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BY: MAUREEN CAVANAGH, RN, M.S.

Directions
Print the following scenarios on individual index cards and distribute them randomly to the group. Eight of the cards begin with YOU HAVE THE FLU! If the group has less than 25 people, make sure that at least one-third of the people in the group receive one of these cards. Participants should assume pandemic conditions and a high need for medical services at their facility and in the community at large.

Once the cards are distributed, have each person read the information on the card he or she has received. Questions are provided at the end of this article to facilitate discussion about each situation.

Time permitting, encourage the group to think of action steps that can be initiated immediately to address ethical conflicts and potential moral distress among staff members.

Scenarios

1. YOU HAVE THE FLU! You are recovering from the flu, but since you are asthmatic, your physician advises against returning to work at the hospital's registration office because you are at high risk for a relapse.
   
   
2. YOU HAVE THE FLU! You are symptomatic and have been sent home from your job as an information associate because your spouse and children are already sick with the flu.
   
   
3. YOU HAVE THE FLU! You are sick with the flu, unable to work and live alone in a rural county 25 miles from the hospital.
   
   
4. YOU HAVE THE FLU! You are sick with the flu and have no paid leave as you have been working at the hospital for only three weeks. You are the sole income earner for your spouse and two young children.
   
   
5. YOU HAVE THE FLU! You are sick with the flu and need hospitalization, but you are triaged to another hospital not covered by your insurance plan. Now you are worried about survival and a substantial hospital bill.
   
   
6. YOU HAVE THE FLU! You started feeling ill two days ago after you flew home from your cousin's funeral. You have been working overtime as a nurse's aide because your unit has been so short.
   
   
7. YOU HAVE THE FLU! You are the night charge nurse in the intensive-care unit and you have been working a lot of extra hours due to staff illness. You need hospitalization and ventilatory support. Despite these efforts, you begin to show signs of multi-organ system failure.
   
   
8. YOU HAVE THE FLU! You have been working in a unit at the long-term care facility which has been quarantined. Now you are afraid to go home as no one in your family is sick and you don't want them to get the flu.
   
   
9. You work in housekeeping on the night shift and take two buses to work. The transportation authority has curtailed routes due to illness of its drivers. The buses you usually take are no longer running and you don't know when they will resume.
   
   
10. You have been designated by the nursing department to receive "just in time" training on ventilators. The respiratory therapy department will be conducting the two-hour training, after which you will be assigned to stable patients on ventilators. You are worried that you might not be able to provide safe care. Liability is also a concern.
    
    
11. You are the director of the hospital day care center. Most of the other day care centers have closed per the county health department recommendations. Several of the children you care for are sick, but you know that if you close, a number of health care workers will be without child care and potentially unable to work.
    
    
12. You are the emergency department physician and you have already worked 10 hours. The department is overcrowded and your mother-in-law, who has been watching your two preschool children, calls to tell you that one of them has a temperature of 103 degrees.
    
    
13. You are the occupational health nurse and in charge of the mandatory vaccination program the county has initiated for all health care workers. Most of the staff are happy to receive the shot but more than a few do not wish to be vaccinated under any circumstances.
    
    
14. You are an intensive-care unit nurse and you have just removed the third patient from a respirator this shift. You know these patients might have survived if flu demands had not excluded them as candidates for ongoing ventilator treatment.
    
    
15. You are the telephone operator. The phone lines have been jammed with people calling to see if the hospital has beds available and access to ventilators should they need one.
    
    
16. You are the chief of surgery and you are angry because elective surgeries have been cancelled due to the surge in flu cases.
    
    
17. You are the chaplain and you are asked to speak with a family whose father was denied a ventilator because he did not meet triage criteria. They ask you how a Catholic facility can discriminate like this.
    
    
18. You work in the system's drug rehabilitation facility. In addition to having some of your patients sick with the flu, your facility has been designated as a triage site because of its central location and easy access to parking and the highway. You are expected to contribute some services (food, space, etc.) for the county health department staff who plan to be there for at least one week.
    
    
19. You are the security guard and you must tell people that visiting has been restricted in the entire hospital for at least the next 10 days. People are angry and demand to be allowed to see their sick family members.
    
    
20. You are not a clinical person but you have been asked to go to the postpartum unit to help feed babies, pass food trays and re-stock supplies.
    
    
21. You are a nurse, working a double shift for the third time this week because so many staff members on your unit are sick. You are tired, short staffed and have just made a medication error.
    
    
22. You are the pharmacy director and you have been notified by the county public health department about a critical shortage of Tamiflu in the county. They are expecting you to:
    1. Evaluate current Tamiflu usage in your facility.
    2. Share your Tamiflu supply with other facilities, according to the department's algorithm.
    3. Use another drug, which has not been approved by the FDA for flu but has been shown to be effective in some studies and is more widely available.
       
       
23. You are the triage officer and you must decide the priority for the remaining two intensive-care unit beds from the following four people:
    1. An 11-year-old asthmatic, a classmate of your own 11-year-old son
    2. Your 55-year-old neighbor who has been caring for her aging parents and is now sick herself
    3. A convenience store owner, 45, the father of four children who, despite financial hardship to his business, has been supplying his local neighbors with food during the pandemic.
    4. A 65-year-old hospital benefactor
       
       
24. You work in the catheterization laboratory, which has been closed for procedures, but the space is being used as an intensive-care unit/step-down unit. You are expected to come to work and staff the unit.
    
    
25. You are the cafeteria manager. One-third of your workforce is sick but you have been asked to devise a plan to provide nourishment around the clock for staff who are well enough to work and who are working extra hours or are quarantined.

Discussion Questions

1. How did you feel when you imagined yourself as the worker represented on the card?
2. Did the exercise bring to mind situations you may not have thought about before?
3. Do you think we are sufficiently prepared to help staff address the issues raised by this exercise?
4. Are there any beginning action steps you can think of to address these issues?
5. Who else could do your job if YOU got sick?
6. What aspects of your job do you think are essential in a flu pandemic?
7. What other jobs could you do in the hospital besides your own?
8. What other training could you provide to help staff members learn another function?
9. What other responsibilities might compete with your job responsibilities in a flu pandemic?

Editor's Note: Maureen Cavanagh, RN, M.S., is well aware of public health concerns about a flu pandemic this fall, so she developed a game to get her colleagues at St. Peter's Hospital in Albany, N.Y., thinking about how well the hospital is prepared to respond. She shares it here in the hope that it will help hospital employees around the country to be ready for the worst.

It wasn't a single event that prompted Maureen Cavanagh to decide she needed to raise consciousness at St. Peter's about the emotional and ethical challenges a pandemic could present. The most obvious of course is the looming threat of a resurgence of the H1N1 (swine) flu and a possible flu-related pandemic this fall — or, if not this fall, in another not-too-far-off season. Or, if not this flu, some other disease, or a natural disaster, or a bioterrorist attack, any of which could put unprecedented stresses on health care systems regionally, nationally or globally.

Something else that got her thinking, Cavanagh told Health Progress, was learning that the New York State Department of Health was offering a program on caring for flu patients in a pandemic if and when ventilator demand, or trained staff to operate ventilators, exceeds the supply. And then there was an unsettling conversation with a friend, a hospital employee in New Orleans who found herself confronted by unimagined challenges when Hurricane Katrina hit in 2005. Her friend told her afterward, "If you think your hospital has a disaster plan, it doesn't."

"I wanted to get people beyond thinking about a pandemic as an academic endeavor to looking at the reality," Cavanagh said — "to think about not only how we would care for patients, but also to realize that we would have to think too about our staffs and their families. That is the flip side of our duty to care."

So Cavanagh developed a game to get people to grapple with some of the thorny ethical issues a pandemic might present. So far, she has used the exercise with the ethics committee at St. Peter's and with the senior leadership team. Both groups "were surprised by some of the new insights they got," she said. The exercise moved participants' thinking beyond the difficult triage questions to the impact a pandemic would have on their own lives and to the human resource questions a pandemic might raise.

Copyright © 2009 by the Catholic Health Association of the United States
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