In the last decades, medicine’s capacity to keep patients alive through technological and pharmacological interventions has been substantially enhanced. Public expectations concerning the prospects for successful medical treatment, even in very complex cases, have risen accordingly. Because intensive care interventions can be burdensome and are associated with many ethical questions, the SAMS published the medical-ethical guidelines «Intensive-care interventions» in 2013 to provide guidance to health professionals.
Intensive care interventions do not only place heavy burdens on both patients and their relatives, it also does not always lead to the hoped-for restoration of health. Therefore, the central question is what goals can be attained with intensive care measures in a given clinical situation. In order to define differentiated treatment goals, the focus must not be on survival alone, but rather on the quality of life, long-term outcomes following intensive care and hospital discharge, as well as cost-effectiveness.
The practice of intensive care medicine is influenced not only by medical and social factors but also by legal and political developments. The right to self-determination as defined in the law on the protection of children and adults also plays a decisive role in cases of lacking capacity to consent in intensive care. With advanced care planning or an advance directive (more information about advance directives are available in French or German), individuals can determine in advance under which conditions they consent or oppose interventions. One example is foregoing resuscitation or ventilation, which would usually entail a (prolonged) stay in the intensive care unit.
Intensive care medicine is confronted with growing tensions between the demands of patients, relatives and referring physicians, ethical questions concerning the appropriateness of certain interventions, and the financial framework set by policymakers, insurers and administrators. In addition, intensive care medicine is facing staff shortages, which were exacerbated by the Covid pandemic. When, due to overworking, health professionals leave or change jobs, the situation for the remaining staff becomes even more difficult.
Given these tensions, there is a need for clearly defined criteria and recommendations for the application of intensive care interventions. The guidelines offer concrete guidance to support decision-making in intensive care medicine on a case-by-case basis.
Triage under resource scarcity
Since 2020, the coronavirus has created additional challenges for intensive care units. Therefore, the SAMS published an appendix on triage decisions under exceptional resource scarcity, supplementing the 2013 guidelines and, specifically Chapter 9.3. «Resource scarcity and triage».
The document has been updated several times and currently focuses less on Covid-19 patients. It can be found together with further documentation on the page Triage in intensive care.