대한중환자의학회

Toolkit for COVID-19— Kansas Department for

Health and Environment

(Kansas, USA)

Clinical ethics

recommendations

for the allocation

of intensive care

treatments in

exceptional resource-limited

circumstances—

Italian Society of

Anaesthesia, Analgesia

and Intensive Care

(SIAARTI)

The Australian and

New Zealand Intensive Care Society COVID-19

Guidelines v1

Ethical principles

concerning

proportionality of

critical care during the COVID-19 pandemic: advice by the Belgian

Society of Intensive Care Medicine

Department of Defense

COVID-19 practice

management guide

(US military hospitals)

COVID-19 pandemic:

triage for intensive

care treatment under

resource scarcity—Swiss Academy of Medical Sciences

COVID-19 rapid

guideline: critical care in adults—National Institute for Health and Care Excellence (NICE)

(UK)

1. Development of guideline process

By expert panel

By expert panel

Consensus-based

By expert panel

By expert panel

Based on previous

pandemic guidelines.

Adapted by experts

Evidence review and rapid consultation

2. Ethical Framework: distributive justice

« triage criteria for allocating resource  

Emphasizes maximising lives saved.

For patients of similar risk-benefit

category, allocation should be at random or first come, first served.

Maximize benefits for the greatest number of people.

Discusses possible need of using first come, first served during resource saturation.

Emphasizes

maximising lives saved.

Emphasizes

maximising lives saved.

Maximising lives saved is a decisive factor for purposes of triage.

Acknowledges

importance of equity

and protecting healthcare professionals.

3. Criteria for admission

Primarily medical

survivability determined by clinical judgement or formal means (eg, SOFA score).

Exclusion criteria for

severe conditions (eg, metastatic disease with poor prognosis, end-stage organ failure).

Age (with possible

upper limit);

comorbidities;

functional status.

Probable outcome

of the patient’s

condition; burden

of ICU treatment;

comorbidities;

likelihood of response to treatment.

Probable outcome of patient’s condition; frailty in elderly patients (eg, Clinical Frailty Score); cognitive

impairment in elderly patients; comorbidities

(particularly severe or life-limiting

conditions);

age alone should not be used

Each hospital should provide a specific plan regarding ICU

admission/exclusion

criteria.

Age and comorbidities

should be a factor

for provision of (any

form of) care for older patients.

Patients who are most

likely to survive to

discharge.

Specific exclusion

criteria given, primarily related to severe life-limiting underlying conditions; when no ICU beds available, a broader set of conditions and any patient aged >85

years, regardless of

underlying health.

Based on likelihood

of recovery. Frailty

(using Clinical Frailty Score or individualised

assessment of frailty if score not appropriate);

comorbidities; patient wishes.

4. Criteria adapt as demand changes

Yes. Hospitals should adapt based on resources.

Yes. Criteria need to

be flexible based on

resource availability.

Yes, living document will be continually revised.

Yes. Different criteria for different levels of capacity

Two sets of criteria

: (A) capacity limited, (B) no beds available.

5. Criteria for discharge

Yes. Reassess every 48 hours, with step down if exclusion criteria are met.

No explicit criteria,

de-escalation decisions should not be postponed.

Yes. Reassess every

48 hours with specific

clinical discontinuation

criteria given

No explicit criteria but stop when not achieving outcomes

6. Equality

between COVID-19 and other health conditions

Yes

Yes

Yes

Yes

Yes

Elective procedure and non-urgent hospital care ¯

7. Equality across healthcare system

Ventilated patients in chronic care facilities would not

be subjected to acute care triage guidelines.

Uniform policies are

required to avoid

inequalities

Partially—principles

established but

anticipate different

thresholds locally based on local capacity and demand.

While similar

criteria should apply

across all jurisdictions,

the ultimate decision-making

is at discretion

of senior intensive care medical staff.

Each hospital drafts

their own ethical

guideline

Each hospital

should have their own criteria and implement based on their own

resources

Yes. Uniform criteria

across the country

Hospitals should discuss sharing of

resources and transfer patients between units in other hospitals to ensure best use of critical care

8. Decision-making processes and support

Triage team (medically led and independent of treating doctor) will

make decisions on

resource allocation for individual patients, and its decision-making

scrutinised by a ‘review committee’.

Decision-making

responsibility is for

doctors managing

care—suggests second opinion for challenging cases.

Treating clinician

responsible for decision-making.

Shared decision-making with other clinicians

Decision to deny or

prioritise treatment

made by two or three doctors in consultation.

Psychological support offered to clinicians making triage decisions.

Keep register of all

triage decisions

Decisions to be made by multidisciplinary team, which may include input from ethicists.

Most senior clinician takes responsibility. Deviation from guidance possible

but must be clearly

stated why

Decision-making is by the critical care team.

9. Communication of decision

Yes. Communicate

decisions with patients and obtain their wishes.

Yes. Shared and

transparent decision-making process with

patients and relatives

Yes. Open

communication with

patient and family

Providers should avoid discussing rationing of

care at the bedside

Discussed but must be

transparent.

Open communication with patient and family and shared decision-making