Intensive care medicine: triage under resource scarcity

As long as sufficient (human and material) resources are available, all patients requiring intensive care are admitted and treated according to established criteria. If an emergency arises in which large numbers of severely ill patients require ICU treatment – for example, during a pandemic – rationing decisions will be necessary, placing considerable burdens on medical staff. This makes it all the more important that uniform criteria for ICU admission and continued occupancy should be applied throughout Switzerland.

In the spring of 2020, at the start of the COVID-19 pandemic, the SAMS, together with the Swiss Society of Intensive Care Medicine (SSICM), prepared guidelines offering practical guidance for decision-making under such difficult conditions. This document supplements the existing SAMS guidelines on «Intensive-care interventions» and thus concerns only a small proportion of patients infected with the coronavirus, namely the group of severely ill patients requiring intensive care. Patients with COVID-19 and other patients requiring intensive care are treated according to the same principles.

The guidelines on triage for intensive-care treatment under resource scarcity were published on 20 March 2020. They will be continuously adapted if experience in practice or new scientific findings so require. Below, you can find the latest version. All previous versions can be found here. For each version, the SAMS has published a Newsletter, highlighting the most important content or changes. The Newsletter (see below) thus provides a rapid overview.

You can find all the medical-ethical guidelines published by the SAMS in the Publications menu.

4 November 2020: Updated guidelines on triage for intensive-care treatment under resource scarcity
German or French

16 April 2020: Covid-19 pandemic: interim report on patient triage in intensive care units
German or French

25 March 2020: Covid-19 pandemic: updated guidelines for triage in intensive care units
German or French

20 March 2020: Covid-19 pandemic: guidelines for triage in intensive care units
German or French

 

The new guidelines on the triage for intensive-care treatment are arousing great interest both in professional circles and among the public. ethix, Lab for Innovation Ethics, aims to broaden the debate. In a blog post (German/French), you can find a document presenting the key elements of the guidelines as well as a questionnaire that submits various triage scenarios for discussion.

The results of the survey provide information on how the ethical considerations underlying triage recommendations are evaluated by the population. Thus, the majority of the participants agree in principle with the SAMS guidelines. The vast majority agree with the principle of non-discrimination. Nationality, insurance status and social value have proven to be irrelevant criteria for setting priorities. However, the age of a person who is sick with Covid-19 seems to have some influence. For 24.7% of the participants, age is a factor in their decision. 90% of the participants felt that priority access to treatment cannot be purchased, as it would violate the principle that «every life has equal value». 

On the ethix website you can find the results of the survey in German or French.

The coronavirus infection threatens the entire population but elderly people, who are often multimorbid and frail, are the most vulnerable to serious and fatal outcomes. Severe diseases with an unfavourable prognosis and dying situations require good palliative care for those affected. The current pandemic and the publication of the guidelines for triage decisions have prompted the Association for Geriatric Palliative Medicine (FGPG) to draw up additional practice-oriented recommendations. The SAMS welcomes this initiative.

Here you will find interviews and publications that shed light on various aspects of triage under resource scarcity in intensive care units.

Recommendations on Covid-19 triage: international comparison and ethical analysis (Bioethics, 25 September 2020)

Ethics guidelines on Covid-19 triage – an emerging international consensus (Universität Zürich, May 2020)

Covid-19: Occupancy in Swiss intensive care units between April and June 2020 (SGI, July 2020), available in German or in French.