Introduction
Ethics guidelines on COVID-19 triage—a synopsis
Italy | Switzerland | Austria | Germany | UK | Belgium | |
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Issuing body | Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) | Swiss Academy of Medical Sciences/Swiss Society for Intensive care (SGI) | Austrian Society for Anesthesiology, Reanimation and Intensive Care (OEGARI) | Several intensive care professional associations/Academy for Ethics in Medicine (AEM) | NICE | Belgian Society of Intensive Care Medicine |
Equity | All patients (COVID and non-COVID) who require intensive therapy treated according to the same criteria | - All patients requiring intensive therapy treated according to the same criteria - No discrimination - Fair allocation procedures | – | All patients who require intensive therapy treated according to the same criteria | All patients who require intensive therapy—before admission clinical frailty scale (CFS) | All patients evaluated according to the same criteria in order to avoid discrimination |
Maximizing benefit | - Probability of survival - Life expectancy - Comorbidities and functional status | - Preserving as many lives as possible - Short-term prognosis is decisive - Protection for health professionals | - Short-term survival - Comorbidity | - Short-term survival - Long-term prognosis | - Frailty - Optimizing critical care bed usage (discuss sharing with other hospitals) | - Medical urgency - Frailty - Comorbidities |
Considering age/life span | - Age limit “may ultimately need to be set” | - Age “not in itself” a criterion but affects short-term prognosis - Exclusion > 85 years from admission to ICU (if no ICU beds available, resource management through discontinuation of treatment = stage B) | – | - No (de) prioritization “solely because of biological age” | – | - “Age in itself is not a good criterion to decide on disproportionate care” |
Additional criteria | – | - Other criteria such as lottery, first come first served, social utility explicitly rejected | - Goals of care - Indication - First come, first served explicitly rejected | - Indication - Social criteria not permissible | – | - Cognitive impairment |
Patient will | + | + | + | + | + | + |
Termination of therapy | - Decisions to withhold or withdraw life-sustaining treatments “must always be discussed and shared among the healthcare staff, the patients, and their proxies” | - Staged approach to definition of “ICU treatment no longer indicated” - Change therapy goal | - Futility - Proportionality | - Futility - Therapy goal unrealistic - Patient-centered decision | - Desired critical care treatment goals unrealistic - Document decisions and discussions with patient and family | - Disproportionate care (poor long-term expectations) - Openly discuss decision not to initiate or to withdraw life-sustaining therapies with patients/relatives |
Additional recommendations | - Every admission to ICU considered and communicated as an “ICU trial” subject to daily reevaluation - Offer non-ICU bed or palliative care | - Resuscitation “not recommended” (stage B) - Transparent decision-making - Offer palliative care | - Initiate decisions as early as possible - Transparent and (as far as possible) participatory decisions (patients/representatives) - Documentation of reasons for forgone interventions - Palliative sedation in ICU | - Use comorbidities, general frailty, prognostic scores (SOFA) for prioritization - Palliative care | - Discuss risks, benefits, and possible likely outcomes with patients, families, and carers - Use decision support tools (where available) - Discuss DNAR decisions with patient | - Measures to maximize ICU capacity - Advance care planning (e.g., nursing home residents) - No out-of-hospital CPR on “elderly patients” during pandemic |
Reevaluation | + | + | + | + | + | + |
Who decides? | - Second opinion from Coordination Centers or designated experts in difficult cases | - Interprofessional team when possible - Most senior professional carries responsibility | - Mobile intensive care team - Collegial consultation - Ethics advice, if necessary - Debriefing to avoid PTSD | - Interprofessional team - Where appropriate, clinical ethics - Communication strategy through hospitals - Psychosocial support of teams | - Involving critical care teams in ICU admission decision - Support all healthcare professionals | - 2 to 3 physicians with experiences in respiratory failure in the ICU - Teleconsultation - Psychological support for triaging physicians |