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  1. Salladay, Susan A. RN, PhD

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I work at a community hospital located in a rural area. The staff has practiced triaging for some types of disasters, such as a multivictim highway accident, but I'm worried about other things we haven't practiced for, such as an avian flu pandemic. How can hospitals ethically ration scarce resources such as mechanical ventilators, which are already "scarce" at a small facility like mine?-O.E., IND.


No one has easy answers for hard questions about how to allocate scarce resources in a crisis. But you're wise to raise the question because the threat is very real: The U.S. Department of Health and Human Services estimates that pandemic flu could sicken 90 million Americans and kill 1.9 million. An estimated 1.5 million would require intensive care.


How can equipment, medication, and other resources be ethically rationed in such circumstances? Before a health care crisis develops, policy makers need to establish policies and procedures that are fair and consistent with ethical principles and values. Guidelines that meet standards of justice and fairness will save lives if applied consistently. First responders, emergency personnel, and other health care professionals must be taught how to apply these guidelines in advance-not left to "make it up as they go along."


Many resources are available to help health care facilities prepare for a pandemic by fashioning ethical policies and procedures tailored to the needs of individual facilities and communities. Encourage hospital leaders in nursing, respiratory care, infection control, and risk management to team up with community health leaders to add pandemic planning to their disaster protocols. Nurses should have a strong presence at the decision-making table. Here are a few resources to get you started.


* Flu pandemic and the fair allocation of scarce life-saving resources: How can we make the hardest of choices? The Hastings Center Bioethics Backgrounder, 2006. Available at http://www.thehastingscenter.org.


* Guidelines for acquisition of ventilators to meet demands for pandemic flu and mass casualty incidents, American Association for Respiratory Care, May 25, 2006. Available at http://www.aarc.org/resources/vent_guidelines.pdf.


* National strategy for pandemic influenza, Homeland Security Council, November 2005. Available at http://www.whitehouse.gov/homeland/pandemic-influenza.html.


* Hick JL, O'Laughlin DT, Concept of operations for triage of mechanical ventilation in an epidemic, Academic Emergency Medicine, February 2006.