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    Moral dilemma: Saving lives when resources are scarce

    Credit: Belga

    The infection and mortality curves in most countries have not yet been flattened. With the limited number of intensive-care units and respirators, hospitals need to be prepared for a situation when they might face difficult decisions and moral dilemmas about which patients to prioritize.

    Even under normal circumstances, when there is no pressure on ICU beds, disproportionate care is avoided. According to the ethical guidelines issued by the Belgian Society of Intensive Care Medicine, most patients in Europe who die in an ICU will do so after a decision not to initiate or to withdraw life-sustaining therapies.

    In general, writes the society, intensive care medicine should be reserved for patients in whom a good or at least acceptable outcome can be expected, after hospital discharge. In the coronavirus crisis, existing guidelines might need to be updated and adapted to the new situation so that medical staff will be prepared in time for the tough decisions they will have to take.

    The Belgian guidelines state that age plays a role but is not the only factor. “Many COVID-19 patients will be elderly, but age in itself is not a good criterion to decide on disproportionate care. Priorities should be decided based on medical urgency.”

    A controversial point in the guidelines is the approach to people in retirement homes. In Belgium and other countries these homes have been more hit by the virus than other places, resulting in high mortality rates. Although they have been closed to outside visitors, not enough testing of residents and staff was made.

    The total number of deaths in Belgium since the beginning of the pandemic jumped in the two last days to 3,019 (10 April) because of previously unreported suspected corona cases in retirement and care houses.

    According to the Belgian guidelines, an advanced care plan should be discussed with residents of retirement homes, or their relatives, in advance. “Patients for whom critical care would be disproportionate, are identified early, to avoid that they are sent to an overcrowded hospital unnecessary.”

    The Belgian Society of Intensive Care Medicine did not respond to a request from The Brussels Times for comment.

    Same principles, new situation

    For comparison, The Brussels Times contacted the Swedish National Board of Health and Welfare (Socialstyrelsen), where an expert group recently issued guidelines for intensive-care in the current crisis situation.

    ”In fact, these are not new guidelines but based on previous guidelines on life-sustaining care,” explained Dr. Thomas Lindén, Government Chief Medical Officer. “Normally, intensive care is only given to severely ill patients whose state of health might otherwise deteriorate.”

    Until now, at the request of the patient and relatives and after consultation with the physicians, such care was also given to patients with underlying conditions and a low probability of survival. But this cannot be done during the coronavirus crisis.

    ”In the current crisis, with the risk of lack of resources, we’ll might find ourselves in situations where medical staff have to apply existing guidelines in a different way and prioritize which patients will receive intensive-care,” he says. “The principles are the same but the situation is different.”

    The fundamental principles in the guidelines are respect of human life and equal treatment of all irrespective of chronological age, origin, social background and disability. The only criterion for rationing treatment is the medical assessment of expected survival.

    The guidelines divide patients in need of intensive care into three groups depending on their life expectancy after the treatment: More than 1 year (group 1), 6 – 12 months (group 2) and patients with low initial probability of survival (group 3). In the third group, intensive-care is normally only started in order to enable a new assessment in consultation with the relatives.

    In any case, on-going intensive-care can be reassessed and interrupted and the patient moved to another priority group. All patients shall be offered alternative care to intensive-care.

    Is it at all possible to make a reliable prognosis of expected life survival for patients in intensive-care?

    “Comparisons are often made between two patients but it’s never about applying a single parameter,” replies Dr. Lindén. “The most important factor in the assessment is the existence of multi-diseases with risk of organ failure.”

    What about persons in group 1 – will a younger person with much longer life expectancy be prioritized? “We don’t see this scarcity of resources today and expect that all persons in the group will receive intensive care.”

    Ideal world and reality

    The moral, religious, social and legal aspects of the treatment of the severely ill and dying patients are among the most difficult and widely discussed topics in modern medicine. The issues concerning end-of-life decisions present difficult dilemmas in the current crisis.

    “In an ideal world, everyone will receive treatment but in a crisis situation there are not enough resources. In view of this, the guidelines seem reasonable,” commented an EU official in her 50-ies to The Brussels Times.

    Another one in his 60-ies remarked that remaining quality of life is an important criterion. He added that lying sedated in an intensive-care bed for weeks, connected to a ventilator, can cause considerable damage and is also an ordeal for younger people. The use of ventilators should be avoided for so long as possible because of its side effects. “It has to be worth it.”

    A retired Swedish physician in his 70-ies stressed the conflict between religious-ethical rules on the sanctity of live and a cruel reality with lack of resources where death-and life decisions have to be taken. “Hopefully the curve will flatten so that the health-care system will manage to treat everyone in need without any drastic prioritisation.”

    What is the chance that I or those close to me will receive intensive care if we would need it during the corona crisis? asks Dr. Assaf Nini, an Israeli senior physician in intensive care, in an op-ed (Haaretz, 9 April). “The most important principle according to which physicians work is the sanctity of life. We have no right to determine what is a meaningful life.”

    But he admits that it is impossible to treat everyone in the time of a pandemic. “The principal approach is to save as many people as possible but those in the queue are the most severely ill and also younger people who might lose many life-years. Facing a unit full with patients, we are considering two factors only: the severity of the illness and underlying health issues.”

    He concludes that the possible outcomes of each decision are not necessarily life or death. “We are all more afraid of an interim situation with prolonged dependence on life-sustaining equipment. We know that it’s a terrible situation where the patients are lingering between death and life without full consciousness but with pain and anxiety.”

    M. Apelblat
    The Brussels Times