Pandemic priority decisions and triage, from good to ugly

By Hans Flaatten, Michael Beil, and Susannah Leaver.

The present COVID-19 pandemic has fuelled discussions regarding the prospects and limitations of treatment in critically ill patients. This commentary describes a framework for understanding pandemic triage ranging from “business as usual” (“good”) to the extreme depletion of all resources (“ugly”). This is illustrated with different stages based on the combination of patient numbers and available resources in intensive care. These variables move simultaneously in opposite directions. We describe triage changing from being patient centered (egalitarian) to society oriented (utilitarian). Further, we challenge societies and government to develop triage rules based upon what would be acceptable from their perspective, rather than transferring this responsibility to the medical profession.

The COVID-19 pandemic has opened a “Pandora’s Box” with regard to triage decisions and has demonstrated how strange and unpleasant the content can be. Also, in some countries in Europe we have glimpsed a look into this “box”. Criteria for ICU admission at the peak have been far from usual practice in European ICUs, with some apparently using age as a single criterion for ICU admission. This differs from common practice but is also understandable. The old have “lived their life” compared to young individuals who may have more than half their expected lifespan before them.

Within the European Society of Intensive Care Medicine (ESICM) we have for some years had a research group focusing on the outcomes of the very old ICU patients (≥80 years). Through several large prospective cohort studies throughout Europe (the VIP-studies), we investigated which factors are important to understand survival in this patient group. The aim is to create ICU admission criteria in patients >80 years old based on their chances of survival as well as the quality of life in those who survived. There is still a lot to learn, but our understanding increases with each study, based on enthusiasm and interest for the topic. We have consistently demonstrated that pre-existing frailty is an important predictor of survival, and that other geriatric issues such as cognitive impairment, reduced activities of daily living and comorbidities seem to offer little additional value for prognostication.

When this pandemic started our research-group was interested to follow how the elderly patients faired, since it was postulated early on that old age was a “risk factor”. However, data showing that age was indeed an independent risk factor was less well documented. We therefore commenced a study (COVIP) of elderly COVID-19 patients (≥70 years) in Europe and some Mediterranean countries, again collecting data on frailty and markers of severity of the disease. This study is now nearing completion. The study group have had a weekly “zoom-meeting” to discuss this and ethical issues surrounding triage of COVID-19 patients. It quickly became apparent that we did not have a unified view on triage within Europe, and some otherwise very sophisticated countries even lacked guidelines! It seems that most countries not severely hit by the COVID-wave managed triage differently from those that “drowned”.


Paper title: The good, the bad and the ugly: pandemic priority decisions and triage

Blog post authors and affiliations: 

Hans Flaatten, Department of Anaesthesia and intensive care, Haukeland University Hospital, Bergen, Norway

Michael Beil, General Intensive Care Unit, Haddassah Medical Center, Jerusalem, Israel

Susannah Leaver, Intensive Care and Respiratory Medicine, St George’s NHS Foundation Trust, London UK

Competing interests: None


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