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Covid-19 & Critical Care: Ethical Dilemmas

As demand for critical care outstrips supply, doctors have had to agonise over rationing ICU beds and ventilators based on who has the greatest chance of survival. Guidance documents help in this regard. By Dr KK Aggarwal

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The Covid-19 pandemic has significantly increased the demand for acute and critical care services. This also means that there should be an increase in the capacity to provide care for more patients, including those requiring intensive care unit (ICU) admission, and mechanical ventilation.

This increase in capacity can be achieved by maximising resources across three domains: care spaces (beds), staff and physical equipment. This includes expanding ICU care into non-ICU spaces, utilising non-critical care trained staff to participate in delivering critical care and innovative approaches to obtain, conserve and increase the efficiency of physical equipment, including personal protective equipment (PPE, repeat or extended use of N95 masks) and mechanical ventilators. In some instances, such as in Italy, despite mobilising resources for surging capacity, demand so outpaced supply that overt rationing had to be done and who should get critical care had to be decided by doctors.

Some experts have published preliminary data to highlight the use of one ventilator for multiple patients. Use of this measure as a life-saving measure in patients with Covid-19 could be complicated if patients are not matched well in terms of their ventilator settings.

All hospitals facing the potential of an acute surge due to Covid-19 should have a legal and ethical process to tackle the allocation of scarce resources such as ICU beds and mechanical ventilators. Most individual states in the US have guidance documents which can be adapted for local institutions.

The general principles that guide scarce resource allocation policies include: Maximisation of lives saved and/or life years saved; transparency; stakeholder and public input; separation between the clinical team and the triage process (ethics committees for difficult triage decisions) and robust palliative care and supportive measures for patients who are not provided with critical care resources.

The role of informed consent is very important. It is a process of communication between a clinician and a patient or surrogate decision-maker that results in the patient agreeing or refusing to undergo a specific medical intervention. The primary ethical justification for obtaining informed consent from patients is to respect their right to determine what happens to their bodies (respect for autonomy). This entails a right to approve or refuse treatments that clinicians judge to be medically reasonable.

Patients who lack the capacity to make an informed decision (due to critical illness or medications) are unable to participate in medical decision-making because they cannot understand the choices available or the potential consequences of their medical decisions. Instead, the medical team and persons who are most acquainted with the patient (e.g., family) should attempt to reconstruct the patient’s judgement by analysing their prior statements, values, and beliefs.

Let us imagine a hypothetical scenario involving two patients with respiratory failure, one 65 and the other 85 with coexisting conditions. If you have just one ventilator, who will you intubate? In addition to the number of co-morbidities, the hospital also considers the severity of respiratory failure and probability of surviving prolonged intubation. It will dedicate its limited resources to those who both stand to benefit the most and have the highest chance of surviving. Age was often given the most weight. There were reports from Italy about an 80-year-old who was “perfect physically” until he developed Covid-19-related respiratory failure. He died because mechanical ventilation could not be offered.

Contributing to the resource scarcity is the prolonged intubation many of these patients require as they recover from pneumonia—often 15 to 20 days of mechanical ventilation, with several hours spent in the prone position and then, typically, a very slow weaning.

In the midst of the outbreak’s peak in northern Italy, as physicians struggled to wean patients off ventilators while others developed severe respiratory decompensation, hospitals had to lower the cut-off age—from 80 to 75 at one hospital. The agony of these decisions prompted several of the region’s physicians to seek ethical counsel. In response, the Italian College of Anaesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) issued recommendations under the direction of Marco Vergano, an anaesthesiologist and chair of the SIAARTI’s ethics section.

The committee did not suggest that age should be the only factor to determine resource allocation. It acknowledged that an age limit for ICU admission may ultimately need to be set. Ventilating patients who were extremely unlikely to survive meant denying ventilatory support to many who could. Nevertheless, even under the direst circumstances, rationing is often better tolerated when done silently. Participants seemed to value saving those with the greatest chance of short-term survival, followed by saving those who, thanks to a relative lack of coexisting conditions, have the greatest chance of long-term survival.

No matter the ethical framework, should such resource scarcity occur, there are many scenarios that will still feel morally untenable, particularly in the face of heightened prognostic uncertainty. Would you remove a ventilator from one patient who was having a rocky course, for instance, to give it to another in the throes of an initial decompensation? Would you preferentially intubate a healthy 55-year-old over a young mother with breast cancer whose prognosis is unknown?

In an effort to address such quandaries, experts have offered three process-related principles that seemed as imperative as the ethical ones.

The first and most important is to separate clinicians providing care from those making triage decisions. The “tri­age officer”, backed by a team with expertise in nursing and respiratory therapy, should make resource-allocation decisions and communicate them to the clinical team, the patient and the family. Second, these decisions should be reviewed regularly by a centralised state-level monitoring committee to ensure that there are no inappropriate inequities.

Third, the triage algorithm should also be reviewed regularly as knowledge about the disease evolves. If we decided not to intubate patients with Covid-19 for longer than 10 days, for example, but then learned that these patients need 15 days to recover, we would need to change our algorithms.

All these lessons will have to be learned through trial and error now.

—The writer is President, Confederation of Medical Associations in Asia and Oceania, and former National President, IMA

Lead picture: UNI

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