By Ludovica De Panfilis, Silvia Tanzi and Massimo Costantini.

The world continues to face the COVID-19 outbreak. It has radically affected health care organizations, care approaches, clinical and ethical choices, the perception of death and dying process, and people’s daily lives.

Italy is the first and one of the most affected countries in Europe. The first case was identified on February 21, 2020, and as of April 19, 2020, more than 175,000 cases and 23,000 deaths have been recorded.

The COVID-19 outbreak required managing an extraordinarily high number of patients at the same time. Based on the available data, almost 10% of the people affected by COVID-19 need to be hospitalized in the Intensive Care Unit.

At the peak of the emergency, on March 6, 2020, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published the ‘Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances”.

One month later, on April, 8th, the Italian National Committee for Bioethics (CNB) published a document called “Clinical decision in exceptional, resource-limited circumstances and the triage-criteria under pandemic”.

The first document implies a scenario of medicine during catastrophes; ‘a wartime’, as seen by many. The “age limit” is the third recommendation indicated, after general considerations about the allocation of ICU resources and the importance of flexible criteria, and before comorbidities and functional status. The underlying principle would be to save limited resources which may become extremely scarce for those who have a much higher probability of survival and life expectancy. The document received a high level of media attention at the most challenging time.

In contrast, the clinical criterion is the most appropriate point of reference for triage decisions, according to the Italian CNB. Triage must be based on preparedness, clinical proportionality and current assessment.

In a public health emergency such as the current COVID-19 crisis, an ethically sound framework has to balance the patient-centred duty of care—the focus of clinical ethics under normal conditions—with public-focused duties to promote equality of persons and equity in the distribution of risks and benefits in society—the focus of public health ethics.

As palliative care physicians and medical ethicists, we think that figuring out a way to personalize care during COVID-19 outbreak is a moral duty. Each person has the same “moral claim” to equality. Dignity is not a category related to age or social, mental and physical conditions. In a pluralistic society, it is neither possible nor desirable to identify a set of objective criteria that assert that one individual is intrinsically more worthy of saving than another. Person’s preference and values are the basis of a shared decision-making process. During this medical emergency, limited healthcare resources can restrict the tendency to maximize the patient’s autonomy.

The criteria for a treatment’s appropriateness and its corresponding ethical proportionality should be evaluated with the necessity to allocate (limited) resources while offering a valid alternative care path to intensive care when it is not considered appropriate. In essence, health care professionals should save as many lives as possible, continuing to care for each patient.

The difficult choice regarding who will undergo intensive treatments should be associated with personalized care to ensure that the patient and his/her family members do not perceive the feeling of being less important or less valuable to treat. Due to the lack of scientific evidence, the evaluation needs to be based on an individualized, multidimensional and multidisciplinary approach. A hospital-based palliative care team can help in managing not only symptoms not responding to medical treatments, but also multidimensional needs that patients affected by COVID-19 and their family are facing. Moreover, a palliative care approach has a role in supporting health care professionals in the relational, communicative and ethical issues. Lastly, they can also support triage and complex decision making.

One of the focuses of palliative care is the discussion of patient wishes, expectations and values via advanced care planning to personalize the goals of care. During a pandemic, the challenge for palliative care is finding a way to care for each person not as a member of a specific category (older, fragile, vulnerable) but as an individual with specific needs.

It is also important to discuss care choices made by health care professionals with patients and family members, also highlighting the uncertainties and the absence of scientific evidence.

Ethics works if it can put forward concrete proposals that can have an impact on society. Medical ethics has to avoid the risk in simplifying an extremely complex situation. We propose some guidelines, hoping that they will stimulate the debate.

First of all, in a medical emergency characterized by the scarcity of resources, multidisciplinary, multidimensional and individualized evaluation of every single patient is required. It is necessary to avoid a narrow simplification based on objective criteria, and it is essential to contextualize recommendations and guidelines, also encouraging those directly involved in their application to take part in a constructive debate.

We also believe that it is necessary to develop strategies to build up practical decision-making support, in order to not leave the health care professionals alone in making difficult decisions and in communicating bad news to family members. Clinical ethics committees can represent an essential resource to support health care professionals and health care organizations.

Finally, it is crucial that institutions and scientific community, in their area of expertise, keep maintaining an open dialogue with citizens, in order to ensure sincere, transparent and adequate communication aimed at empowering and informing the population.

 

Author(s):

Ludovica De Panfilis¹, Silvia Tanzi², Massimo Costantini³

Affiliations:

1 Unit of Bioethics,

Azienda USL-IRCCS di Reggio Emilia, Italy

2 Palliative care Unit

Azienda USL-IRCCS di Reggio Emilia, Italy

3 Scientific Directorate,

Azienda USL-IRCCS di Reggio Emilia, Italy

Competing interests:

None

Social media accounts of post author(s):

Twitter account: @LPanfilis; @sillytanzi; @costia56