For example, the report says, "In states with limited numbers of local health departments and in the approximately one-third of states in which the state health department assumes responsibility for providing local public health services ...the state may need to take a more active role in ensuring appropriate local stakeholder representation in state-level CSC planning, as well as in furthering community and provider engagement."
The report devotes specific attention to EMS personnel, who are often volunteers with full-time jobs and families, but who may be alone in making decisions about where to take patients harmed by a disaster, especially if that disaster has already destroyed hospital base stations that would ordinarily direct them.
Ethical challenges in delivering care during a disaster is another theme in the report. For example, one of the discussion points deals with considerations of administering mechanical ventilation when there aren't enough licensed personnel for all patients who need it. Family members of some patients may wish to do it themselves. However, the report says:
"It is ethically inappropriate to allow patients to be ventilated by family members while others without family members do not receive the same support. The facility clinical care committee and ethics committee should determine how to handle these situations, as they are likely to arise and will require a thoughtful response. Additionally, individuals unable to keep up with the physical requirements of bagging may feel that they have contributed to the patient's death."