Natural Disasters, Climate Change, and the Impact on Hospice and Palliative Care Teams and Their Patients

Larry Beresford

Several recent natural disasters, including highly destructive wildfires in Los Angeles and Maui and flooding in the North Carolina hills caused by rains from Hurricane Helene, have provided vivid reminders that disasters can happen anywhere, anytime. Hospice and palliative care providers, responsible for the care of patients with serious illnesses who live in their homes and in long-term care facilities, could be dealing with disruptions in power or phone service, other communication barriers, staffing shortages, impassible roads, even large-scale evacuations of their patients.

We are seeing increasing incidence and severity of these kinds of weather events, which scientists have attributed to climate change. But a disaster, typically, comes without much warning. Are agencies doing what they can to plan, prepare, and practice for managing disasters, which could also include human-caused crises or events like earthquakes that are not subject to weather or climate?

These disasters often disproportionately impact underserved populations and older adults. A recent scoping review of climate change medical literature concluded that climate-related extreme weather events could increase demand for hospice and palliative care due to rising respiratory illnesses, heat-related impact, waterborne diseases, and aggravated chronic conditions.¹

Aldebra Schroll, MD, consulting medical director with Butte Home Health and Hospice in Chico, CA, has seen the fallout in her community from the Camp Fire of November 2018, which caused 85 fatalities in Butte County, destroyed 18,000 structures, and leveled the town of Paradise, as well as the more recent Park Fire in July 2024, the fourth largest wildfire in the state’s history in terms of ground covered. Dr. Schroll was director of palliative medicine at Enloe Health Medical Center in Chico during the Camp Fire evacuations. She saw survivors, evacuees, people who had to flee their homes in a hurry, without their medications or oxygen equipment.

“All of a sudden, the [Chico] hospital got a whole lot more patients,” she said. Some evacuees ended up living in the local Walmart parking lot in tents or in recreational vehicles. Hospice staff were visiting their patients at their encampments.

“One thing I have seen in our hospice patients, as they do their life reviews, they want to talk about the day they escaped the fire. And when we go to their home, it can seem sterile, with new furniture, no family pictures on the wall, no hand-me-downs.” So, it’s a whole different kind of meaning making, she explained.

How Do We Talk About Climate?

“A lot of people are putting a lot of time into trying to organize medical groups to combat climate change. Others are asking: How do we talk to our patients about climate?” said Debra Dobbs, PhD, a sociologist who conducts clinical trial research related to palliative care and hospice in long-term care settings at the University of South Florida and lead author of the recent study “Mortality among Nursing Home Residents Enrolled in Hospice and Hospice Utilization Post-Hurricane Irma.”² Other research has confirmed that exposure to natural disasters has a significant impact on nursing home residents.³

For hospices dealing with emergencies and disasters, she said, “how do we do that with the right language?” Concerns have been raised about funding for medical research that uses the word “climate.” Therefore, it might be safer to talk about emergencies and disasters.

Everyone in the country needs to be ready for disasters. Hospices need to have a plan in place for how to collaborate with other providers, including the facilities where they are following patients.

In her research on an unusual winter storm in Texas, Dr. Dobbs discovered that providers and facilities weren’t prepared to deal with the resulting loss of power. The lesson there is that everyone in the country needs to be ready for disasters. Hospices need to have a plan in place for how to collaborate with other providers, including the facilities where they are following patients.

Every state has a statewide emergency management team, with emergency directors and representatives from fire departments, cities and counties, she said. “They have meetings, including quarterly emergency management trainings and webinars.” Hospices and other agencies should also have their own comprehensive emergency management plans (CEMPs), but these need to be in accord with the CEMPs in the long-term care facilities where they have patients.

“Can you arrange for more staff people in advance of an emergency?” Dr. Dobbs posed. “Can you have extra people on duty, weekend staff or alternates, willing to work extra days? Do you have people who will be willing to work in a disaster even if they’re also dealing with their own families and emergency situations? What are you doing to make it easier for them to fulfill that role?”

That may involve bringing their families to the office, including pets. “Maybe bring in a day care professional or someone like that to watch the kids. What else can you do to keep staff working, to make sure their family is taken care of, to address the moral distress responding staff may be feeling in the disaster? It’s not enough to just appeal to their higher instincts,” she suggested. What about extra pay for working in a disaster?

Nathan Boucher, DrPH, lead author of the recent article “Caregiving in U.S. Gulf States During Natural Disasters and COVID-19”⁴ has studied the combined impact of hurricanes or floods and COVID-19 on the lives of caregivers. He said the research has identified the disruptions in care that are particularly relevant to hospices, including staffing and staffing shortages; communication barriers; and the need for psycho-social-spiritual support, which can get overlooked or treated as of secondary importance during a crisis. “Just being present and bearing witness might be the biggest need,” he said.

A Time of Disasters

Sonia Malhotra, MD MS FAAP FACP FAAHPM, associate chief of palliative medicine at Tulane University in New Orleans, said that climate response builds on core palliative skills. “One of those core skills is naming things, naming emotions, naming what is the best-case scenario, the worst-case scenario. I think we can name the fact that we are living in a time that is fraught with disasters,” she said.

“I have tried to focus on my sphere of influence. And that is trying to prep people the best I can for when disasters arise,” Dr. Malhotra said. “Can you build a rainy-day fund, saving some of the money you get from your disability check, your social security check, so you can get the heck out of town if you need to?” she added.

“As a palliative care service, we are not an activation [emergency response] team for our hospital when disasters like hurricanes occur, which means that we are able to leave the city and keep working from a distance.” A lot of people were evacuated during Hurricane Ida in 2021, with few left in the city, she said.

“My family and I evacuated to Atlanta. My team was all scattered. What we did was come together as a team daily at the same time, 9 am, to huddle and talk through the patient lists and communicate with teams as to what further communication was needed. And we would give recommendations or put in orders for our teammates that were in the hospital taking care of patients.”

Thomas Morel, MD, a palliative care physician at Ochsner Medical Center, located by the banks of the Mississippi River in Jefferson, LA, said that palliative care is recognized as an essential service in crises at his medical center. “I think we made a name for ourselves during COVID-19, and ever since, we’ve been designated as A-team essential personnel. We actually lobbied for that.”

The palliative care program at Ochsner reviews its plan annually and makes sure that all staff know what team they are on and what role they will play in a disaster. Team members can be designated as A-team remote and do a lot of telemedicine contact with patients and families. “What sometimes falls by the wayside is the importance of communicating with family members because so often the hospital, in our case literally, can become an island,” Dr. Morel said.

Leading in Climate Medicine

Jill Denny, MD, a palliative care physician who now lives in Seattle, coauthored a recent article for the Center to Advance Palliative Care⁵ underscoring how the Los Angeles wildfires highlighted the urgent role of palliative care in protecting vulnerable patients and helping to build climate-resilient health care. She also recently completed a diploma program in climate medicine at the University of Colorado, which she called an amazing learning experience, covering topics such as how to communicate about these issues with patients.

“I think palliative care has so much potential to be a leader in the climate medicine movement.”

“I think palliative care has so much potential to be a leader in the climate medicine movement,” Dr. Denny said. “Every time I talk to people in this field about what climate medicine is and why it’s important, it just sort of clicks for them. In palliative care we have this unique skill set of being able to talk to people about things that are frightening,” she said. “We can use that skill set to really help people understand the crisis that we’re facing and how we can, as a country, or as a community, face it together, hopefully protecting those who need protecting and really caring for each other,” she said.

But what does that look like on a day-to-day basis? For a hospice or palliative care nurse interacting with a patient, they could say, “‘Hey, you know we’re coming up on wildfire season, or smoke season. We know that these storms or fires are more frequent now. Let’s talk about what our plan might look like if the air quality gets really bad. If there’s a big storm coming, what are we going to do if the power goes out at your home?’” Dr. Denny related. “‘Let’s do a bit of brainstorming about what it would look like if the roads out of your neighborhood were flooded. Where would you go, or who could come to you, and how would you get food?’”

She made an analogy to the rescue kit of potential medications that is left in the home when a patient enrolls in hospice, so that if they have a pain crisis or a nausea crisis, the meds are already there. “We already have this mindset for addressing what-ifs to make sure that we have covered them. I think we have to start thinking about natural disasters in the same way.”

Effects of the Heat

“At the clinical level, it’s not always advantageous or necessary to bring up climate change,” said Nisha Shah, DO, palliative care physician and team medical director for Family Hospice, Part of UPMC, in Pittsburgh, PA. “But patients are seeing the effects of it on their health, on their family’s health. And so that’s a way to talk about it sensitively,” she said.

“In our older population, what we’re seeing with extreme heat and climate-related weather events are exacerbated symptoms related to cardiovascular diseases, cerebral disease, respiratory illnesses, which converge with a lot of the other risk factors that older adults and seriously ill patients have,” she explained. Plus, there’s the stress of being evacuated.

Dr. Shah also completed the climate fellowship at the University of Colorado: “I’m trained in sustainable health care and how to navigate climate-related issues as they relate to health care.” Currently she works part-time in her hospice clinical role but is also seeking ways to utilize her climate training. “There are not a lot of developed positions in this space, so it’s something I’m trying to create on my own.”

She encouraged other clinicians to become engaged and get involved any way they can in organizations of like-minded people and environmentally focused groups within their medical societies. She is spearheading a group of about 15 AAHPM members, Hospice and Palliative Care Professionals for Planetary Health, an interdisciplinary group formed to deepen understanding, collaborate across fields, and advocate for equitable climate solutions. It focuses on quantitative, research-based academic work; climate-related qualitative and narrative storytelling in the HPM field; and advocacy for climate solutions and professional engagement.

“Since our group is from around the country (with one of us even in Nigeria), we exclusively meet virtually on a monthly basis and collaborate virtually in between meetings as needed. We started meeting in August 2024 and are currently developing our mission and vision statements.” Contact [email protected] if you’d like to connect with Dr. Shah for more information about this hospice and palliative care advocacy group.

A Hurricane in the Mountains

Ruth Thomson, DO MBA HMDC FAAHPM, chief medical officer at Four Seasons, a hospice and palliative care agency based in Flat Rock, NC, lived through the flooding in the mountains of North Carolina resulting from Hurricane Helene in September of 2024. She suggested that one positive outcome from the COVID-19 pandemic for hospices has been a greater focus on disaster planning. Obviously, weather-related disasters are different than a pandemic. “But COVID was a huge challenge to deal with. A lot of hospices very quickly had to pivot and respond, better preparing themselves for future large-scale challenges,” she said.

“Our organization’s disaster plan includes an incident command structure. In a disaster, we have to decide when we are going to open the command center in order to respond to what’s happening on the ground. Ideally, you do that sooner rather than later, but we don’t always have that luxury.”

It was hard to know what was happening on the ground when power and cell service went out, Dr. Thomson said. “We just had to figure it out on the fly. It was truly all hands on deck.” Reverting back to basics when technology fails can include old-school tools like walkie-talkies. “One of the first things we did was account for all of our staff and make sure that everybody’s okay. And if they weren’t, where were they, did they need to evacuate?” she said. Many people, including some hospice staff, simply left the area because they had no home, no water, no power. Tracking staff made it possible to come up with a plan for how they were going to check up on their patients.

“That was our focus for the next 4 or 5 days—our boots on the ground. We had our patient list, and we had to go one by one—even visiting the emergency shelters,” she said. A lot of it was just physically getting in contact with people by knocking on their doors to make sure they were okay. Which is what first responders were doing, also.

“We have learned that any time we get an inkling there’s a natural disaster coming our way, we will preemptively put in a call, a kind of shout-out to the nurse case managers, telling them, ‘You need to check all your patients, make sure they have an adequate supply of medications and supplies. If they need anything, get it now before the pharmacies are no longer available,’ because that was a situation with this hurricane,” Dr. Thomson said.

“Early on, I think, people had no idea of the magnitude of the impact the hurricane would have on this part of our state. When the hurricane came through, the water from the mountaintops came down and overwhelmed the water reservoirs. Then it just overflowed downhill and took a lot of stuff with it—homes, people, lots of trees,” she said.

“We recently hit the 6-month anniversary of the hurricane, and it’s still hard to wrap your mind around it. It leaves you speechless to see all the debris, cars just totaled and left in the creek beds or by the side of the road.” And a few months after the flooding came the wildfires. Overall, the hospice’s staff felt pretty shell-shocked by the whole experience, she said.

In a disaster, patients and families are the highest priority, but staff need to be right behind.

In a disaster, patients and families are the highest priority, but staff need to be right behind. “We had staff that lost their entire home, that had to evacuate emergently, that saw devastation people shouldn’t have to witness first-hand,” Dr. Thomson said. “We had some staff that said, ‘I can’t do this right now, I need to resign.’ They left the area because it was such a huge trauma. And trauma affects people in different ways, at different times,” she said.

Four Seasons has tried to emphasize greater involvement of patient and family support services and grief services teams, not only for patients and families but also to support staff in different ways to help them cope with the trauma. “I think it’s really important to honor people’s experience with that kind of trauma support and trauma-informed care,” she said. “What do you do when your house and life have been devastated, but you’ve got patients to see? How does that play out in your life?”

Resources

There is a large and growing number of resources that can help healthcare professionals talk to their patients about disaster planning.

References

Harris D, Chekuri B, Schroll A, et al. The impact of climate change on hospice and palliative medicine: a scoping and narrative review. J Clim Chang Health. 2024;18:100323. https://doi.org/10.1016/j.joclim.2024.100323.
Dobbs D, Skarha J, Gordon L, Jester DJ, Peterson LJ, Dosa DM. Mortality among nursing home residents enrolled in hospice and hospice utilization post-Hurricane Irma. J Palliat Med. 2022;25(9):1355-1360. https://doi.org/10.1089/jpm.2021.0475.
Dosa D, Jester D, Peterson L, Dobbs D, Black K, Brown L. Applying the age-friendly-health system 4M paradigm to reframe climate-related disaster preparedness for nursing home populations. Health Serv Res. 2023;58(Suppl 1):36-43. https://doi.org/10.1111/1475-6773.14043.
Boucher NA, McKenna K, Dombeck CB, et al. Caregiving in U.S. Gulf states during natural disasters and COVID-19. Gerontol Geriatr Med. 2022;8:23337214221133719. https://doi.org/10.1177/23337214221133719.
Denny J, Carlson E. Los Angeles wildfires, climate change, and palliative care: a call to action. Center to Advance Palliative Care. Published January 21, 2025. Accessed May 7, 2025. https://www.capc.org/blog/los-angeles-fires-climate-change-and-palliative-care-a-call-to-action/.

Larry Beresford is a medical journalist in Oakland, CA, with a strong interest in hospice and palliative care.