key: cord-0771034-qzp9a2qi authors: Marckmann, Georg; Neitzke, Gerald; Schildmann, Jan; Michalsen, Andrej; Dutzmann, Jochen; Hartog, Christiane; Jöbges, Susanne; Knochel, Kathrin; Michels, Guido; Pin, Martin; Riessen, Reimer; Rogge, Annette; Taupitz, Jochen; Janssens, Uwe title: Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic: Clinical and ethical recommendations of DIVI, DGINA, DGAI, DGIIN, DGNI, DGP, DGP and AEM date: 2020-07-29 journal: Med Klin Intensivmed Notfmed DOI: 10.1007/s00063-020-00709-9 sha: 1243b7a7e032129b1a091089f14ab2980ef7003b doc_id: 771034 cord_uid: qzp9a2qi In view of the globally evolving coronavirus disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary group of authors with the support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethicolegal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supraindividual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. The assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient’s general health status prior to the current illness. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s00063-020-00709-9) includes Fig. 1 “Documentation support for prioritisation in case of resource scarcity” and Fig. 2 “Flowchart—decision-making in the case of insufficient intensive care resources” for download. Contributions and additional material are available at www.springermedizin.de. Please enter the article title in the search field, the additional material can be found under “Ergänzende Inhalte”. In the face of the globally evolving Coronavirus Disease 2019 (COVID- 19) pandemic, German hospitals rapidly expanded their intensive care capacities. 2nd revised version S1 Guideline-17 April 2020 (AWMF Registration Number 040-013). The board of the German Academy of Ethics in Medicine (AEM) supports the recommendations with a majority vote. G. Marckmann, G. Neitzke and J. Schildmann contributed equally to the work. This article is published simultaneously in English (https://doi.org/10.1007/s00063-020-00709-9) and German (https://doi.org/10.1007/ s00063-020-00708-w). Extended author information available on the last page of the article. However, it seems still possible that even an optimal use of the increased intensive care resources will not be sufficient to treat all patients who require them [13, 19] . Consequently, the need for guidance on the potentially resulting dilemmas prompted the authors, in coordination with the boards of directors of the participating scientific societies, to develop recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic [17, 18] . The guidance is intended to support responsible decision makers with medically and ethically justified criteria and procedures. Experts from clinical emergency medicine, intensive care medicine, medical ethics, law, and further disciplines were involved in drafting the recommendations. Several experts reviewed a prior version; they are listed at the end of the document. These recommendations will be further developed on the basis of new scientific evidence, practical experience and other relevant developments. The current German version can be found at www.divi.de and www.awmf.org (S1 guideline, register number 040-013) [8] . Comments on the recommendations are explicitly encouraged. Medical decisions must always be based on the needs of the individual patient (see 2.1). In addition to this patient-centred approach, prioritisation in the event of a resource shortage requires a supraindividual perspective (see 2.2). If the available resources are not sufficient-neither in-house nor regionally or transregional-inevitably a decision has to be made which critically ill patients should be treated with intensive care and which should not (or no longer) be treated withintensive care. Ifresources are scarce, the following situations may develop: 4 No intensive care resources available, but resources in the emergency room (e.g. temporary ventilation therapy until transfer) 4 No intensive care resources available, no resources in the emergency room, but resources in surrounding hospitals (e.g. coordination by a regional task force of the respective crisis management team) 4 No intensive care resources available, no resources in the emergency room, no accessible additional resources. Ifnoresources are available afterchecking the above-mentioned provisions, a deviation from the usual patient-centred approach to treatment decisions becomes necessary. This poses enormous emotional and moral challenges for the treatment team. In this case, decisions about the allocation of the scarce resources must be made in analogy to triage decisions in disaster medicine. This prioritisation requires transparent, medically and ethically wellfounded criteria [11, 14, 21, 22] . Such an approach can support the hospital staff involved and increase public trust in the hospitals' crisis management. The prioritisation is explicitly not intended to assess the value of people or human lives. Instead, the prioritisation shall allow as many patients as possible to benefit from the (limited) medical resources under the conditions of a pandemic crisis. The prioritisation of patients should therefore be based on the criterion of clinical prospect of success [18] . Accordingly, those patients who have a very low chance of survival will-if unavoidable-not be treated with intensive care. Priority will be given to those patients who are more likely to survive when receiving intensive care. The clinical prospect of success must be assessed as carefully as possible for each individual patient. Prioritisations The following procedures for prioritisations only apply if intensive care capacities are not sufficient for all patients. In clinical practice, a distinction can be made between: 1. Decisions about for which patients intensive care treatment should be initiated and 2. Decisions about for which patients ongoing intensive care treatment should be withdrawn. Both decisions are related, and the following criteria and procedures apply to both. The decisions have to be re-evaluated regularly, at intervals appropriate for COVID-19, and adjusted, where applicable; in particular: 1. In the case of clinically relevant changes in the patient's condition and/or 2. When the ratio of needed to available resources has changed. It must be ensured that appropriate treatment is available for those patients who cannot, or can no longer, be treated in intensive care units [6] . A predefined decision-making process with clearly assigned responsibilities is a prerequisite for consistent, fair, medically and ethically well-founded prioritisation. Therefore, whenever possible, the decisions should be made according to the multiple-eyes principle including: 4 Two physicians experienced in intensive care medicine, if possible, including practitioners from the involved clinical departments and specialties, In view of the globally evolving coronavirus disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary group of authors with the support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethicolegal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supraindividual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. The assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient's general health status prior to the current illness. Prioritisation · Triage · Scarcity · Justice · Intensive care medicine Fig. 1 ). Prioritisations must be made based on the best available information. [20] In addition, current experiences and knowledge must be taken into account, in particular regarding treatment options and chances of success in COVID-19. The decision-makingstepsand the criteria to be used are as follows (see also flowchart in . Fig. 2 ). Step 1: Assessment of the need for intensive care treatment 4 Respiratory or haemodynamic failure Results: a) Intensive care treatment required → step 2 b) Intensive care treatment not required → transfer, for instance, to general ward Step 2: Assessment of the patient's individual clinical prospect of success, i.e. the probability of surviving the current illness through intensive care treatment. The diseases and conditions mentioned below do not represent exclusion criteria for treatment in contrast to other triage protocols [3] . Rather, an overall assessment should consider all important factors influencing the prospect of success (current illness, comorbidities, general health status). Pre-existing diseases are only relevant if they influence the probability of surviving the current illness. This assessment also serves as the basis for any prioritisation which may be necessary (step 4). The following criteria-depending on the degree of their expression-are indicators of a poor clinical prospect of success of intensive care treatment: 4 Step 3: Check informed consent to intensive care treatment (current, declared in advance, previously orally expressed or presumed patient wishes) after disclosure of medical information and prospect of success to the patient or her legal representative. Results: a) No informed consent → no intensive care treatment, but adequate alternative treatment including palliative care b) Informed consent given or patient's wishes cannot be determined → step 4 Step 4: Prioritisation (only in case of resource scarcity) 4 After assessing the prospects of success of possible intensive care treatment 4 Regarding a realistically achievable patient-centred treatment goal 4 Compared to the prospect of success of intensive care treatment for other patients 4 Taking into account the available resources For reasons of justice, all patients who require intensive care treatment should be considered equally in the prioritisation. In Germany, this may touch legal limits if intensive care measures are withdrawn in the context of prioritisation (see the ad hoc statement of the German Ethics Council on the Corona crisis) [10] . As there are currently no specific legal regulations in Germany, the decision-makers bear the responsibility for these decisions. A re-evaluation should be undertaken and documented if there are changes in the patient's state of health and/or the available resources. Notwithstanding the above, the indication for continuing intensive care treatment must be reviewed carefully on a regular basis. Step Step 1: Does the patient need intensive care? If possible two physicians experienced in intensive care, incl. practitioners from the involved clinical departments and specialties, a member of the nursing staff, if necessary further disciplines (e.g. clinical ethics) Step 3: Is the patient's informed consent available (current, declared in advance, afore orally expressed or presumed)? Step 2: Is there a realistic clinical prospect of success from intensive therapy at the current time? Step 4: Prioritisation based on the Multiple-Eyes Principle after Evaluation of criteria for therapeutic success and of available resources In the preclinical field, the careful assessment of indicators for hospital admission with possible intensive care treatment and the determination of the patient's preferences are of paramount importance. However, any prioritisation of patients must take place in the relevant in-patient facilities; the emergency physician and paramedic staff only have limited diagnostic options and do not have sufficient information about the current availability of intensive care capacities and allocation criteria [2] . Where possible, decisions about whether hospital admission and, if necessary, transfer to an ICU, is medically indicated and/or wanted by the person concerned in case of a health deterioration, should be determined in advance. This process should involve the general practitioner and be documented reliably [9] . If COVID-19 patients are initially admitted to a general ward, it should be assessed and documented as early as possible whether intensive care treatment in case of a critically deteriorating health status is (a) medically indicated and/or (b) in accordance with the patient's preferences. Here, too, the multiple-eyes principle and the support of the treating staff by experienced specialists are required to ease the burden on the intensive care team [15] . Triage decisions can be a major challenge and burden for the staff involved. Support for the decision-making process and communication of the decision, as well as guidelines for psychosocial support, can be found in the following sources (with link to the respective websites): Ethical support services: discussion paper of German Academy of Ethics in Medicine (AEM) on the role of ethics committees and other ethics support services in the context of prioritisation [1] . Communication: Hospitals and other relevant institutions should develop strategies for communicating with patients and next of kin in preparation for a medical crisis [4] . Psychosocial support: Regarding psychosocial support for both medical and nursing staff, and patients and next of kin refer to the recommendations by DIVI and DGP [5, 7] . Ein Diskussionspapier der Akademie für php?id=163. Accessed Bundesvereinigung der Arbeitsgemeinschaften Notärzte Deutschlands (BAND) e. V. (2020) Leitplanken für Notärztinnen und Notärzte bei der Zuteilung von Behandlungsressourcen im Kontext der COVID-19-Pandemie A multicentre evaluation of two intensive care unit triage protocols for use in an influenza pandemic Covid-19 kompatible Kommunikation Empfehlungen zur Unterstützung von belasteten, schwerstkranken, sterbenden und trauernden Menschen in der Corona Pandemie aus palliativmedizinischer Perspektive Handlungsempfehlungen zur Therapie von Patient*innen mit COVID-19 aus palliativmedizinischer Perspektive 2 Deutsche interdisziplinäre Vereinigung für Intensiv-und Notfallmedizin (DIVI) (2020) Klinische psychosoziale Notfallversorgung im Rahmen von COVID-19 -Handlungsempfehlungen DIVI) (2020) Entscheidungen über die Zuteilung von Ressourcen in der Notfall und der Intensivmedizin im Kontext der COVID-19-Pandemie -Klinisch-ethische Empfehlungen Ambulante patientenzentrierte Vorausplanung für den Notfall. Ein Leitfaden aus Anlass der Covid-19-Pandemie Solidarität und Verantwortung in der Corona-Krise. Ad-hoc-Empfehlung Fair allocation of scarce medical resources in the time of Covid-19 Preparing intensive care for the next pandemic influenza ICU admission, discharge, and triage guidelines: a framework to enhance clinical operations, development of institutional policies, and further research Clinic for Anaesthesiology, Intensive Care, Emergency Care and Analgesic Therapy Dokumentation Therapiebegrenzung -Empfehlung der Sektion Ethik der Deutschen Interdisziplinäre Vereinigung für Intensiv und Notfallmedizin (DIVI) unter Mitarbeit der Sektion Ethik der Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN) Grenzen der Sinnhaftigkeit von Intensivmedizin Österreichische Gesellschaft für Anästhesiologie Reanimation und Intensivmedizin (ÖGARI) (2020) Allokation intensivmedizinischer Ressourcen aus Anlass der Covid-19-Pandemie Schweizerische Akademie der Medizinischen Wissenschaften(2020)Covid-19-Pandemie: Triage von intensivmedizinischen Behandlungen bei Ressourcenknappheit Thetoughest triage-Allocating ventilators in a pandemic The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine model-hospital-policy-allocating-scarce-criticalcare-resources-available-online-now. Accessed A framework for rationing ventilators and critical care beds during the COVID-19 pandemic The authors would like to thank Prof. Doris Schroeder and Dr. Kate Chatfield (University of Central Lancashire, UK) for providing a translation as basis for this English version of the recommendations. The authors also thank the numerous commentators for their helpful feedback on the first version of these recommendations. Suggestions have been carefully checked and considered as reflected in the second version.