The Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (Italian acronym: SIAARTI) has just published its "Clinical Ethical Guidelines for the Admission and Suspension of Intensive Care Treatment in Exceptional Conditions of Imbalance between Needs and Available Resources" in the context of the Covid-19 epidemic.
Made in collaboration with our partners at esanum.fr and esanum.it
The following text includes excerpts from the SIAARTI document titled "Clinical Ethical Guidelines for the Admission and Suspension of Intensive Care Treatment in Exceptional Conditions of Imbalance between Needs and Available Resources" (in Italian: Raccomandazioni di etica clinica per l’ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili) and the reactions and comments of an anesthesiologist-resuscitator working near the epidemic epicenter in Italy. Our esanum editorial partners in France and Italy have synthesized articles to provide our visitors with a reader's digest on the key information coming from Italy in recent days regarding the Covid-19 situation.
Triage areas, physicians crying over their helplessness...In Lombardy, the heart of the coronavirus epidemic in Italy, the hospital beds shortage is forcing physicians to make increasingly difficult choices.
In an interview published in the daily newspaper Corriere della Sera, Christian Salaroli, an anesthesiologist at a hospital in Bergamo, explained: "The choice is made inside an emergency room used for mass events, where only COVID-19 patients enter. If a person is between 80 and 95 years old and suffers from severe respiratory failure, they probably won't make it."
On Monday (March 2nd, 2020), over 70% of the 7,900 recorded cases were in Lombardy. Everything is being done to increase hospital capacity: entire wards are being converted, operating rooms are being transformed into intensive care units. Physicians are working around the clock to replace their colleagues who fall ill.
But when there aren't enough respirators for everyone, it's time for tough choices. In some cities (Bergamo, Lodi, Pavia) hospitals are almost saturated and the epidemic is spreading at a dizzying pace. The usual rule - "first come, first served" - no longer makes sense in this context.
Priority should be given to treating younger, otherwise healthy patients rather than older patients or those with pre-existing conditions... By giving these guidelines, SIAARTI wants to avoid physicians being left alone to make "such difficult ethical choices," says Luigi Riccioni, an anesthesiologist and head of the SIAARTI ethics committee.
According to forecasts of the ongoing coronavirus epidemic in some Italian regions, the coming weeks will see an increase in acute respiratory failure cases in some places of such magnitude that it will create a huge imbalance between clinical needs and the availability of intensive care resources.
Criteria for access to intensive care may be required.... Such a scenario is quite similar to the field of "disaster medicine" for which ethical deliberations have developed over time a wide range of concrete guidelines for physicians and paramedics engaged in difficult choices.
The aim is to guarantee intensive treatment to patients with the greatest chance of therapeutic success, thus promoting "greater life expectancy". This means that it is not necessary to follow the "first come, first served" criterion for admissions to intensive care.
It is understandable that caregivers, in terms of culture and training, are not accustomed to reasoning with these triage criteria. The availability of resources does not generally play a role in the decision-making process.
The objective of the recommendations is also to relieve clinicians of some of the responsibility for making choices, which can be emotionally burdensome.
I work near the epicenter of the SARS-CoV-2 outbreak. For the past two weeks, I have been working continuously, without even having time to understand what is going on around me. There were four of us on my team for several days. The others were either hospitalized with COVID-19 or quarantined.
I lost track of the patients I saw, the intubations I did, the calls I answered. In the meantime, around me, the hospital was transformed, walls came up, new services were organized overnight. Everything has been transformed, it's almost surreal.
This is to make you understand that in this extremely urgent situation, I am up to my neck in it, with my colleagues, the tireless nurses, and all the hospital staff who are doing their best. We are all important in this phase, even those who are in the kitchen and make us smile by putting a piece of cake on the tray.
I've been thinking about all the hard decisions I've already had to make over the past two weeks. I thought about all those discussions with colleagues who were struggling to understand what kind of hell we are in. I thought that the imbalance between needs and available resources was already there.
I made some notes on that document, which I'd like to share with you. Nothing scientific or particularly refined, just the considerations of someone who is touching this emergency with his own hands. I hope that they will be useful to those who, in the coming weeks, will find themselves in my situation.
The extraordinary criteria for admission and discharge from intensive care are flexible and can be adapted locally to the availability of resources, the practical possibility of transferring patients, the number of current or announced admissions. These criteria cover all patients, not just those infected with Covid-19.
Always be clear about protocols and guidelines, but never forget the word "flexibility". The way you work may change several times in the same day due to clinical, logistical or organizational problems.
There's been talk in the media for the past two weeks of solving the emergency by increasing the number of ICU spaces. But bed allocation is a complex choice because an excessive increase in ICU beds would divert resources, attention, and energy away from ICU patients alone. Every ICU patient needs resources that are difficult to find, organize and coordinate.
There is also the foreseeable increase in mortality from conditions not related to the current epidemic, due to reduced surgical and ambulatory activities.
This is a matter of reserving resources that may be very scarce for those most likely to survive and, secondly, for those who may have more life-years saved.
In addition to age, comorbidity and functional status must be assessed. It is conceivable that relatively short recovery time in healthy people becomes potentially longer while resources are also needed for cases of elderly, frail or severely co-morbid patients. If that happens in your hospital, access to the emergency department will be continuous. You will have stable patients with respiratory failure within half an hour who will need to be intubated. Everything will happen at the speed of light, and you will need to stay lucid.
Despite the possibility of using the anesthesia machines in the operating rooms, you will still have limited space. Save them for those who have a better chance of recovery. Your ICU will receive people in their 90s and 40s, cancer patients and others without co-morbidity. You won't be able to help everyone, you will have to choose.
When it comes to triage in a major emergency, I've learned so many acronyms, decision patterns... All these things don't give you any idea of what it means to choose between who to help and who not to help. I understood this at Linate in 2001 [an event of a collision at the Milan airport that left 118 dead]. These days it's all coming back to me. The possibility of advance directives expressed by patients who are already chronically ill must be carefully examined.
For patients for whom access to intensive care is deemed "inappropriate", the decision to cap care must be justified and documented. The "ceiling of care" placed before mechanical ventilation should not preclude lower-intensity care. As for explaining this decision, it should be done, but...When all resources are scarce, it is not easy to find a way to explain to the family that their grandfather was not admitted to the intensive care unit to make room for a younger patient, who is more likely to make it through and therefore occupy the bed for a shorter period of time. It's not easy to find the time to do that, as phones and alarms ring all the time.
It is also not easy to find the place to do it, because anyone who enters the hospital risks being contaminated. As far as communication is concerned, in my humble opinion, special teams should be set up. Don't ask us to do that, not now. Luckily, I've never experienced it, except in my grandfather's stories, but it all seems very similar to what we experience in war. The goal is to increase the number of survivors because it is not possible to save everyone.
In the decision-making process, it can be useful to have a second opinion (even over the phone) from colleagues with a particular experience. An excellent recommendation in theory, but it is certainly difficult to put into practice.
Criteria for access to intensive care should be defined for each patient as soon as possible. Ideally, a list of patients should be created who will be considered "worthy" of intensive care when clinical deterioration occurs (provided that the availability of resources at that time allows it).
A possible "do not intubate" instruction should be present in the medical record, should clinical deterioration occur precipitously and in the presence of caregivers who do not know the patient.
Another recommendation: using the hospital's database, always look at who is accessing the emergency department and why. If you have a 30-year-old male in the ER on suspicion of Covid-19, think of him/her as a potential candidate for intensive care. He may go home or require mechanical ventilation. You don't know that right away, but you can imagine different scenarios very quickly. And if you're a resuscitator like me, the scenario you imagine will always be the worst.
In the same way, decide right now who, regardless of their evolution chart, will not have access to the ICU. Decide and share that decision, so that everyone acts in a coordinated way. In this situation, no one can be the "bad guy" blocking access to the ICU. This happened to me recently, I looked like a bad guy in someone's eyes. I've made some tough decisions, very tough decisions, but grounded in science and in good conscience. And my hands shake just thinking about it.
Palliative sedation in hypoxic patients with progressive disease is necessary and should follow existing recommendations. If a non-short-term agonal period is anticipated, transfer to a non-intensive environment should be considered. Any access to intensive care should, in any case, be considered as a "trial intensive care setting" and should be subject to a daily reassessment of appropriateness, treatment goals and proportionality of care.
In the event that a patient does not respond to prolonged initial treatment or whose condition becomes severely complicated, a decision to "therapeutic withdrawal" from intensive care to palliative care - in a scenario of exceptionally high patient influx - should not be postponed.
The decision to withdraw should be discussed and shared as collegially as possible by the treatment team and - to the extent possible - in dialogue with the patient (and family members) but should be made in a timely manner. As I mentioned earlier, the situation I've been in for the past two weeks makes it hard to imagine a team meeting to make collective decisions.
I hope this time will be used to organize the other hospitals to deal more effectively with the emergency. Here, so far, everything has happened at the speed of light, including the difficult decisions.
The use of ECMO (extracorporeal membrane oxygenation) as a resource-consuming alternative to ordinary hospitalization in the intensive care unit, under conditions of extraordinary influx, should be reserved for extremely selected cases with a relatively quick withdrawal prediction.
Ideally, it should be reserved for high-capacity centers, where the ECMO patient absorbs proportionally fewer resources than in a less specialized center. Nothing to add. But keep this in mind before you pick up the phone and imagine a transfer to a center with ECMO.
When working conditions permit, at the end of the emergency, it will be important to devote time and resources to debriefing and monitoring the operators' burnout and moral distress.
A lot of unverified information leaks into social networks. Physicians who, instead of consulting the scientific literature, gather information about the pathology from what is said on television by self-proclaimed experts, may then discuss it in social gatherings.
Communication is important, as it is in all fields. It is fundamental in this situation. All health professionals should, in my opinion, engage with and use the media with care and in an effective way.
The impact on family members admitted to the Covid-19 ICU must also be considered, especially in cases where the patient dies at the end of a period of total visits restriction.
Based on my experience, it is very difficult to imagine being able to care for the relatives of deceased patients as well. It may be fatigue, but these days I can't stop thinking about excerpts from various war films, in which an officer knocks on the family door to announce the death of a fallen soldier. I think that should happen, that someone should be prepared to give that news to the families and to do it in the best way possible.
You can't think about doing it in a small hospital room, you can't think about doing it behind a mask, you can't think about doing it without taking the time. You can't think about doing it over the phone, as I've been doing for the last few days. Even death, no matter how painful, has its own dignity.
1. SIAARTI. Raccomandazioni di etica clinica per l’ammissione a trattamenti intensivi e per la loro sospensione, in condizioni eccezionali di squilibrio tra necessità e risorse disponibili - versione 01. 06/03/2020