Which is less fair life or death

Doctors face life and death decisions because of COVID-19

The intensive care and emergency physicians expect difficult decisions to be made at the hospital beds. On Thursday they presented a guide on triage in the corona pandemic.

In Italy, doctors had to learn very quickly and with little lead time which patients could still be treated in intensive care and which could not.

Now the intensive care and emergency physicians in Germany are preparing to have to decide between life and death when treating corona patients. It is "likely that even in Germany in a short period of time and despite capacity increases that have already taken place, there will no longer be sufficient intensive care resources available for all patients who need them", according to a recommendation from seven medical societies with the cumbersome title that was widespread in the morning "Decisions on the allocation of resources in emergency and intensive care medicine in the context of the COVID-19 pandemic". The authors ask for a lively discourse in order to be able to further develop the content according to the situation.

The eleven-page paper, which was formulated under the direction of Georg Marckmann, Gerald Neitzke and Jan Schildmann, is intended to give doctors guidance in the event of "conflicts to be expected when making decisions about intensive care treatments". Exclusion criteria should already be defined in the preclinical phase in old people's and nursing homes as well as in the emergency services. At this point, the general practitioners should be included in the decision-making process.

The will of the patient counts

As in other conflict situations in end-of-life treatment, “indication and patient will” should form the basis of medical decisions. If a patient has indicated in a living will or in other ways not to be treated in intensive care, this should be complied with.

If the dying process has begun, the prognosis is poor or if survival would only be possible with permanent intensive medical care, intensive therapy is also not indicated, according to the paper that is available in the "Ärzte Zeitung".

Triage like in a disaster

It becomes more critical for doctors when decisions have to be made due to a lack of material. Then, "analogous to triage in disaster medicine, a decision must be made about the distribution of the limited resources available," the authors write. Transparent and ethically well-founded criteria could relieve the teams at this point and strengthen the trust of the population in crisis management in the hospitals.

Any necessary prioritization should therefore not be suspected of “evaluating human life”, but should be based solely on clinical prospects of success. The better overall forecast should decide. All patients would have to be included in the overall assessment, not just the COVID-19 patients. Calendar age or social status alone were also not sufficient grounds for exclusion.

Clear decision-making paths

The authors advise defining clear decision-making paths and defining procedures in the event of dissent in advance. "Consistent, fair and medically and ethically well-founded prioritization decisions" can be brought about, for example, with the principle of multiple eyes in a team of two doctors with intensive care medicine, a nurse and, if necessary, other specialists.

For practitioners, this has created “a very high level of security”. "At the end of this difficult, painful process, we want to be able to say: It was a well-founded, fair decision," commented the President of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI) Professor Uwe Janssens on the paper. Nobody in Germany needs to be afraid that decisions will be made on the principle of thumbs up, thumbs down.

Source: Doctors newspaper

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