Viral pandemics tend to be a serious threat to the stability of health systems, imposing extraordinary and sustained demands on them, which can exceed the service capacity regarding all their available supplies and technologies, as well as trained human/professional resources. Pandemics pose the enormous challenge of balancing equality of all people and equity in distribution of risks and benefits among them.
In the last months, the many unexpected cases of Covid-19 in the population, forced physicians to evaluate best practices for optimizing the use of available means and resources. Thus, considering the unavailability of intensive care beds and respirators for all individuals, affected or not by the disease, it has been essential to establish clinical and ethical criteria for the best use of them, to enhance results and generate the best possible benefits.
During this current pandemic, in many countries, physicians have encountered dilemmas regarding the allocation of scarce resources among the most critically ill patients in their own facilities.
They had to make difficult decisions with the primary goal of saving as many lives as possible and with the secondary goal of saving the most life-years possible, always in the respect for human dignity of all individuals.
In countries such as Italy, China, the United Kingdom, and Spain, frontline medical staffs have faced a dilemma throughout the Covid-19 crisis: Which patients should be treated first when resources are stretched to the limit? Should you save as many patients as possible, or save patients with the most urgent need?
Physicians in Italy, the first European country plagued by the corona pandemic, were overwhelmed with difficult triage dilemmas as around 10% of those effected with Covid-19 required some form of respiratory assistance. On 7 March 2020, the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care published new guidelines regarding the triage of patients due to under availability of resources. “It is a scenario where criteria for access to intensive care and discharge may be needed, not only in strictly clinical appropriateness and proportionality of care, but also in distributive justice and appropriate allocation of limited healthcare resources.”
According to the mass casualty incident model of triage, privilege was given to those with the ‘greatest life expectancy’, thus abandoning the traditional ‘first come, first served’ model. Unfortunately, due to the high number of patients needing respiratory support, these decisions occurred at great frequency and at a fast pace. Factors such as age, comorbidities and functional were evaluated in the decision for critical care admission.
On 20 March 2020, in response to the Covid-19 pandemic, the National Institute for Health and Care Excellence in the UK published the Guideline with clinical decision-making. This Guideline provided a clear and detailed algorithm for the allocation of critical care beds and treatment of critical patients during the Covid-19 outbreak. The basis of the Guideline was to maximise patient safety and appropriate use of resources. Admission to an intensive care unit was based on some assessment of frailty, comorbidities and likeliness to recover from the intensive treatment.
Other guidelines were, then, developed around the world and helped clinicians decide about one of the greatest responsibilities we can face during our work: to decide who to treat and who not…
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