Triage, rationing, and palliative care in disaster planning.

In this issue of Biosecurity and Bioterrorism, Matzo and colleagues introduce the roles of palliative care in the response to catastrophic mass casualty events. This work is part of a larger effort supported by the Agency for Healthcare Research and Quality (AHRQ) to define and plan for the ‘‘altered standards of care’’ considered inevitable during a mass casualty event. Here we offer some additional perspective on a number of issues raised in their article. The authors and the AHRQ conferees are to be congratulated for their thoughtful deliberations and for disseminating their recommendations through the peerreviewed literature. We hope that publication of their work will both catalyze scholarly discourse on the subject and broaden the base of stakeholder input. Matzo and colleagues conclude that planning for the medical response to a mass casualty event should include provisions for palliative care surge capacity. The authors offer some creative ways to address this requirement, including developing Disaster Palliative Assistance Teams under the aegis of the Medical Reserve Corps or the National Disaster Medical System. Such teams could be specially trained and equipped to provide some level of palliative care under the demanding operational constraints of a mass casualty event response. These are valuable suggestions to planners at all jurisdictional tiers of response. Their assertion, however, that palliative care may ‘‘free up resources to optimize survival of others’’ is unproven and counterintuitive. The addition of a large number of patients rendered terminally ill or injured in a mass casualty event to the population of patients already receiving palliative care will certainly generate the need for palliative care surge capacity. Patients from a mass casualty event who will require some elements of palliative care include those who have been assigned to several different triage categories: (1) ‘‘expectant’’ patients, who are considered so unlikely to benefit from life-saving interventions that those interventions are not offered; (2) ‘‘immediate’’ patients, who could potentially survive with aggressive therapy, but limited medical or transportation resources render it temporarily unavailable; and (3) both ‘‘immediate’’ and ‘‘delayed’’ patients, who will eventually receive life-saving, definitive care but require supportive care, symptom control, and other comfort measures while waiting for it. Although the categories listed above are generally used in the field or emergency department triage of trauma victims who need surgical care, they can be readily correlated with patients requiring critical care during a pandemic. Different ethical principles inform management of the patients within these various triage categories. In the first, the availability or scarcity of resources has little bearing on whether attempts at curative therapy should be offered or provided. Palliative care is the only efficacious option for these patients, and the ethical principles relate primarily to proving that other therapeutic interventions would be futile. The second group faces rationing of potentially useful resources, and different ethical principles apply. It is the responsibility of planners and responders to minimize the size of this group through both prospective and real-time solutions to the challenges presented by various types of