I recently met with my facility's palliative care team and asked, "What is your role in a disaster, and in our emergency response plan?" It was eye-opening when they explained that they believed their primary responsibility is to comfort family members arriving at the facility following the initial stages of a disaster. 

The primary focus for these teams should be to minimize suffering and provide comfort to those who are dying and to coordinate care of those who are imminently at the end of life, against a backdrop of scarce resources. 

In a localized disaster, each health care facility continues to provide services and care for its patients. In-patients who are dying continue to have the same needs as they had before the disaster. Continuity of care must be maintained; the last moments of life are just as important as the first moments of life.

Role of palliative care

Supporting and caring for the final moments of life is an essential underpinning of the palliative care team and ensures that the thread of caring is found in all aspects and stages of the disaster plan. 

The palliative care team is a highly specialized multidisciplinary team of professionals, and it is essential that their role be clearly defined when responding to a mass casualty incident (MCI). To be able to meet patient care demands, this team has specific clinical resource needs:

• Pain control medications (for example, narcotics, Tylenol, etc.)

• Sedatives (for example, valium)

• Anti-emetics (for example, gravol)

• IV general anaesthetic agents (in special circumstances)

• Oxygen

• Specialized gas mixtures (for example, nitrous oxide/oxygen, heliox)

• IV fluids

• Noninvasive ventilation

• Airway adjuncts (for example, emergency tracheostomy, heated humidity)

• Physical comfort measures (for example, warm blankets, cold packs, fans)

• Communication tools (for example, internet, telephone) for patients and family members.

When reviewing or planning MCI responses, the role of palliative care is often overlooked, but it needs to be recognized. Failure to do so represents a significant gap in care and poses a legal risk arising from evading preparedness. The potential liability for failure to plan is as much a reality as is the MCI itself.

Triage and re-triage decision-making

Many of the casualties from MCIs arrive having passed through the emergency medical services triage process with the category of "expectant" (dying) or "critical" (will die without medical intervention). On arrival at the health care facility, they again undergo triage, and categories are either confirmed or altered. This re-triage process is confirmation of the legal obligations to provide care, as mandated by federal, state, and municipal laws, and reflects the altered standards of care initiated by the MCI.

Tertiary triage in hospital settings involves sorting patients to those who require care and those who have a high risk of death. Those who meet the inclusion criteria for tertiary care are prioritized and offered life-sustaining treatment. Others are excluded from treatment but should be provided palliative care.¹ Having a tool that reflects evidence-based, equitable triage is vital. One historic study found that in two large MCIs triage officers were unable to identify as many as half the victims who sustained life-threatening injuries.²

Depending on the scope of the disaster, the health care system's resources may be significantly challenged, and shortfalls may occur, resulting in some patients being unable to access even the most basic life-sustaining interventions; rationing may be unavoidable.^3,4

Following the initial triage of casualties, the palliative care team should be called to assist. During an MCI, the emphasis is on preservation of life, yet there are ethical considerations that must recognize the role and importance of palliative care.⁵

The type and scale of the incident shapes the triage decisions and the demands placed upon the palliative care team.  An integral part of this team's role is to re-triage patients who, following the initial triage as "expectant," terminal or dying, are found to be possibly treatable as the initial stages of the disaster pass. As resource allocation becomes more stable, patients who may have been "expectant" may be re-triaged to "critical." As palliative care minimizes the suffering of those who die, it may also free up additional resources to optimize survival for others.⁶

Palliative care is an essential part of the patient care continuum, and its role even more important during a disaster where altered standards of care place a high value on minimizing and managing suffering. In the final moments of life, will your plan come up short?