Italy | |
How | What |
Planning ahead | Care should be discussed and defined for each patient as early as possible, ideally creating in time a list of patients who may come to benefit of intensive care (IC) when and if clinical deterioration occurs, provided that the availability at that moment allows it. It should be considered also the foreseeable increase in mortality due to other clinical conditions because of the reduction of surgical and elective activity and the scarcity of intensive resources. |
Proportionate care | Consider clinical appropriateness and proportionality of care. If patients have no criteria for admission in the ICU, consider palliative care and transfer to another ward. |
Distributive justice and triage procedures: | Consider criteria of distributive justice and appropriate allocation of healthcare resources. This means not necessarily having to follow ‘first come, first served’. The criteria apply to all IC patients whatever the pathology. |
Prioritising the longest life expectancy | Beyond clinical criteria and proportionality of care, criteria of ‘fair distribution’ are essential, guaranteeing IC treatment to those with the greatest probability of therapeutic success, giving privilege to ‘the longest life expectancy’. The need for IC must be integrated with other elements of clinical suitability, including: the type and severity of the disease, the presence of comorbidities, the impairment of other organs/systems and their reversibility, functional status. It may be necessary to set an age limit for ICU admission. Invest ‘ in primis’ in those patients with greater probability of survival and secondarily, in those who may have ‘greater number of years of life saved’. If a patient does not respond to initial treatment or has a severe complication, the decision of treatment withdrawal and remodulation to palliative care should not be postponed. ECMO should be reserved for extremely selected cases. |
Protection of professionals | It is important to prevent burnout of the professionals. |
Precaution | The decisions should be discussed and shared by the treating team and, as far as possible, in dialogue with the patient and family. Check for previously expressed patient will. In situations of special difficulty and uncertainty, look for a second opinion from experienced interlocutors. |
Respect for patient autonomy | |
Transparency | Patients and their families must be informed of the extraordinary nature of the measures in place, due to a duty of transparency and maintenance of trust in the public health service. |
ECMO, extracorporeal membrane oxygenation; ICU, intensive care unit.