 2011;14(1):91-100. [CrossRef] [PubMed]
 
Docter SP, Street J, Braunack-Mayer AJ, van der Wilt GJ. Public perceptions of pandemic influenza resource allocation: a deliberative forum using grid/group analysis. J Public Health Policy. 2011;32(3):350-366. [CrossRef] [PubMed]
 
Taylor-Clark KA, Viswanath K, Blendon RJ. Communication inequalities during Public Health disasters: Katrina’s wake. Health Commun. 2010;25(3):221-229. [CrossRef] [PubMed]
 
Etienne M, Powell C, Amundson D. Healthcare ethics: the experience after the Haitian earthquake. Am J Disaster Med. 2010;5(3):141-147. [PubMed]
 
Holt GR. Making difficult ethical decisions in patient care during natural disasters and other mass casualty events. Otolaryngol Head Neck Surg. 2008;139(2):181-186. [CrossRef] [PubMed]
 
Mitchell JT. Collateral damage in disaster workers. Int J Emerg Ment Health. 2011;13(2):121-125. [PubMed]
 
Wessells MG. Do no harm: toward contextually appropriate psychosocial support in international emergencies. Am Psychol. 2009;64(8):842-854. [CrossRef] [PubMed]
 
Pahlman I, Tohmo H, Gylling H. Pandemic influenza: human rights, ethics and duty to treat. Acta Anaesthesiol Scand. 2010;54(1):9-15. [CrossRef] [PubMed]
 
Klopfenstein ML. Pandemic influenza and the duty to treat: the importance of solidarity and loyalty. Am J Bioeth. 2008;8(8):41-43. [CrossRef] [PubMed]
 
Lurie N, Manolio T, Patterson AP, Collins F, Frieden T. Research as a part of public health emergency response. N Engl J Med. 2013;368(13):1251-1255. [CrossRef] [PubMed]
 
Vaslef SN, Cairns CB, Falletta JM. Ethical and regulatory challenges associated with the exception from informed consent requirements for emergency research: from experimental design to institutional review board approval. Arch Surg. 2006;141(10):1019-1023. [CrossRef] [PubMed]
 
Perlman D. Public health practice vs research: implications for preparedness and disaster research review by State Health Department IRBs. Disaster Med Public Health Prep. 2008;2(3):185-191. [CrossRef] [PubMed]
 
Fleischman AR, Wood EB. Ethical issues in research involving victims of terror. J Urban Health. 2002;79(3):315-321. [CrossRef] [PubMed]
 
Daugherty EL, White DB. Conducting clinical research during disasters. Virtual Mentor. 2010;12(9):701-705. [CrossRef] [PubMed]
 
Chung B, Jones L, Campbell LX, Glover H, Gelberg L, Chen DT. National recommendations for enhancing the conduct of ethical health research with human participants in post-disaster situations. Ethn Dis. 2008;18(3):378-383. [PubMed]
 
Macklin R, Cowan E. Conducting research in disease outbreaks. PLoS Negl Trop Dis. 2009;3(4):e335. [CrossRef] [PubMed]
 
Sumathipala A, Jafarey A, De Castro L, et al. Ethical issues in post-disaster clinical interventions and research: a developing world perspective. Key findings from a drafting and consensus generation meeting of the Working Group on Disaster Research and Ethics (WGDRE). Asian Bioethical Review. 2010;2(2):124-142.
 
Cook D, Burns K, Finfer S, et al. Clinical research ethics for critically ill patients: a pandemic proposal. Crit Care Med. 2010;38(suppl 4):e138-e142. [CrossRef] [PubMed]
 
Fowler RA, Webb SA, Rowan KM, et al. Early observational research and registries during the 2009-2010 influenza A pandemic. Crit Care Med. 2010;38(suppl 4):e120-e132. [CrossRef] [PubMed]
 
Mfutso-Bengo J, Masiye F, Muula A. Ethical challenges in conducting research in humanitarian crisis situations. Malawi Med J. 2008;20(2):46-49. [PubMed]
 
O’Mathúna DP. Conducting research in the aftermath of disasters: ethical considerations. J Evid Based Med. 2010;3(2):65-75. [CrossRef] [PubMed]
 
Geiling J, Burkle FM Jr, Amundson D, et al; on behalf of the Task Force for Mass Critical Care. Resource-poor settings: infrastructure and capacity building: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e156S-e167S. [CrossRef] [PubMed]
 
Geiling J, Burkle FM Jr, West TE, et al; on behalf of the Task Force for Mass Critical Care. Resource-poor settings: response, recovery, and research: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest. 2014;146(4_suppl):e168S-e177S. [CrossRef] [PubMed]
 
Merin O, Ash N, Levy G, Schwaber MJ, Kreiss Y. The Israeli field hospital in Haiti—ethical dilemmas in early disaster response. N Engl J Med. 2010;362(11):e38. [CrossRef] [PubMed]
 
Varghese SB. Cultural, ethical, and spiritual implications of natural disasters from the survivors’ perspective. Crit Care Nurs Clin North Am. 2010;22(4):515-522. [CrossRef] [PubMed]
 
Bennett B, Carney T. Law, ethics and pandemic preparedness: the importance of cross-jurisdictional and cross-cultural perspectives. Aust N Z J Public Health. 2010;34(2):106-112. [CrossRef] [PubMed]
 
Richards P. Ritual dynamics in humanitarian assistance. Disasters. 2010;34(suppl 2):S138-S146. [CrossRef] [PubMed]
 
Welling DR, Ryan JM, Burris DG, Rich NM. Seven sins of humanitarian medicine. World J Surg. 2010;34(3):466-470. [CrossRef] [PubMed]
 
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).
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