In the last few hours, the situation of COVID-19 in Italy and in the world has evolved rapidly, creating the conditions for developing new criteria for admission to intensive health treatments.
A few hours ago an official document (1) of the resuscitating doctors was disclosed, in collaboration with other figures, such as jurists etc, which outlines the principles to be followed regarding the admission and suspension of intensive treatments in hospitals, specially prepared for this moment awesome.
The reason why this guideline has become necessary is understandable: our health system is experiencing a moment of imbalance between the need to provide intensive care and the resources available, which are increasingly lacking today.
In particular, cases of acute respiratory failure are expected to increase over the next few weeks, dramatically amplifying this imbalance.
If this situation were to occur, rules were put in black and white to prepare scientific and objective criteria that identify who to give access to intensive care.
Such a scenario is comparable to the “disaster medicine” environment, in which ethical commissions have over time developed concrete indications for doctors and nurses engaged in difficult choices.
It is important to emphasize, before continuing, that these criteria will be applied only after medical personnel have made all possible efforts to increase the availability of resources (such as intensive care beds) and after any possibility of transfer of the patients to centers with greater availability of resources.
From the data collected during these first two weeks in Italy, about one tenth of infected patients require intensive treatment with assisted ventilation.
- It may be necessary to place an age limit on entry into intensive care. This criterion aims to give precedence to those who are most likely to survive, to increase the benefits for the greatest number of people as much as possible;
- The presence of multiple pathologies in a single individual must be carefully evaluated, as it can potentially greatly lengthen the time necessary to heal;
- Any wishes previously expressed by patients should be considered;
- In the event that a patient is assessed as “inappropriate” for access to intensive treatment, this does not mean that he is precluded from other types of treatment.
- Furthermore, these judgments are based solely on the extraordinary nature of the situation;The criteria for access to Intensive Care should be discussed and defined for each patient as early as possible, ideally creating a list. Any “DO NOT INTUBATE” instruction should be present in the medical records, just in case;
- Palliative sedation, used to relieve pain, becomes necessary in patients who have poor oxygenation of the organs with disease progression. In the event that a period of long-lasting agony should be expected, it is suggested that the patient be transferred to a non-intensive environment.
- All access to intensive care must be re-evaluated daily to ensure that it is the right choice.
For example, if a patient hospitalized for some time does not respond positively to prolonged treatments or his situation becomes more complicated, a possible decision change from intensive to palliative care must be considered.
This type of decision should be made promptly, but after a shared discussion by the treating team and, as far as possible, in dialogue with the patient and family members;
Once the emergency is over, it will be very important to “network”, exchange information between centers and individual professionals, analyze what has happened and monitor the psychological condition of the healthcare staff and the strong stress deriving from the moment just past.