Ann. Medit. Burns Club - vol. VI - n. 3 - September 1993


Kbnigovd R.

Burn Centre, University Hospital, Prague, Czechoslovakia

SUMMARY. A survey is made of current thinking on the matter of ethical problems in mass disasters. One basic question is the selection of patients to be treated and patients for whom treatment is either unnecessary or useless. The psychological problems of mass burn victims are also considered. Predictive models have their advantages but they are not the absolute answer to all practical problems in individual cases. Euthanasia is another consideration that brings in ethical and moral problems. However, certain principles are clear: the timehonoured tradition of medicine is to provide disaster victims with considerate management of their pain and their fears. Outcome prediction, cost efficiency and quality of life assessment are important tools for the solution of these problems.

In 1977 Rudolf Frey conveyed his thoughts on the missions and roles of the medical profession, which include prevention, diagnosis and treatment not only of the health problems of individual patients but also the management of disasters which strike communities or nations and result in mass casualties.
In 1988 Peter Baskett and Robin Weller asked: What planning might help alleviate the effects of disasters? What can be done to help afterwards? (Baskett and Weller, 1988).
The most basic disaster response must include methods for determining which victims will receive treatment first and what type of treatment will be given during the various stages of the disaster.
At the International Symposium on Burns in Padua, Italy, organized by the late Prof. Dogo in September 1980, one session was dedicated to psychology in association with mass burn disasters. One communication (K6nigovd and Pond(51f&k, 1981), prepared by the Prague Burn Centre, discussed the psychological problems encountered in burn victims. Many of these perish not only because of their somatic injury but also as a result of mental stress and breakdown. They are prone to so-called "blind action" or to chaotic behaviour. Often they do not realize the seriousness of their injury or even the danger to their life. This condition has been defined as "trauma agnosis". It expresses a "dead point" in the conscience of the victims in a state of general panic, which may be the cause of the death not only of the injured and burned but also of a great number of healthy individuals. We resolved to draw attention to the psychological aspects of the affected population. Bearing in mind the consideration that without a psychological approach the patients' selection triage for treatment and transport is inadequate, we address the first stage of the ethical problems.

Who shall receive higher and who lower priority in triage?

Modem triage is based on the assessment of the patient which is completed at the accident site, in conjunction with the judgement of the actual and possible severity and prognosis of the bum victims. In 1988 Howard Champion pointed out the lower priority for patients who will live without treatment and for those who will die despite treatment (Champion, 1988).
Over-response to the disaster may deplete valuable resources, while under-response may increase mortality. Over-response may even result in increased mortality, by depleting scarce resources wasted on hopeless cases. Some types of injury, and in particular bums, require continuous use of operating-room time over a period of days or weeks for dressings and grafting. Arrangements need to be made not only to provide sufficient operating-room time but also sufficient numbers of surgeons and anaesthetists skilled in the management of such cases.
The identification of savable patients - and again, in burns, there are numerous factors influencing individual outcome - is difficult under optimal conditions, let alone under the chaotic circumstances created by a disaster.
"To treat or not to treat" was the topic of Bent Sorensen's "Rudy Hermans Memorial Lecture" at the 3rd EBA Congress in Prague in 1989 (Sorensen, 1989). The title did not express exactly the intention of the contents, which dealt with the more serious ethical question of "how to treat". More than 200 years ago Samuel Johnson had taught medical students: "It is our duty to serve society..." However, true service to the society has changed over the centuries and especially during the last decades. This is due to advances in science, along with changes in the law and societal perceptions. Critical care has established its place in modern medicine, but in spite of all the accumulated knowledge and recent innovations the successful treatment of many critically ill patients seems to be an ever-receding goal. We are confronted with more complicated syndromes on the one hand and ethical, economic and social considerations on the other (Crippen, 1992).
Previously inconceivable possibilities have been developed, at a price. This price has included not only tremendous financial costs but also the additional cost of human suffering. We cannot cure all patients, and many patients are "saved" but remain with severe disabilities that may cause socalled "social death" (K6nigovd and PonWlf(~ek, 1987). Intensive therapy is very expensive and therefore its performance should be carefully examined even under normal conditions. Under disaster conditions, when not all can live, we have to decide who shall live, knowing very well that withdrawal of medical treatment is more difficult than withholding treatment before it has commenced (Sprung, 1990).

Various models for prognostic prediction provide rough estimates of patient outcome, but they cannot be applied prospectively to a single patient with any confidence. Several scoring systems seek to measure the severity of injury or illness and thus quantify the risk of death. Their primary use in disaster is to triage patients for treatment and to allocate resources.
There are statistical reasons why a predictive model may not work when tested in different populations. Another consideration regards the misclassification rate and the specificity of the rule. The model should not incorrectly predict death in patients whose recovery is feasible. What level of specificity is chosen, and who sets it, is a difficult problem. The balance required to set a reasonable level of specificity is not solely based on mathematics. It also includes factors such as the wishes and options of relatives and society to continue to treat such patients despite the cost, both in human and financial terms (Crippen, 1992).
Prediction rules suffer from criticisms that are not based upon their design (Krob et al., 199 1):

1. They have not been shown to be better than clinical judgement (APACHE 111 modification is being developed);
2. There is disagreement on how much computer predictions should influence clinical judgement, when the use of such rules may lead to clinical nihilism. If treatment is withdrawn on the basis of a prediction rule, the prediction will almost certainly be fulfilled.

A computer-generated prediction of death is an objective statement concerning the patient's inability to overcome the initial insult despite therapy. Nevertheless, appropriately used prediction rules may represent an advanced form of audit. They will confirm early decisions about the relevance of continuing treatment.
The channelling of resources to the most appropriate patients is an important aspect of clinical management, particularly in mass disasters.
In 1991 Kroh, D'Amico and Ross inquired: "Do trauma scores accurately predict outcomes for patients with bums?" (Krob et al., 1991).
The scoring systems of Baux, Edlich and Zawacki place significant emphasis on bum size and the patient's age, the two most important factors in determining survival. Other factors that are considered in the formulae (Baux et al., 1989) are:

- partial pressure of arterial oxygen at the time of admission;
- presence of inhalation injury; and
- history of bronchorespiratory disease.

The short-term outcome is still the most commonly used measure for the efficacy of treatment, but in disaster triage the long-term outcome must not be disregarded, this being influenced not only by age but also by underlying diseases and primary services (medical and/or surgical).
In making triage decisions, apart from age factors, the mechanism of injury should be considered. There is a tendency to prolong resuscitation in children, leading to a higher survival rate but also an increased incidence of sequelae (Miranda, 1990).
Concern over management, cost and efficiency could reduce our concern for the patient as a person, but interest in the assessment of quality of life (following ICU treatment) provides a framework for maintaining the importance of the total patient. Quality of life measurement requires also that the clinicians make an effort to determine how the patient was functioning prior to his injury or illness - information vital for prognosis, but also Potentially useful for tailoring treatment to an individual's ability to benefit.
In 1989 Reichel and Dyck published their contemplation on euthanasia - a contemporary moral quandary. They stressed that the highest goal of a community is to protect the lives of all its members. The affirmation of life is not just the concern of a particular religion or culture but is the basis for the whole human community. What Albert Schweitzer called a "reverence for life" underlies all our moral principles and values of civilized society, and is the basis of a professional ethic that has served humanity well over the past 2000 years. Our role as physicians should be to maximize the potential for life, even though death is inevitable. On the other hand, with limited resources in mass disasters, the patients with end-stage injury or disease should not be given intensive care, even if the recognition of terminal condition, on emergency admission, can be very difficult. Permitting death without intervening (passive euthanasia) avoids unnecessary distress and expense.
When we no longer heal, our ethical duty is to palliate and comfort. We can best serve disaster victims by considerate management of fear and pain. This has been the time-honoured tradition of medicine (Knaus, 1989).
Outcome prediction, cost efficiency and quality of life assessment have not been taught in medical schools, nor are they emphasized in residency or postgraduate training. However, they may be among our most important tools for meeting the challenges of tomorrow.

RESUME. Cet article considère les opinions actuelles sur la question des problèmes éthiques présentés par les catastrophes. Un problème fondamental est le triage des patients à traiter et les patients pour lesquels le traitement est superflu ou inutile. Les problèmes psychologiques des victimes des désastres d'incendie sont aussi considérés. Les modèles prédictifs offrent des avantages mais ils ne représentent pas la solution parfaite de tous les problèmes pratiques dans les cas particuliers. L'euthanasie est une autre considération qui introduit des problèmes éthiques et moraux. Il y a quand même certains principes très précis: la tradition consacrée de la médicine, pour ce qui concerne les victimes des désastres, reste toujours la gestion attentive de leur douleur et de leur peur. La prédiction des résultats, l'efficacité-coût et l'évaluation de la qualité de la vie sont tous des outils importants pour la solution de ces problèmes.


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