Clinical ethics recommendations for the allocation of intensive care treatments in exceptional, resource-limited circumstances: the Italian perspective during the COVID-19 epidemic

Tracheostomy in the COVID-19 pandemic

“…Tracheostomy offers several advantages in terms of improved comfort management, reduced sedative, and paralytic medical support, reducing death space. Moreover, tracheostomy reduces airways resistance, lessening the work of breathing optimizing the tracheal secretion control [5].…”

Age, comorbidity, frailty status: effects on disposition and resource allocation during the COVID-19 pandemic

“…Whereas disposition decisions should ideally be independent of available resources, they pose an even greater challenge in times of resource scarcity due to COVID-19. Although age and comorbidity are considered to be important outcome predictors in Swiss [30] and Italian [31] guidelines on resource allocation, frailty intensive care assessment (with the Clinical Frailty Scale) has so far only been endorsed by guidelines of the UK National Institute for Health and Care Excellence (NICE) [32], as well as the guidelines of the German Society of Intensive Care [33].…”

The ethical dimension of prioritization and allocation decisions within the context of the COVID-19 pandemic

“…17 In many countries, the serious epidemiological situation has led to the publication of clinical guidelines and experts' statements on making decisions on key issues including priority access to treatment, allocation of medical resources, and, in particular, the way mechanical ventilation and other advanced medical technologies (eg, ECMO) should be utilized. [18][19][20][21][22] In Poland, the Experts of the Polish Bishops' Conference on Bioethics announced the statement on the distribution of emergency measures in the event of a pandemic caused by SARS-CoV-2. 23 The guidelines not only provide clinical advice but also discuss relevant ethical considerations: how to maximize benefits; when to discontinue futile therapy (sometimes also referred to as persistent therapy); the moral division into ordinary (obligatory) and extraordinary (optional) measures-the last may be stopped; respect for autonomy (verification of the patient's living will, respecting the patient's or the proxy's decision to discontinue therapy or provide a "do not intubate" order, also stressing the doctor's duty to justify and document this in written form and to inform the patient and his or her loved ones accordingly); collective responsibility for decision making; separating a triage officer / team from clinicians; prioritizing a specific group (eg, healthcare workers as a high-risk group, research participants); not relying on a first-come, first-served approach; openness to guideline verification and swiftly responding to new research data; applying the same ethical principles to all patients, regardless of the fact whether they have been infected with SARS-CoV-2 or not.…”