The Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care just published the most extraordinary medical document I’ve ever seen.
To help people from Germany to America understand what we’re about to face, I am publishing translated extracts here.
A week ago, Italy had so few cases of coronavirus that it could give each stricken patient high-quality care.
Today, some hospitals are so overwhelmed that they simply cannot treat every patient. They are starting to do wartime triage.
Here’s the guidance for that.
“It may be necessary to establish criteria of access to intensive care not just on the basis of clinical appropriateness but inspired by the most consensual criteria regarding distributive justice and the appropriate allocation of limited health resources.”
“This scenario is substantially comparable to the field of ‘catastrophe medicine,’ for which ethical reflection has over time stipulated many concrete guidelines for doctors and nurses facing difficult choices.”
“In a context of grave shortage of medical resources, the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.
It’s a matter of giving priority to ‘the highest hope of life and survival.'”
1) The extraordinary criteria of admission and discharge are flexible and can be adapted in accordance with the local availability of resources.
These criteria apply to all patients in intensive care, not just those infected with CoVid-19.
2) “Allocation is a very complex and delicate choice. […]
The foreseeable increase in mortality for clinical conditions not linked to the current epidemic due to the reduction of chirurgical activity and the scarcity of resources needs to be taken into consideration.”
3) “It may become necessary to establish an age limit for access to intensive care.
This is not a value judgments but a way to provide extremely scarce resources to those who have the highest likelihood of survival and could enjoy the largest number of life-years saved.”
“This is informed by the principle of maximizing benefits for the largest number.
In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”
4) “In addition to age, the presence of comorbidities needs to be carefully evaluated. It is conceivable that what might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”
“For patients for whom access to intensive care is judged inappropriate, the decision to posit a ceiling of care nevertheless needs to be explained, communicated, and documented.”
I spent many years sitting in seminar rooms thinking about questions of distributive justice.
Let me be honest: It’s left me not one bit wiser about what to do in these kinds of dramatic circumstances. So I don’t don’t mean to pass judgment on the contents of this document.
BUT here’s the point I do want everyone to take away from this:
Doctors in America will likely be faced with similarly heartbreaking dilemmas very soon.
But we can avoid that if we:
- Start engaging in extreme forms of social distancing
- Radically expand ICU capacities
The moral choices involved in figuring out who gets care when hospitals do not have the resources to treat all critical patients are heart-breaking.
But the moral choices involved in doing what we can today to avert that situation are straightforward.
Cancel everything now.