Recommendations from the German Interdisciplinary Association for Intensive and Emergency Medicine—published on 25 March 2020
| Germany | |
| How | What |
| Planning ahead | A predefined decision-making process with clearly defined responsibilities is a prerequisite for consistent, fair, medical and ethical well-founded prioritisation decisions. Exclusion criteria for admission to the ICU should be identified before admission to the hospital. If possible, consult the family doctor beforehand to determine and reliably document whether hospital admission and, if necessary, transfer to an ICU is indicated and desired by the patient. If patients with COVID-19 are admitted primarily to a general ward, it should be recorded early as to whether IC therapy is indicated in case of clinical deterioration and/or covered by the patient’s will. |
| Proportionate care | IC is not indicated if the dying process has started inexorably, the therapy is considered medically hopeless because no improvement or stabilisation is expected or survival is linked to a permanent stay in the ICU. |
| Distributive justice and triage procedures: | If the resources are insufficient, a decision must be made as to which patients are treated with IC medicine and which should not (or no longer) be treated in that way. The prioritisation to all patients in need of IC should always be independent of where they are being cared for (emergency room, general ward, ICU) and be based on the principle of equality—not just within the group of COVID-19 sufferers and not permitted solely on the basis of age or social reasons criteria. |
| Maximising the global benefits | The prioritisation of patients should be based on the criteria of the clinical prospect of success, wavering treatment for those who have no or very little chance of success. There is a need for regular re-evaluation, in particular in the case of clinically relevant changes in the patient’s condition and/or when the ratio of needs to available resources has changed.If the ICU capacity is not sufficient, the team will have to decide which measures of the patient should be initiated and which ones already initiated need to be suspended. It must be ensured that there is adequate (further) treatment for those patients that are no longer candidates for IC. Prioritisation decisions must be based on the information on the patient’s current clinical condition, the patient’s will, medical history/comorbidities, general condition (eg, Clinical Frailty Scale), laboratory parameters and forecast-relevant scores (eg, SOFA score). Assess the prospect of success in terms of survival of IC or the achievement of a realistic therapy goal. |
| Respect for patient autonomy | Patients who refuse intensive therapy are not candidates. This can be based on the currently expressed, declared, previously verbal or presumed will respectively. |
| Protection of professionals | Offer support for all employees: clinical-ethical support, communication strategies and psychological support. |
| Precaution | Decisions should be made according to the multi-eye principle with participation of two physicians experienced in intensive medicine, by a representative of the nursing staff, if possible, and, if necessary, other technical representatives. Representatives of clinical emergency medicine and IC medicine must be involved. If possible, decisions should be made by consensus. |
| Transparency | It requires transparent, medically and ethically well-founded criteria, for the necessary prioritisation. Such an approach can relieve the teams and strengthen the public confidence in crisis management. The decisions should be transparent in the cross-professional and cross-functional group teams, transparent to patients and relatives (as far as possible) and properly documented. |
IC, intensive care; ICU, intensive care unit; SOFA, Sequential Organ Failure Assessment.