by Mario Picozzi, MD Ph.D., Federico Nicoli, Ph.D., Paolo Severgnini, MD
The Varese Hospital is located in northern Lombardy and has a total of 582 beds. Last April, 206 of these were dedicated to positive Covid19 patients and 47 were reserved for the Intensive Care Unit (ICU).
During the emergency, we have chosen to carry out triage with reference to the criterion of proportionality. This criterion considers both clinical indications and patient preferences, along with treatment costs. We have decided to use this criterion for two reasons: first of all, it actually allows a choice on a case-by-case basis, without falling into arbitrariness; in addition, it is respectful of both objective clinical criteria and the peculiarity of the patient.
The clinical criteria refer to the urgency and efficacy of the intervention: they enable the staff to evaluate what the patient’s prognosis will be if they undergo invasive mechanical ventilation operations to be implemented in the ICU. The efficacy of the intervention depends on the patient’s previous comorbidities, such as severe diabetes, heart disease, nephropathy or liver disease. In this perspective, the patient’s age is not an exclusive criterion in the decision-making process. However, we need to recognize that an older patient usually has more pathologies than a younger patient; as a consequence, the prognosis of the former is likely to be less favorable than the latter. Thus, if we ground our decision on clinical criteria only, when we compare two patients, the most vulnerable will always be at a disadvantage.
The experience in our hospital attests that in early days the clinical course of COVID19 patients in ICUs follows a very differentiated path which makes it difficult to predict an evolution. There are elderly patients who stabilize in the first days and then take a sudden turn for the worse. There are young patients who get over the acute phase after 20 days in ICUs, entering a rehabilitation phase in other units and after a few days there must go back to ICUs for unexpected deterioration. Because of this complexity, in order to ensure the best allocation of available resources, patients require continuous monitoring along with the review of all decisions already taken.
The patient’s history and his will would seem impractical to use in times of pandemic, given the urgency of the situation. Reality has shown, at least in our experience, that it was not impossible to retrieve the patient’s history. Certainly, some patients arrive in the Emergency Room in very critical clinical conditions which impose an immediate transfer to the ICU; however, most of them are first admitted to other departments for a diagnostic classification. That is the crucial time to make a good decision through an interdisciplinary and shared judgment by those in charge of the patient, a decision which needs to consider the patient’s history. The patient or his family on his behalf can tell his history. In this evaluation we need to examine the treatment burdens, in particular the patient’s ability to withstand the invasive therapies if he were to be hospitalized in ICU.
The team in charge to assess the proportionality of the intervention and therefore the adequacy of the transfer to ICU must be composed by the doctors responsible for the patient’s care, both those who are currently managing it (for example the infectious disease specialist or the pulmonologist) and those who will have to manage it (the intensivist). Since they are aware of the actual situation in their respective departments, the inclusion of all these professionals ensures a shared evaluation compatible with the overall scenario of the entire hospital.
Proportionality combines several criteria enables an accurate case-by-case evaluation, considering the patient’s changing conditions and the clinical progression attempts without discriminating the most vulnerable subjects. If we contemplate his whole existential and clinical situation, a young handicapped patient would not be penalized as everybody might think; on the contrary he would benefit from this approach. In most cases, if we ground a decision on clinical criteria only, because of his comorbidities the final evaluation would penalize him when compared his situation to other patients’. If we used equity as a yardstick based on just a few clinical indicators, as a matter of fact we would always discard the most vulnerable patients. Therefore, it is not a matter of applying new criteria during an emergency, but rather to apply the proportionality criterion routinely used, while bearing in mind the limited resources available. This criterion is not generic and standardized; however, its application recalls general factors in any case considered.
In this perspective, for several reasons it is not acceptable that the demanding and dramatic moral decision to allocate ventilators is taken by an outsider committee composed by people who are not directly involved in the care of the patient. The first reason concerns the meaning of giving care, which necessarily means attention to the patient. How can the physician be deprived of his responsibility to provide care by an external committee? Secondly this perspective would sanction the reduction of the medical act to a technical performance. In complex cases, this would legitimate that a doctor does not take on the inevitable moral responsibilities of his profession. Finally, it is said that being involved also emotionally, does not help in making good decisions. But a good decision is made not because we neutralize the subjects, but rather because we also identify and interpret one’s emotions to reach an ethically pertinent judgment. When in front of crucial and demanding choices, doctors usually do not ask to be relieved of their responsibility but they want to be accompanied and not left alone.
In this frame, the role of the ethics consultant comes in as a member of the clinical team; his task it to help and facilitate the attending physicians to take responsibility for the decision. The attending physicians will disclose their decision to the patient and his relatives through a participatory and empathetic communication, which will not be cold and detached as would be in the case of an external committee. The proposed decision-making process would also help to soothe the severe moral distress felt by many care givers in this pandemic phase. The moral dilemmas at the root of this experience must be thoroughly handled within the department through debated and shared and not simply delegated to a psychotherapy outside the working context.
In this perspective, we achieve to give reasons for the role of the ethics consultant. Differently, he would have a role only when defining the guidelines prior an epidemic and he would be totally absent in the direct management of triage during the epidemic itself.