Specific Topic(s): balancing the needs of your patients with the needs of your team, both individually and as a group.

Key references:

‘Ethical principles of health care in times of armed conflict and other emergencies’ – In armed conflict or other emergencies, health-care personnel are required to render immediate attention and requisite care to the best of their ability. No distinction is made between patients, except in respect of decisions based upon clinical need and available resources.

Geneva Conventions: not applicable

Ethical principles: WMA STATEMENT ON MEDICAL ETHICS IN THE EVENT OF DISASTERS - https://www.wma.net/policies-post/wma-statement-on-medical-ethics-in-the-event-of-disasters/ It is ethical for a physician not to persist, at all costs, in treating individuals “beyond emergency care”, thereby wasting scarce resources needed elsewhere. The decision not to treat an injured person on account of priorities dictated by the disaster situation cannot be considered an ethical or medical failure to come to the assistance of a person in mortal danger. It is justified when it is intended to save the maximum number of individuals. However, the physician must show such patients compassion and respect for their dignity, for example by separating them from others and administering appropriate pain relief and sedatives, and if possible ask somebody to stay with the patient and not to leave him/her alone.

Discussion:

Review of the question: this question examines the balance the needs of your patients with the needs of your team, both individually and as a group.

Interpretation of the principles/policy from the references: like all resources, the energy and endurance of healthcare workers to provide care in an emergency is limited and precious. Therefore it is ethical to manage this resource is the same way as other medical resources in order to ensure the best outcome for the largest number of patients.

Framework for answering the scenario/question:

• What is the background the emergency? – is it a single event (such as a natural disaster) or is it likely to be persistent (such as a military campaign)?

• What is the likelihood of further pressure on the medical system, and any relief? – is the intensity of the workload likely to diminish and when?

• Are all methods of controlling workload and intensity been implemented? – e.g. triage, rigorous shift work, evacuation or diversion of patients?

• What is the mood and views of your team? – do they agree that they are fatigued, do they agree that they are making errors, will they rest if stood down?

• In the final analysis, you have duty to protect you team and their health; even if there is a detriment to the clinical care of your patients. What measures can you take?

o Shift work and enforced time away from clinical duties

o Ensuring food/water and breaks

o Stopping all non-essential duties – e.g. routine administration

o Monitoring the impact on each person, and resting those most vulnerable

Further issues for consideration:

• The immediate issue is to mitigate the physical impacts of this workload however there are also likely to be psychological and mental impacts – how might you mitigate these?

Amy B. Adler, PhD, Amanda L. Adrian, PhD, Marla Hemphill, MC USA, Nicole H. Scaro, MSC USA, Maurice L. Sipos, MSC USA, Jeffrey L. Thomas, MSC USA, Professional Stress and Burnout in U.S. Military Medical Personnel Deployed to Afghanistan, Military Medicine, Volume 182, Issue 3-4, March-April 2017, Pages e1669–e1676, https://doi.org/10.7205/MILMED-D-16-00154

Gabel S. (2011). Ethics and values in clinical practice: whom do they help?. Mayo Clinic proceedings, 86(5), 421–424. https://doi.org/10.4065/mcp.2010.0781

Paul Sargent, MD, Jeffrey Millegan, MD MPH, Eileen Delaney, PhD, Scott Roesch, PhD, Martha Sanders, MA, Heather Mak, MD, Leonard Mallahan, BA, Stephanie Raducha, BA, Jennifer Webb-Murphy, PhD, Health Care Provider Burnout in a United States Military Medical Center During a Period of War, Military Medicine, Volume 181, Issue 2, February 2016, Pages 136–142, https://doi.org/10.7205/MILMED-D-14-00449

Alhaffar, B.A., Abbas, G. & Alhaffar, A.A. The prevalence of burnout syndrome among resident physicians in Syria. J Occup Med Toxicol 14, 31 (2019). https://doi.org/10.1186/s12995-019-0250-0