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Table 1 Synposis of key aspects

From: Ethics guidelines on COVID-19 triage—an emerging international consensus

 ItalySwitzerlandAustriaGermanyUKBelgium
Issuing bodyItalian 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)NICEBelgian Society of Intensive Care Medicine
EquityAll 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 criteriaAll 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
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