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LIKE many of our colleagues, I have been involved to varying degrees in the response to a number of community “disasters”. As a medical student at the London Hospital in 1975, I became scribe for the triage registrar on the day of the Moorgate London Underground crash that killed 52 people. When I was a junior house officer in 1979, a severe paediatric gastroenteritis outbreak on Palm Island in Far North Queensland required the evacuation of large numbers of children who filled the then Townsville General Hospital and brought routine surgery to a halt for many days.
Since then, here in Townsville, we have experienced the Blackhawk helicopter disaster, which killed 18 soldiers in 1996, and sporadic cyclones that, during my time, have caused significant short-term disruption to health care delivery, but no mass casualties.
Although the next disaster will never be like the last one, these events focus the mind on the importance of system and personal preparation for such events. Disasters can reasonably be predicted to occur somewhere unpredictably. Both disaster plans and those implementing them must be prepared to be flexible and to deal with the worst-case scenarios for which no preparation is possible.
Disasters kill people and cause grievous injuries and illness that must always be managed appropriately and as efficiently as possible. Good medical practice: a code of conduct for doctors in Australia tells us that:
“Doctors have a vital role in assisting the community to deal with the reality of death and its consequences. In caring for patients towards the end of their life, good medical practice involves:
3.12.3 Understanding the limits of medicine in prolonging life and recognising when efforts to prolong life may not benefit the patient.
3.12.4 Understanding that you do not have a duty to try to prolong life at all cost. However, you do have a duty to know when not to initiate and when to cease attempts at prolonging life, while ensuring that your patients receive appropriate relief from distress.” (Good medical practice, 3.12, p 11)
Palliative medicine specialists tend to see the world, and the expected and unexpected life-threatening events that arise, from a particular perspective that has relevance to disaster planning. So when, in 2007, the Townsville Hospital Emergency Plan was subjected to a broad and open review, I realised that the plan did not address the palliative care needs of those people who were deemed to have non-survivable illness or injury.
The palliative care service was identified as being best able to fill this gap as its team of clinicians has the necessary range of skills and experience in providing appropriate care for dying people and supporting their relatives. In the event of a disaster, the palliative care service does not have any competing responsibilities, other than maintaining the care of existing patients.
The Disaster Plan was revised to include a new entity named the Non-survivable Injuries Unit (NIU). The purpose of this pop-up unit is to ensure that in the event of a disaster, patients who have been diagnosed as dying receive the palliative care that is appropriate to their condition. These are patients who are so sick or badly injured that life-prolonging measures would be futile and the goal of their treatment has become comfort.
In an emergency, triage doctors are able to make clinical decisions about resuscitation without seeking consent. The NIU admits patients who are assessed as dying and operates under a blanket guidance that resuscitation will not be undertaken. Patients must come with a treatment plan (in Queensland an Acute Resuscitation Plan) that has been completed by the doctor who assessed them and describes their condition and includes an instruction not to initiate resuscitation. The presumption is that the assessment in triage has been correct and should not be overruled by the consultant in the NIU without very good reason. This instruction is vital as it removes the burden of responsibility that many clinicians might feel when they cease attempts to stop a patient from dying.
In addition to being in the best interest of such patients, the transfer of dying people to the NIU ensures that the emergency department and other wards can be used more effectively to deliver treatments to those who might benefit.
So, the next time we have a disaster, the NIU will be activated and await the arrival of those who are assessed to be dying, just as in normal times the palliative care unit is generally the preferred place of inpatient care for those who are dying from inexorably fatal illness.
The leader of our NIU team is the Director of Palliative Care, or the palliative care consultant on call. The NIU has an assigned location in the gym of the hospital’s rehabilitation unit. It is staffed by the Palliative Care Service who have experience in providing appropriate symptom relief to dying people, while not making any attempt at futile resuscitation. The team are supplied with medication (opioids, sedatives, anticonvulsants etc) and equipment (cannulas etc) to meet the palliative care needs of patients, but no additional equipment for resuscitation.
During a disaster, relatives who come to the hospital to see patients are generally kept away from treatment areas. However, subject to resources and the scope of the disaster, it would be appropriate for relatives to be permitted to visit the dying patient in the NIU.
The NIU also has a role in ensuring that coronial requirements are met and in the normal course of events that means leaving patients where they have died until assessed. Having said that, this should not be allowed to interfere with the needs of those still living. It may be necessary to move the bodies of those who have died to the mortuary if the scale of the disaster precludes an immediate coronial response and the space is needed by others.
The triage and the disaster management teams have the responsibility to maintain the standard of decision making and achieve the best possible outcomes for all patients in what can be very trying circumstances. At such times of great stress, the continuous guidance and support of Good medical practice: a code of conduct for doctors in Australia should not be forgotten as we strive to make wise choices and provide the right care for our patients, whatever their condition or prognosis.
The creation of the NIU is one way of ensuring that when difficult decisions are being made, both clinicians and the community at large will know that patients who are dying will continue to receive the most appropriate care from the most experienced clinicians available.
Dr Will Cairns, OAM, is a palliative care specialist based in Townsville, Queensland.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.