Between Usual and Crisis Phases of a Public Health Emergency: The Mediating Role of Contingency Measures.

Much of the sustained attention on pandemic preparedness has focused on the ethical justification for plans for the "crisis" phase of a surge when, despite augmentation efforts, the demand for life-saving resources outstrips supply. The ethical frameworks that should guide planning and implementation of the "contingency" phase of a public health emergency are less well described. The contingency phase is when strategies to augment staff, space, and supplies are systematically deployed to forestall critical resource scarcity, reduce disproportionate harm to patients and health care providers, and provide patient care that remains functionally equivalent to conventional practice.

A Health Care Systems Approach to Improving Care for Seriously Ill Patients.

Health care systems can go beyond advance care planning to create mechanisms for eliciting and documenting the goals of care and life-sustaining treatment decisions of patients with serious life-limiting illnesses. These systems can help ensure that patients receive care that is consistent with their values and preferences. We describe a case in which even though a patient with a serious illness had completed an advance directive and had discussed preferences with family, clinicians failed to identify the patient's authentic preferences for life-sustaining treatment.

A Comprehensive Approach to Eliciting, Documenting, and Honoring Patient Wishes for Care Near the End of Life: The Veterans Health Administration's Life-Sustaining Treatment Decisions Initiative.

Background: There is an emerging consensus that clinicians should initiate a proactive "goals of care conversation" (GoCC) with patients whose serious illness is likely to involve decisions about life-sustaining treatments (LSTs) such as artificial nutrition, ventilator support, or cardiopulmonary resuscitation. This conversation is intended to elicit the patient's values, goals, and preferences as a basis for shared decisions about treatment planning. LST decisions are often postponed until the patient is within days or even hours of death and no longer able to make his or her goals and preferences known.

Ensuring Appropriate Care for LGBT Veterans in the Veterans Health Administration.

Within health care systems, negative perceptions of lesbian, gay, bisexual, and transgender persons have often translated into denial of services, denial of visitation rights to same-sex partners, reluctance on the part of LGBT patients to share personal information, and failure of workers to assess and recognize the unique health care needs of these patients. Other bureaucratic forms of exclusion have included documents, forms, and policies that fail to acknowledge a patient's valued relationships because of, for example, a narrow definition of "spouse," "parent," or "family." Bureaucratic exclusion has taken a particularly prominent form in the U.