AACN Position Statement: Ethical Triage and End-of-Life Care

Aug 13, 2025

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Background

When the demand for care, supplies, and lifesaving equipment exceeds availability, these necessities must be carefully allocated. During such times, decisions about care will likely be made rapidly under a triage system. The traditional ethical foundation for decision-making during triage is utilitarianism, which aims for outcomes that provide the greatest good for the greatest number of people.1,2,3,4 Crises affecting healthcare operations may result from many causes, such as severe weather events, terrorism, acts of war, or infectious disease pandemics.

In ordinary circumstances, nurses are duty-bound to provide beneficent care for their patients. This foundational duty remains even in situations where crisis standards of care and triage are necessary. However, in these situations the duty to perform only well-intended actions for the patient must shift from a focus on the individual patient to a focus on the general public. 1,2,3,5

Few clinicians, and very few patients and their families, have expertise in the nuanced ethics of triage. During a crisis, clinicians may be forced to make heartbreaking decisions under circumstances they have never faced before. In actuality, normally expected standards of care cannot be met in every situation or for every patient in times of crisis. The implementation of triage systems under the umbrella of crisis standards of care will fluctuate depending on resource availability and demand.2,3,5 Because of this, some decisions made in dire circumstances may feel unfair or immoral to the healthcare team and the public. Skilled communication is key in educating the healthcare team and the public about how and why decisions are made.6

Even when nurses and other members of the healthcare team are working under crisis standards of care, it is important that all patients receive compassionate end-of-life care.1 This is necessary for the well-being of patients, patients' families, and those caring for them. Every effort to alleviate physical and emotional pain and provide other comfort must be made, even if this can only be a compassionate presence and recognition of the personhood and value of that patient. Nurses have always cherished their roles as advocates for patients and their families. When crisis standards restrict visitors or no family is identified, nurses may also be called upon to offer final words of comfort and serve as caring witnesses at the end of a patient's life.

AACN's Position

Healthcare institutions have a duty to ensure that decision-making under crisis standards of care be fair, ethical, legal, transparent, and compassionate. Institutions must also ensure that decision-making in triage situations is shared so no clinician bears this burden alone. Effective communication is crucial at all times.6 Institutions must institute guidelines and education about triage and end-of-life care so nurses and other members of the healthcare team fully understand considerations and consequences. Nurses must strive, as always, to provide patients with the best end-of-life care possible.

Recommended Actions for Healthcare Institutions

Every organization must:

  • Recognize the Three Ethical Duties of healthcare leaders in responding to a crisis affecting healthcare operations:
    • Duty to plan—Manage uncertainty, especially regarding staff, space, and supplies.
    • Duty to safeguard—Support workers and protect vulnerable populations.
    • Duty to guide—Use contingency levels of care and crisis standards of care to guide fair allocation of resources.7
  • Ensure that vulnerable populations are treated fairly under a triage system. A decision support framework may help with this and every healthcare organization should have a crisis (or disaster) policy/plan.1,2,3,5,8
  • Use crisis communications strategies to provide clear and understandable explanations for healthcare teams, patients, and patients' families regarding how triage is considered and conducted.5
  • Incorporate palliative interventions for end-of-life care into the planning and implementation of crisis response plans.
  • Offer palliative care education for clinicians serving in unfamiliar situations who may not have developed end-of-life care skills.
  • Provide debriefing and support for all clinicians at regular intervals to help them deal with the moral distress of decision-making in triage and crisis situations.
  • Put systems in place to guarantee that all clinicians operating under crisis standards of care or triage systems are operating within legal and regulatory parameters.
  • Maintain ready availability of ethics consultants and triage teams to ensure the burden of decision-making is shared.
  • Establish policies for respectful care for the dead, and ensure that patients' loved ones are informed of that care.

Recommended Actions for Nurses

Nurses must:

  • Hone communication skills regarding decision-making under crisis standards of care in order to better explain those decisions to patients and their families.1,9
  • Be honest and transparent in all communications to patients and their families regarding the plan of care and other relevant information.9
  • Use cell phones, tablets, letters, and other methods to build relationships and help family members stay in touch or say good-bye to a loved one. Remember that family members may not be emotionally prepared to see their loved-one. If there has been a sudden physical decline, consider using nonvisual communication.
  • Apply palliative and end-of-life care knowledge and skills to provide patients with the comfort, compassion, and dignity they deserve.1,10
  • Embrace flexibility and creativity. Even those who are well versed in palliative and end-of-life care will likely find that best practices are not possible in a crisis.

References

  1. American Nurses Association. (2025). Code of ethics for nurses. https://codeofethics.ana.org/home
  2. Hanfling D, Hick J, Hunt R, Toner E. Crisis Standards of Care: Quick Guide for Health Care Providers. National Academy of Medicine. Published December, 2020. Accessed June 17, 2025. https://nam.edu/wp-content/uploads/2020/12/csc-provider-guide_updated.pdf
  3. National Academy of Medicine. Crises standards of care: a systems framework for catastrophic disaster response. Washington, DC: The National Academies Press, 2012.
  4. Rajczi A, Daar J, Kheriaty A, Dastur C. The University of California Crisis Standards of Care: Public Reasoning for Socially Responsible Medicine. Hastings Cent Rep. 2021;51(5):30-41.https://www.doi.org/10.1002/hast.1284
  5. White DB, Lo B. Structural Inequities, Fair Opportunity, and the Allocation of Scarce ICU Resources. Hastings Cent Rep. 2021;51(5):42-47. https://www.doi.org/10.1002/hast.1285
  6. Barden C, Cassidy L, Cardin S, eds. AACN Standards for Establishing and Sustaining Healthy Work Environments: A Journey to Excellence. 2nd ed. Aliso Viejo, CA: American Association of Critical-Care Nurses; 2016. https://www.aacn.org/nursing-excellence/standards/aacn-standards-for-establishing-and-sustaining-healthy-work-environments
  7. Berlinger N, Wynia M, Powell T, et al. Ethical framework for health care institutions & guidelines for institutional ethics services responding to the coronavirus pandemic: managing uncertainty, safeguarding communities, guiding practice. The Hastings Center. March 16, 2020. Accessed June 17, 2020. https://www.thehastingscenter.org/ethicalframeworkcovid19/
  8. Cleveland Manchanda EC, Sanky C, Appel JM. Crisis Standards of Care in the USA: A Systematic Review and Implications for Equity Amidst COVID-19. J Racial Ethn Health Disparities. 2021;8(4):824-836. https://www.doi.org/10.1007/s40615-020-00840-5
  9. Engel M, Kars MC, Teunissen SCCM, van der Heide A. Effective communication in palliative care from the perspectives of patients and relatives: A systematic review. Palliat Support Care. 2023;21(5):890-913. https://www.doi.org/10.1017/S1478951523001165
  10. National Institute on Aging. Providing Care and Comfort at the End of Life. Published November 17, 2022. Accessed June 17, 2025. https://www.nia.nih.gov/health/end-life/providing-care-and-comfort-end-life

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