Caring for those who can survive: the protocol for the ICUs in Italy

The increase in the number of coronavirus cases in Italy is leading medical professionals to take decisions criticism in no timeoften with a great moral burden. Right now, there are more than 12,000 diagnosed cases and more than 800 deaths. Hospital ICUs are full and do not have enough respirators, so not everyone can be treated under the same conditions. The big question everyone asks is Who yes and who no?

Given this situation, the SIIARTI (Italian Society of Anesthesia, Analgesia, Reanimation and Intensive Care) published last Saturday a document with its recommendations for Italian doctors in an exceptional situation compared to a war campaign. The title says it all. "Clinical ethics recommendations for admission and suspension of intensive treatments in exceptional conditions of mismatches between needs and available resources."

Intensive treatments must be guaranteed to patients with the greatest chance of success; it is about privileging the ‘longest life expectancy’

“We are in a scenario in which criteria for access (and discharge) in intensive care may be necessary, not only based on the clinical adequacy and proportionality of care, but also based on a criterion of distributive justice and appropriate application of limited health resources”Indicates the introduction of the seven pages of the document, which outlines a plan for the coming weeks. "A scenario of this type is assimilable to the one known as‘catastrophe medicine"For which ethical reflection has developed over time indications for doctors and nurses in difficult situations."

The criterion to be addressed in a critical context of resource allocation, he explains, is to "guarantee intensive treatments for patients with greater chances of therapeutic success; therefore, it is a matter of giving priority to the ‘highest life expectancy”. Access to intensive care must take into account other factors such as type and severity of the disease, presence of comorbidities, deterioration of other systems, and reversibility.

What does not make sense in such a situation, the company document continues, is follow the principle of "on a first come, first served basis"Because "it would be equivalent to choosing not to treat any of the patients who arrived later, who would be immediately excluded from intensive care."

The association document was released at the same time as the anesthesiologist resuscitator Christian Salaroli He explained to ‘Il Corriere de la Sera’ that at the Papa Giovanni XXIII hospital in Bergamo, he was already deciding who to treat “based on age and health conditions" "As in all situations of war," he added.

What criteria?

The text proposes a series of patterns to be applied when admitting some patients or others, taking into account that the reduction of places in intensive care units would not only harm patients with the present disease but would also increase the morbidity between “clinical conditions not linked to ongoing disease, due to the reduction of the surgical and ambulatory activity and the shortage of resources ”. The principles apply to everyone, whether they are Covid-19 patients or not.

It is about reserving scarce resources for those who have a better chance of survival and life expectancy

"It may become necessary to establish an age limit to enter the ICU”, Indicates the SIIARTI. “It is not a matter of solely evaluative decisions, but of reserving resources that could be scarce for those who are more likely to survive and, in addition, to those who may have more years of life expectancy, in order to maximize the benefits for most of the people"

Other factors are comorbidity (presence of other disorders) between patients and their functional status. "It is possible that a relatively short development among healthy people is potentially longer and, therefore, consumes more resources ('resource consuming') in the case of elderly patients, frail or with severe comorbidity ".

Other possibilities fit. For example, the expressed expression of the will of the patients not to receive treatment or a limited treatment through a living will (DAT, in Italy) that stipulates a shared planning of the treatment. The report also recalls that those patients who do not access intensive treatment should not be harmed other lower-level attentions. Furthermore, they must be "communicated, explained and documented".

“Criteria for access to intensive care should be discussed and defined for each patient as early as possible, if possible by creating in time a list of patients who will be considered in need of intensive care at the time the clinical deterioration occurred. , whenever the availability of that moment allows it ”, indicates the document. "Any instruction from ‘Do not intubate’ must be present in the medical record, ready to be used as a guide if clinical deterioration occurs precipitously and in the presence of caregivers who they have not participated in the planning and they do not know the patient"

The doctor should not decide

One of the goals of this class of guides is to rid practitioners, in a moment of extreme stress, of making moral decisions that would make it impossible to deal with the situation efficiently. As the text stresses, the goal is to “relieve doctors of some of the responsibility for their choices, which may be emotionally expensive if they have to go case by case ”.

It is foreseeable that the need to make those decisions repeatedly will make the decision-making process more robust

"The decision to limit intensive care should be discussed and shared in the most collegial way possible by the treating team and, as far as possible, in dialogue with the patient (and family members), but it should be timely" , explains the text. "It is foreseeable that the need to make those decisions repeatedly will make the decision-making process more solid and better adapted to the availability of resources. "

If situations of "particular difficulty and uncertainty" arise in the decision-making process, there must be a second opinion from other organisms. In the case proposed by SIIARTI, the Regional Coordination Centers. The association also advocates for palliative sedation among hypoxic patients with an advanced state of the disease as "a sign of good medical practice." "If the dying period is not short, it should be done a transfer to a non-intensive environment"