Table 1 Summary of the ethical recommendations issued by the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) during the COVID-19 epidemic

Allocation of ICU resources

Allocation of ICU resources is a complex and delicate task. Criteria for ICU admission and discharge under exceptional, resource-limited circumstances must be flexible and should be locally adapted according to the availability of resources, the potential for inter-hospital patient transfer, and the ongoing or foreseen number of hospital and ICU admissions. These criteria apply to every patient potentially in need of ICU admission, not only to COVID-19 infected patients.

Triage principles and criteria

Age, comorbidities, and the functional status of any critically ill patient should carefully be evaluated. A longer and, hence, more “resource-consuming” clinical course may be anticipated in frail elderly patients with severe comorbidities, as compared to a relatively shorter and potentially more benign course in healthy young subjects. The underlying principle would be to save limited resources which may become extremely scarce for those who have a much greater probability of survival and life expectancy, in order to maximize the benefits for the largest number of people. In the worst-case scenario of complete saturation of ICU resources, a “first come, first served” criterion is not recommended, as it would ultimately result in denying access to ICU care to a large number of potentially curable patients.

Advance healthcare directives

The presence of advance healthcare directives or advance care planning should be carefully evaluated, especially for patients affected by severe chronic illnesses. These plans should be shared as much as possible between the patient, their proxies, and all the healthcare staff involved in patient care. A decision to deny admission to the ICU by applying a “ceiling of care” should always be motivated, communicated, and documented. The decision to withhold invasive mechanical ventilation does not necessarily imply that other, non-invasive, modalities of ventilatory support should also be withheld.

Decision-making process

The decision to withhold or withdraw life-sustaining treatments must always be discussed and shared among the healthcare staff and, when possible, the patients and/or their proxies. A second opinion (e.g., from Regional Healthcare Coordination Centres, or from other recognized or designated experts) may be useful when dealing with particularly difficult or distressing cases.

Palliative care

Appropriate palliative care must always be provided to hypoxemic patients when a decision to withhold or withdraw life-sustaining treatments is made. Palliative care should be provided according to national or international recommendations, as a matter of good clinical practice.

ICU trials and proportionality of care

Every admission to the ICU should be considered and communicated as an “ICU trial.” The appropriateness of life-sustaining treatments should be re-evaluated daily, considering the patient’s history, current clinical course, wishes, expected goals, and proportionality of ICU care. When a patient is not responding to prolonged life-sustaining treatments, or severe clinical complications arise, a decision to withhold or withdraw further or ongoing therapies should not be postponed in a resource-limited setting during an epidemic.

Networking and family care

Networking among healthcare professionals is essential to share clinical expertise. Dedicated time and resources should be anticipated for team debriefing and monitoring of burnout symptoms or moral distress among the healthcare staff once time permits. Also, the impact of restricted visiting policies on families and proxies should be considered, especially when the death of a loved one occurs during times of complete restriction of family visits.