Learning Objectives
Apply ethical frameworks to bioterrorism response scenarios
Explain crisis standards of care and when they apply
Describe Nevada legal reporting obligations under NAC 632.340
Differentiate between isolation and quarantine
Recognize and address moral distress in healthcare workers
Implement psychological first aid and self-care strategies
Ethical Frameworks in Bioterrorism Response
The Ethical Challenge
During mass casualty bioterrorism events, nurses face profound conflicts between utilitarian principles (greatest good for greatest number) and individual duty of care. Normal ethical frameworks must adapt to extraordinary circumstances.
Utilitarian Approach
"Greatest good for the greatest number"
- • Prioritizes public health security
- • May justify quarantine, mandatory vaccination
- • Resource allocation based on maximum benefit
- • Focuses on saving the MOST lives overall
Allocating limited ventilators to patients most likely to survive, even if others are sicker
Duty-Based Approach
"Professional obligation to provide care"
- • Emphasizes nursing professional obligations
- • Duty to care balanced against duty to self/family
- • Competence and ethical standards
- • Obligations to patients, employers, profession, society
Nurse's duty to treat contagious patients vs. duty to protect family from exposure
Rights-Based Approach
"Individual autonomy and liberty"
- • Emphasizes individual rights and informed consent
- • Requires strong justification to restrict liberty
- • Due process protections
- • Patient autonomy considerations
Patient's right to refuse quarantine vs. public health need for isolation
Justice-Based Approach
"Fair and equitable distribution"
- • Ensures equitable resource allocation
- • Non-discrimination in treatment
- • Protection of vulnerable populations
- • Procedural fairness in decision-making
Allocation criteria must be transparent and applied equally regardless of race, wealth, or social status
Recommended Integrated Approach
In bioterrorism events, use utilitarian principles tempered by rights-based protections. Maximize benefit to population while maintaining due process, transparency, and protection of vulnerable groups. No single framework is sufficient alone.
Crisis Standards of Care
What Are Crisis Standards of Care?
Crisis standards of care are a substantial change in usual healthcare operations and the level of care possible to deliver. They are triggered when resources are insufficient to meet usual care standards during emergencies.
Conventional → Contingency → Crisis
Normal operations
Usual standard of care. Resources adequate. Normal staffing ratios. Full scope of services available.
Adapting to strain
Functionally equivalent care with adaptations. Substitute resources, modified staffing. Care still adequate but adapted.
Resources overwhelmed
Resources insufficient for usual care. Allocation decisions required. Focus shifts to population outcomes. Triage protocols activated.
Crisis Standards ALLOW
- • Allocation decisions to maximize lives saved
- • Expanded scope with training/supervision
- • Modified staffing ratios
- • Legal protection for good-faith decisions
- • Use of alternate care sites
Crisis Standards do NOT ALLOW
- • Abandoning patients
- • Ignoring infection control protocols
- • Unilateral allocation decisions without oversight
- • Eliminating documentation requirements
- • Discrimination in allocation
Resource Allocation Ethics
The Hardest Decisions in Healthcare
When resources (ventilators, ICU beds, antidotes, vaccines) are scarce, allocation decisions must be made. These decisions should be guided by transparent, ethically defensible criteria - NOT by first-come-first-served, social worth, or ability to pay.
Ethical Allocation Principles
Resources to those most likely to benefit and survive. Save the most lives/life-years possible.
Fair process with consistent criteria. No discrimination by race, gender, income, disability, or social worth.
Criteria publicly known and consistently applied. Decisions documented and reviewable.
Restrictions on individual liberty proportional to the threat. Least restrictive measures first.
Factors That Should NEVER Determine Allocation
Race/Ethnicity
Ability to Pay
Social Worth
Political Status
Immigration Status
Disability*
Religion
Sexual Orientation
*Disability may only be considered if directly relevant to likelihood of survival from the acute illness
Nevada Legal Requirements
Nevada Administrative Code - Nurse Obligations
Nevada nurses have specific legal obligations related to bioterrorism preparedness and response under the Nevada Administrative Code (NAC).
NAC 632.340 - Reporting Obligations
Mandates that nurses report certain conditions to appropriate authorities.
- Report unusual disease clusters to health authorities
- Report suspected bioterrorism events immediately
- Mandatory reporting of specific communicable diseases
- Cooperate with epidemiological investigations
Report to local health department IMMEDIATELY - do not wait for lab confirmation
NAC 632.355 - Competency Requirements
Requires nurses to maintain competency necessary for their practice.
- Maintain competency in practice area
- Includes emergency preparedness knowledge
- Seek education and training appropriate to role
- This course fulfills CE requirements under this mandate
Bioterrorism preparedness is part of professional competency requirements
Balancing Confidentiality and Public Health
Nurses must maintain patient confidentiality while fulfilling public health duties. HIPAA permits disclosure to public health authorities for disease surveillance and outbreak investigation. This is NOT a HIPAA violation - it's legally required reporting.
Isolation vs. Quarantine
These Are NOT the Same!
Many people confuse isolation and quarantine. Understanding the difference is critical for proper public health response.
ISOLATION
Separation of SICK (symptomatic) individuals
- Who: Confirmed or suspected cases - people who ARE sick
- Why: Prevent transmission from infectious person to others
- Where: Hospital, dedicated facility, or home (depending on severity)
- Duration: Until no longer infectious (varies by disease)
Patient with confirmed Ebola is isolated in negative pressure room with full PPE protocols
QUARANTINE
Restriction of EXPOSED (asymptomatic) individuals
- Who: People exposed but NOT yet sick - healthy contacts
- Why: Monitor for symptoms during incubation period
- Where: Usually at home; may be designated facility
- Duration: Length of disease incubation period
Healthcare worker exposed to smallpox patient quarantines at home for 17 days, monitoring for fever
Legal Authority for Isolation and Quarantine in Nevada
The Nevada State Health Officer, through the Division of Public and Behavioral Health, has legal authority to order isolation and quarantine to protect public health.
- • Can be voluntary (cooperative) or mandatory (legally enforced)
- • Due process protections apply to mandatory orders
- • Individuals can appeal through administrative process
- • Law enforcement may assist with enforcement of mandatory orders
Moral Distress
What is Moral Distress?
Moral distress occurs when you know the ethically correct action but constraints prevent you from taking it. It's the painful feeling of being unable to do what you believe is right.
This is common during crisis care when resources are scarce and difficult choices must be made.
Common Sources of Moral Distress in Bioterrorism Response
Not enough ventilators, beds, medications, or staff for all patients
Being involved in decisions about who receives treatment
Enforcing no-visitor policies when patients are dying
Being unable to provide usual standard of care
Addressing Moral Distress
- • Recognize it as a normal response to abnormal situations
- • Name what you're feeling - put words to the distress
- • Talk with colleagues who understand
- • Seek ethics consultation when available
- • Participate in debriefing sessions
- • Access EAP or mental health resources
Psychological First Aid (PFA)
The 3 L's of Psychological First Aid
PFA is a compassionate, non-intrusive approach to help individuals in distress. It is NOT therapy or diagnosis - it's immediate practical support and stabilization.
LOOK
- • Observe the environment for safety
- • Identify people with obvious urgent needs
- • Look for signs of serious distress
- • Assess for immediate medical needs
LISTEN
- • Approach people who may need support
- • Ask about their needs and concerns
- • Listen actively without judgment
- • Don't pressure them to talk
LINK
- • Connect to practical help (food, shelter)
- • Provide accurate information
- • Link to social support (family, friends)
- • Refer to professional help if needed
PFA is NOT...
PFA is NOT psychological debriefing. NOT therapy. NOT diagnosis. NOT asking people to analyze what happened. It's simple, compassionate support focused on immediate needs and safety.
Self-Care & Resilience
You Cannot Pour from an Empty Cup
Bioterrorism response is extraordinarily stressful. Sustainable response requires taking care of yourself. Working to exhaustion leads to burnout, errors, and inability to help anyone.
Warning Signs of Burnout and Compassion Fatigue
- • Chronic fatigue
- • Sleep disturbances
- • Frequent illness
- • Headaches
- • Irritability
- • Anxiety
- • Depression
- • Emotional numbness
- • Withdrawal from others
- • Decreased effectiveness
- • Cynicism about work
- • Increased substance use
Self-Care Strategies
- Recognize stress as a normal response
- Maintain boundaries between work and home
- Seek peer support - talk with colleagues
- Use EAP - Employee Assistance Programs
- Participate in debriefing sessions
- Take breaks - even brief ones help
- Maintain connections with family/friends
- Seek professional help if needed
Remember
"Self-care is not selfish. It's essential for sustainable care of others."
Key Takeaways
Crisis standards shift from individual care to population outcomes
Resource allocation must be transparent, equitable, and non-discriminatory
NAC 632.340 requires immediate reporting of suspected bioterrorism
Isolation = separating SICK; Quarantine = restricting EXPOSED
Moral distress is normal - recognize it and seek support
PFA uses the 3 L's: Look, Listen, Link
Self-care is essential for sustainable response
Duty to care is balanced against duty to self and family