The following is excerpted with permission from JAMDA. A recent study in JAMDA (2017;18: 664–670) demonstrated that all-cause mortality of long-term care residents is increased within a 6-month interval following evacuation from natural or man-made disasters compared to pre-evacuation and sheltering-in-place. Perhaps most geriatricians would intuitively predict this to be true. The stress of transfer per se on the frail elderly, problems with availability of information and medical records, and disrupted human and tangible resources are described by the authors. Additionally, care delivered by temporary staff or staff at a new venue of care who are unfamiliar with residents might contribute. The increased potential for medical errors by caregivers wrenched from their routines and disorganized thinking of caregivers who, themselves, have had their emotions and their lives disrupted, could also be postulated as causative factors. There might also be disruptions in supervision and leadership by executive nursing, administration, and/or medical direction associated with evacuation. From their review, the authors identify the most vulnerable residents as those over the age of 80 years, frail, dependent, male gender, and with multiple comorbidities. The authors offered a compelling argument that many long-term care residents will predictably have a better outcome by sheltering-in-place in certain disaster scenarios, and that evacuation should not be a default decision. However, disaster management authorities often mandate evacuation or officially and publicly proclaim evacuation as strongly recommended. It is likely that these decisions are made in the best interest of the majority of citizens, for example, those with normal mental capacity, normal mobility, and not dependent on others to meet the demands of ordinary life. These decisions are, then, applied “across the board” without special consideration for the long-term care population we treat. In the case of mandatory evacuation, the clinical decision described above is disallowed. When a strong recommendation to evacuate is officially made, the clinical decision to shelter-in-place becomes possible but is negatively prejudiced by implication. Then, if sheltering-in-place is chosen and a resident is injured or dies as a result of the disaster, the decision maker(s) may be at considerable regulatory or civil liability risk in the aftermath even when a decision was made in good faith and on the basis of sound clinical thinking. And, if evacuation is done and any of the aforementioned problems occur and are a substantial proximate cause of injury or death of a long-term care resident, then these problems may not typically be viewed as inherent risks of evacuation but rather as breaches of the standard of care. A decision to shelter-in-place a group of the most vulnerable elderly, however, requires still another version of caregiver heroism. This decision demands that caregivers must remain to provide care, placing themselves at increased danger since they do not have the vulnerabilities that tip the equation measuring risk from the threat against risk of evacuation as do their residents. It would become necessary to identify volunteers to stay with elders to shelter-in-place in sufficient numbers to meet their needs in what may be unpredictable circumstances and for an unpredictable length of time. Alternatively, it would be necessary to demand that staff place themselves in harm’s way for the well-being of their residents. This seems unlikely, but if it were to be accomplished would require a pre-agreed-upon condition of employment. Enforcement might be extremely problematic. And liability for injury or death of caregivers, whether volunteers or not, would logically fall on the decision maker(s). It may be worthwhile to initiate a discussion with emergency management authorities for our various jurisdictions and advocate for some process of shared decision making among emergency management authorities, clinical decision makers, staff, long-term care residents, and their families. Systematic disaster planning to predetermine the decision to evacuate versus shelter-in-place is probably not possible, as this decision must depend upon the nature of the disaster at hand, availability of resources, and the degree and nature of each individual long-term care resident’s vulnerabilities. Perhaps some preplanning could be designed to streamline that decision and give it a recognized framework that would resist later “Monday morning quarterbacking.” Dr. Smith is with Geriatric Consultants of Central Texas, Brownwood, TX. Mr. Swacina is proprietor of Paul J. Swacina Law Offices, Victoria, TX.
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Apr 20, 2020
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