1. Payne, Kate RN, JD

Article Content

Warm weather has almost passed and the cold and flu season is upon us. Most critical care nurses are aware of the general danger of flu being urged this time each year to get the offered flu shot from their employee health department. At the same time concerns about a possible avain flu pandemic will again be heightened, prompting hospitals and healthcare agencies around the world to review plans for just that possibility.1-3 There have been warnings, articles, and decision-making recommendations in professional journals, particularly those that deal with infectious diseases and public health. Basic science and ethics publications and popular media, as well as private and government Web sites, are also sources of information (Table 1). At a minimum, each nurse must understand what a pandemic is, what the impact might be, and what is being done to prepare for such a public health crisis. One of the characteristics of such public health disasters (think about Hurricane Katrina) is that health needs can quickly overwhelm the human and material resources of the health system, leading to very difficult decisions. Consequently, all nurses will also have to reflect on the ethical issues related to their duty as nursing professionals in the face of a global crisis, such as a pandemic.

Table 1: Web Site Ad... - Click to enlarge in new windowTable 1: Web Site Addresses for Additional Information on Pandemic Flu

What Is a Global Pandemic?

To understand the global concern and the ethical implications, it is important to understand what a pandemic is. Pandemic influenza is best defined as a global flu outbreak where a new influenza virus emerges and spreads easily like regular flu. With a new virus, people will have little or no immunity and vaccines will be unavailable for the new strain, and for both these reasons, people will become extremely sick.4-6 There have been 3 pandemics in the last century. The Spanish flu of 1918 killed 20 to 50 million people worldwide and more than 500000 in the United States. It remains the most devastating pandemic in recent history. In 1957, the Asian flu killed 70000 in the United States and another 2 million worldwide, and the Hong Kong flu killed 1 million globally, with roughly 34000 deaths in the United States in 1968.3-7 The very nature of pandemic means that there is little or no time to plan; vaccines, if developed, come after major exposure, so little can be done to mitigate morbidity and mortality.


Concerns about a possible bird flu pandemic have been increasing since 20038,9 with the emergence of a highly virulent avian virus, H5N1. The virus is responsible for the deaths of millions of domestic fowl and wild migratory birds in Asia, Eastern Europe, the Middle East, and Africa, and as of mid-September, 329 humans had been infected, including 201 who died.9 These numbers underscore the concern that, although human infections have been limited in number, more than half of the confirmed cases have been fatal.8,9 It is important to remember that influenza, in general, is the king in terms of overall global mortality. The World Health Organization estimates 3 to 5 million cases of flu, with 500000 deaths in the United States alone.5 Type A avian influenza has many subtypes and was the culprit in the 3 major pandemics that occurred in the last century.10,11


A pandemic might last 12 to 36 months, coming in waves of 6 to 8 weeks, separated by months, as the virus changes and adapts to humans.1,2 The virus could also be passed along with less virulent regular seasonal flu, or even mutate and become more easily transmissible to humans.12 Most of the human infections have been from dead birds handled by people, with 2 possible reports of human-to-human transmission within family clusters.8 But the small numbers of human-to-human transmission show that it has not been sustained beyond one person, and this is the big fear that such transmission will be sustained, initiating the global pandemic. Most experts agree that the question is not if, but when, this will occur.


The recent experience with severe acute respiratory syndrome (SARS) has also fueled concerns about a potential pandemic and its effects. SARS is the closest the world has come to a true pandemic in modern times, and the rapidity of its spread was a warning of what a new and virulent infectious agent could do.6,13 SARS infected more than 8000 people during a 5-month period in 2003. Caused by a new human corona virus, it emerged in rural China, spread to 5 countries in days, and traveled to 30 countries on 6 continents within several months. Ten percent of those exposed died. SARS demonstrated how quickly a virus or similar infectious agent could travel the globe; it simply walked onto a plane with someone or into the hallways of hospitals in Canada.6,13,14 Even with the relatively low number of deaths, SARS had a tremendously powerful and negative effect on people, particularly nurses confronted with the thought of acquiring a deadly disease just by breathing.13


Worst Case Impact

Imagine the worst weather emergency you have ever experienced in a hospital. Think about what this means for staffing, equipment, travel, and getting basic necessities. Now, imagine it affects everybody, in every kind of job, including those that support the infrastructure-electricity, power, natural gas, water-and it lasts for months. Imagine, now, a global pandemic lasting for months and coming in waves as the virus adapts, and think of the effects that society will feel.


It is estimated that 15% to 35% of the US population could be affected. Some scientists also estimate a lower attack rate.1-4,15-18 This could mean 89 000 to 207 000 deaths in the United States (worldwide deaths are estimated at 100 million), 314 000 to 734 000 hospitalizations, 18 to 42 million outpatient visits, and 20 to 47 million additional illnesses. Patients at high risk, about 15% of the population, will account for approximately 84% of all deaths. Some estimates put the number affected at 90 million with 2 million deaths. Hospitalizations would range from 865 000 to 9.9 million, depending on severity.17 Victims in the previous pandemics were generally younger people who usually worked. With similar losses today, the estimated economic impact in the United States would be $71.3 to $166.5 billion, just related to healthcare. This does not begin to factor in the disruptions to commerce and society.18,19 With 30% to 40% of the workforce out sick, caring for someone who is sick, or just plain scared, it is surprising that perhaps as few as 41% of US businesses have a plan related to a potential pandemic.19


Most of those affected will require some form of medical care. Healthcare facilities would be quickly overwhelmed, with a shortage of hospital staff (predictions are that 30% to 40% of the workforce could be out), beds, equipment, medications, food, and space. Surge capacity at nontraditional sites inside and outside hospitals, such as conference rooms, large auditoriums, or schools, should be considered as sites for care of the sick and dying.2,17,18 Supplies of antivirals are currently inadequate, and there is currently no vaccine for H5N1, although research is continuing on both fronts.1,2,12,16,17


Preparedness and Ethics

Predicting when and if a pandemic will occur is difficult at best, but it is clear from the potential threat that planning is a must. There are 2 main ethical priorities in the event of such a public health crisis: to save lives and keep society functioning. Consequently, critical care nurses must engage in critical thinking and ethical reflection as part of pandemic planning, partly because these priorities are different from usual ethical decision making and because science alone is not enough in any kind of healthcare decision making.20,21 In a pandemic, every type of resource will be severely taxed. The potential for moral distress is high, as nurses will have difficulty providing the care they feel is morally required.22 The Toronto SARS experience showed that ignoring ethical issues and concerns has severe consequences in terms of loss of trust, low morale, role confusion, stigmatization of vulnerable communities, and misinformation. In addition, where guidance is completely clear or consequences cannot be predicted, or where information is constantly unknown or changing and every decision is a life-and-death matter, the value of fairness becomes even more important.23,24


The Code for Nurses (The Code), published by the American Nurses Association, should be looked to as a standard to guide ethical reflection and planning. It is a nonnegotiable standard that takes all nursing activities into account and supersedes specific polices or practices of institutions or others.25,26 A pandemic may call provisions of The Code into question because of the shift in ethical priorities. The Code may help decrease confusion about professional rights and responsibilities by focusing on what the ethical norms are and what decisions are founded on from an ethical perspective. Critical thinking must be employed to balance competing ethical values.


In a pandemic, the nurse will be faced with conflicting responsibilities to work and to family. Nurses and other direct caregivers will face a disproportionate risk of exposure to flu as compared with the general population. Many may fear they will contract the flu or give it to their families. Some may fear the risk is too great and refuse to care for such patients or even come to work. The effect on the healthcare system would be dramatic. The Code is a tool, not a mandate to sacrifice one's life.


Provisions 1, 2, and 3 address nurses' commitment to the dignity and value of each and every person they come in contact with, including the need for compassion, advocacy, and nondiscrimination. In a pandemic, the patient's health problem may pose a direct risk to the nurse and other direct caregivers. Ethics, in a pandemic, demands a balance of advocacy and self-protection.27 Nurses should ensure that personal protective equipment is well-stocked and that good hygiene practices are followed. Knowledge of how influenza viruses are spread is essential for determining ethically grounded strategies. Generally, viruses are spread by aerosol, droplets, or with direct contact with secretions, and with a virulent strain, basic surgical masks are likely inadequate. Nurses should insist on properly fit-tested N95 ventilators28 to diminish the risk to their own health, be able to advocate for the vulnerable, collaborate with colleagues, and eliminate exposure to the virus.


Provisions 4, 5, and 8 address the relationships nurses have with others. Because pandemics are unpredictable, now is the best time to reinforce the need for practicing proper hygiene, using protective equipment, engaging in a plan, and becoming informed of ethically sound policies and practices. Nurses will also have to collaborate inside and outside the hospital, as there will be a lack of beds, a need for alternative spaces to care for those stricken, and the need to share supplies.1-6,16,17 Principles of justice will need to be applied to resource allocation decisions.


Provision 5 also addresses nurses' duties to themselves and to others. Nurses will be confronted with conflicting responsibilities to work and to family. Nurses are morally obligated to care for all patients, but, in some circumstances, the risks of personal harm may outweigh one's obligation to others. The nurse is obligated to provide care if "(1) the patient is at significant risk of harm, loss, or damage if the nurse does not assist. (2) The nurse's intervention or care is directly relevant to preventing harm. (3) The nurse's care will probably prevent harm, loss, or damage to the patient. (4) The benefit the patient will gain outweighs any harm the nurse might incur and does not present more than an acceptable risk to the nurse."27(p2-4) Assessment of the risk must be based on nonjudgmental current and scientific evidence that is linked with adequate protections for caregivers and how the facility handles influenza patients and the provision of protective equipment, vaccines, and antivirals. Healthcare institutions are obligated to provide adequate safeguards to reduce risks and enforce protective measures to minimize risks to nurses.28


Provisions 7, 8, and 9 discuss the broader notions of obligation to the profession and the larger society. Being knowledgeable about the flu, resources and planning may be more valuable than they now seem. All hospital employees should know their institutional and state plan for responding to a pandemic and what their roles are. Pandemic scenario role-plays may be helpful to identify the gap between existing resources and what would be ideal to respond to any given scenario. At the same time, everything should be done to ensure the moral commitment of nurses to planning and response.1,2,29 Key critical care resources and equipment should be focused on in collaboration with key stake holders such as respiratory therapists, infection control practitioners, pharmacists, and physicians. The number of ventilators, as well as beds, is finite. Having a triage plan for all critical care resources is essential.30,31 Leadership should work with human resources to plan for the impact of loss of a large section of the workforce in a worst case scenario.17,18,28 Individuals at all levels of the organization must think about what it would mean for all facets of society to shut down, including air, water, power, and deliveries of all kinds, including food. Dialogue between employers and employees should be happening now, before infected patients arrive. Open discussions about duties and obligations must be facilitated. At the same time, there is a need for empirical research as the pandemic proceeds to know what works and what does not for the benefit of caregivers and the public.


Individuals should know their state plan2 and have a communication plan with family, close friends, neighbors, and work. Know what the 4 or 5 neighbors around you are doing; know what your block is doing; look out for the elderly lady down the street; have 2 to 4 weeks of nonperishable food (human and animal), water, and medicine in place.1,2,32 Have a plan to keep track of colleagues and their health, and be brave enough to intervene if they are sick.


A pandemic will place unprecedented demands on most nurses' knowledge, skill, and moral resolve. The best way to minimize risk and to ensure nurses can work safely to care for the public is to become involved in planning efforts in the healthcare organization and community-to use The Code as a way to determine duty and risk. Nurses have to think ahead and prepare for a constantly changing practice environment, whether a natural disaster, such as Hurricane Katrina, or a pandemic occurs. Know the code of ethics and use in it in dialogue. Become involved in pandemic planning efforts in the healthcare organization and community. It is better to be prepared than to be afraid.




1. World Health Organization (WHO). Epidemic and pandemic alert and response (EPR). 2007. Accessed October 1, 2007. [Context Link]


2. Department of Health and Human Services. Planning and response from U.S. government avian and pandemic flu information. 2007. Accessed October 1, 2007. [Context Link]


3. Juckett G. Avian influenza: preparing for a pandemic. Am Fam Phys. 2006;74(5):784-790. [Context Link]


4. World Health Organization (WHO). Ten things you need to know about pandemic influenza. 2005. Accessed October 1, 2007. [Context Link]


5. O'Malley P. Bird flu pandemic and Tamiflu: implications for the clinical nurse specialist. Clin Nurs Spec. 2006;20(2):65-67. [Context Link]


6. Pascoe N. A pandemic flu: not if, but when. Texas Nurs. January 2006;(80):6-10. [Context Link]


7. National Institute of Allergy and Infectious Diseases of the National Institutes of Health. Time line of human flu pandemics. 2007. Accessed October 1, 2007. [Context Link]


8. World Health Organization (WHO). H5N1 avian influenza timeline. 2006. Accessed May 22, 2007. [Context Link]


9. World Health Organization (WHO). Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO. 2007. Accessed October 1, 2007. [Context Link]


10. Kilbourne ED. Influenza pandemics of the 20th century. Emerg Infect Dis. 2006;12(1):9-14. [Context Link]


11. Morens DM, Fauci AS. The 1918 influenza pandemic: insights for the 21st century. J Infect Dis. 2007;195:1018-1028. [Context Link]


12. Mills CE, Robins JM, Bergstrom CT, et al. Pandemic influenza: risk of multiple introductions and the need to prepare for them. PloS Med. 2006;3(6):e135, 1-5. [Context Link]


13. Rankin J. Godzilla in the corridor: the Ontario SARS crisis in historical perspective. Intensive Crit Care Nurs. 2006;22:130-137. [Context Link]


14. University of Toronto Joint Centre for Bioethics Pandemic Influenza Working Group. Stand on guard for thee. Ethical considerations in preparedness planning for pandemic influenza. 2005. Accessed May 22, 2007. [Context Link]


15. World Health Organization (WHO). Avian influenza frequently asked questions. 2005. Accessed October 1, 2007. [Context Link]


16. Martin SD. Avian flu. Should we worry in home healthcare? Home Healthc Nurs. 2006;24(1):38-45. [Context Link]


17. Darr K. Beyond triage: avian flu and the impending services demand crisis. Hosp Top. 2006;84(1):32-35. [Context Link]


18. Meltzer MI, Cox NJ, Fukuda K. The economic impact of pandemic influenza in the United States: priorities for intervention. Emerg Infect Dis. 1999;5(5):659-671. [Context Link]


19. Delloite Center for Health Solutions. Pandemic flu roundtable on preparation, productivity and profitability. 2007. Accessed May 22, 2007. [Context Link]


20. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York: Oxford University Press; 2001. [Context Link]


21. Lo B, Katz MH. Clinical decision making during public health emergencies: ethical considerations. Ann Intern Med. 2005;143:493-498. [Context Link]


22. Rushton CH. Defining and addressing moral distress. AACN Adv Crit Care. 2006;17(5):161-168. [Context Link]


23. Kotalik J. Preparing for an influenza pandemic: ethical issues. Bioethics. 2005;19(4):422-431. [Context Link]


24. Thompson AK, Faith K, Gibson JL, Upshur REG. Pandemic influenza preparedness: an ethical framework to guide decision-making. BMC Med Ethics. 2006;7:L1-L12. [Context Link]


25. American Nurses Association (ANA) Committee on Ethics. The nonnegotiable nature of the ANA Code for nurses with interpretive statements. 1994. Accessed May 22, 2007. [Context Link]


26. American Nurses Association. Code of Ethics for Nurses With Interpretive Statements. Washington, DC: American Nurses Association, 2001. [Context Link]


27. American Nurses Association Committee on Ethics. Risk and responsibility in providing nursing care. 2006. Accessed May 22, 2007. [Context Link]


28. Sokol DK. Virulent epidemics and scope of healthcare worker's duty of care. Emerg Infect Dis. 2006;12(8):1238-1241. [Context Link]


29. Ethics Subcommittee of the Advisory Committee to the Director of the Centers for Disease Control and Prevention. Ethical guidelines in pandemic influenza. 2007. Accessed October 1, 2007. [Context Link]


30. Hick JL, O'Laughlin DT. Concept of operations for triage of mechanical ventilation in an epidemic. Acad Emer Med. 2006;13:223-229. [Context Link]


31. Christian MD, Hawrylluck L, Wax RS, et al. Development of a triage protocol for critical car during an influenza pandemic. CAMJ. 2006;175(11):1377-1381. [Context Link]


32. Department of Health and Human Services (HHS). Individuals & families from U.S. government avian and pandemic flu information. 2007. Accessed October 1, 2007. [Context Link]