This article reports the results of focus group and key informant interviews with clinicians regarding changes in their roles, identities, duties, and decision-making autonomy that may result from the need to implement crisis standards of care (CSC) during disaster triage, concluding that clinicians’ discomfort with some of these changes in roles and obligations may pose a barrier to implementation during a public health emergency.
Guidance from the National Academy on CSC calls for reallocation of scarce medical resources to those who will benefit the most during extreme situations. The authors note that although expert consensus and careful weighing of relevant ethical issues support this approach, they note that it may be problematic for some bedside clinicians, particularly with respect to potential withdrawal of mechanical ventilation. Guidelines may reduce moral distress by removing decision-making burden from front-line clinician and standardizing approach, but implementation may be difficult, inadequate, or delayed if clinicians regard the approach as ethically unacceptable or legally questionable.
The authors report that this study is the first to use qualitative methods to explore CSC implementation barriers with practicing front-line clinicians. The study protocol was based on the National Academies CSC guidance and New York State guidelines and focuses on allocation of ventilators. Interviewees responses were coded across several theoretical domains relevant to behavior. The domains that were most salient were grouped into two themes: (1) personal and social factors (including domains of Social/ Professional Role and Identity, Beliefs about Consequences, Emotion, and Social influences) and (2) technical factors (including domains of Skills, Ability, Condition/Scientific Rationale, Environmental Context and Resources, Memory, Attention and Decision Processes).
Clinicians reported a variety of concerns about implementing CSC protocols, including diminished physician autonomy and ability to fulfill fiduciary duty to advocate for individual patients, fear of legal repercussions, emotional reactions of clinicians and of patients’ family members, inherent challenges in predicting patient response to treatment, and how to address potential bias regarding quality of life assessments. However, clinicians generally recognized the importance of having a protocol in place before a disaster, even if the protocol is inherently imperfect.