California Pharmacist Spring 2025 - Flipbook - Page 40
ethically speaking
The LA Fires: Triage and Ethics in Action
Amy Reese Hohmann
Emergency preparedness is a topic very
close to the hearts of many Californians. Unfortunately, our beautiful
state is at risk for and subject to many
natural disasters. As we consider ethical issues within emergency
preparedness, the concepts associated
with triage in medical settings come to
mind. Triage is the process of prioritization through a process and criteria
developed to determine the delivery of
healthcare.2 Emergency preparedness
incorporates the method of triaging
critical and noncritical patients.
Use of Triage Principles in
Disaster Situations
The process of triage is commonly used
in the emergency department, but it is
often used in disaster situations. Triage
is accomplished by determining the
acuity of each person in an emergency
or disaster situation. Victims of disaster
situations are grouped according to
medical need. Medical utility becomes
the determining factor on who receives
care first.2
Four groups of triage are used: patients
who will die without immediate medical attention have first priority; patients
who require acute but not immediate
medical attention have second priority;
patients with minor injuries have third
priority; and patients who only need to
be verified that they need no medical
treatment have fourth priority.2
In disaster management situations,
frontline workers use a quick guide
to triaging patients. Healthcare
The Ethically Speaking
column is coordinated by Amy
Reese Hohmann, PharmD,
MBe, Redlands, California.
amy.c.reese@gmail.com
38
vol. 72, no. 1 | California Pharmacist
professionals working in the field of
a disaster situation can tag patients
based on the severity of the patient’s
condition – deceased, immediate,
delayed, and minor.3 The triage tag
system is the epitome of medical utility
because it solely looks at the severity of
the individual and sorts the individual
according to medical need.
Many institutions lay out triage protocols and procedures to ensure that
healthcare professionals know the goals
of emergency management and the
criteria for patient prioritization. An
algorithm can be created to determine
which patients receive what kind of
care (such as was used during the recent pandemic). The U.S. Department
of Health and Human Services uses the
SALT Mass Casualty Triage Algorithm
to triage patients: sort, assess, lifesaving
interventions, treatment/transport.4
This quick algorithm is useful for
determining which casualties need the
fastest access to care.
Considering the Ethics of Triage
The ethics of triage revolves around 3
principles of bioethics: beneficence,
nonmaleficence, and justice. The autonomy principles is not as relevant in
emergent situations.
Beneficence pertains to doing good for
patients within the context of triage.
Beneficence ensures that all patients
receive care, no matter how acutely ill
a patient is in an emergency or disaster
situation. Each patient ought to receive
at least minimal medical attention because no one ought to be looked over
for appearing physically unaffected by
the situation.
Nonmaleficence pertains to ensuring
harm does not come to patients. In
the case of triage, the most acutely ill
or wounded patients receive care first,
but that does not mean that others are
ignored. Every patient is given as much
care as possible within the limits of
available personnel and resources.
Justice pertains to the distribution of
scarce resources. Unfortunately, healthcare services will always be finite and
scarce during an emergency or disaster
situation. Healthcare professionals will
not be able to fully provide all needed
care to every patient all the time.
In an emergency or disaster situation,
healthcare services are distributed to
people at the highest acuity first followed by others based on triage status.
For example, in the beginning of the
coronavirus disease 2019 (COVID-19)
pandemic, ventilators were distributed
to the highest acuity patients who had
a chance of survival with immediate
respiratory support. Patients who
could survive without a ventilator were
not provided with this scarce resource
as a triage measure to ensure that those
in dire need received critical care.
Autonomy does not play as significant a role in emergency situations
because emergent consent is assumed
in life-threatening situations.5 Emergent consent is generally accepted for
medical care that a reasonable person
would want in a critical situation
where life could be lost if action is not
taken immediately.6 Patients in the
first tier of triage would typically fall
under the emergent consent because
of their general lack of coherence and
decision-making capacity. Autonomy
may be a factor in the lower levels of
triage because decision-making capacity can be assessed in those patients.
Still, the principle of autonomy is not
as crucial as the other 3 principles due
to the time-dependent nature of care in
emergency situations.
Pharmacists’ Roles in Disaster
Situations
Pharmacists participate in triage at
every level of practice. Whether in an
emergency department, critical access
hospital, or community pharmacy,
pharmacists triage emergency or disaster situations.
During the pandemic, pharmacists in
the community were forced to allocate
scarce medications to the most vulnerable patients. During the fluid shortage
caused by the hurricane in North Carolina, pharmacists were a part of the
