Skip Navigation

New IOM Guidance on Crisis Standards of Care for Use in Disaster Situations

By Brooke Courtney, JD, MPH, October 2, 2009

On September 24, 2009, the Institute of Medicine’s (IOM) Committee on Guidance for Establishing Standards of Care for Use in Disaster Situations released Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report.1

The IOM convened the committee in response to a request by the U.S. Department of Health and Human Services’ Office of the Assistant Secretary for Preparedness and Response (ASPR) to develop guidance that state and local public health officials, health sector agencies, and healthcare institutions can use in developing and implementing standards of care for disaster situations during which critical healthcare resources are scarce. The committee was responsible for establishing a framework for planning and implementation, but not for establishing and defining the specific standards of care and triggers.

This report defines crisis standards of care and sets forth a vision for a system of just care in catastrophic events that includes fairness; equitable processes; community and provider engagement, education, and communication; and the rule of law. It also concludes that “there is an urgent and clear need for a single national guidance for states for crisis standards of care that can be generalized to all crisis events.” The significance of consistency in states’ development and implementation of crisis standards of care is emphasized throughout the report, which offers 6 recommendations and 2 brief case studies.


  1. Develop consistent state crisis standards of care protocols with 5 key elements. State health departments (and other relevant agencies) should develop protocols that include a strong ethical grounding; community and provider engagement, education, and communication; legal assurances; clear indicators and triggers; and evidence-based clinical processes and operations.

  2. Adhere to ethical norms in crisis standards of care. While resource-scarce situations may limit patient care choices, they do not permit healthcare practitioners to engage in actions that violate ethical norms.

  3. Seek community and provider engagement. State, local, and tribal governments should ensure strong community and provider stakeholder engagement in developing crisis standards of care protocols, creating and disseminating educational tools and messages, developing and implementing communication and community resilience strategies, and learning from response situations.

  4. Provide necessary legal protections for healthcare practitioners and institutions implementing crisis standards of care. State and tribal governments should authorize the institution of crisis standards of care in areas affected by disaster and adjust scopes of practice and licensure and credentialing practices as needed in declared emergencies.

  5. Ensure intrastate and interstate consistency between neighboring jurisdictions. States, tribes, localities, and the federal government should communicate and develop processes to ensure consistency in crisis standards of care implementation within and across states.

  6. Ensure consistency in crisis standards of care implementation. To accomplish this, the committee recommends such efforts as convening a state-level “disaster medical advisory committee,” providing palliative care services for all patients, mobilizing mental health resources, developing response measures for populations that are vulnerable or have special medical needs, and implementing robust situational awareness capabilities.

While the committee was charged with developing guidance for state and local public health officials, the report can be used by a range of healthcare practitioners and officials in planning for catastrophic situations during which it becomes impossible to provide care in routine ways. Drafted under an accelerated time frame, the letter report is the first phase of the project. The statement of task includes a second, longer-term phase that will update and expand the initial guidance and seek additional stakeholder input.


Institute of Medicine. Guidance for Establishing Crisis Standards of Care for Use in Disaster Situations: A Letter Report. 2009. Washington, DC: The National Academies Press.