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If intensive care units reach their maximum capacity, if beds and ventilators are lacking, which patients should be considered priority? Age should not be the only criterion for admission of patients to intensive care units (ICU), these decisions should be considered by a team and the criteria apply to all patients, not just those with covid- 19, recommends the National Council of Ethics and Deontology of OM. In an extreme scenario, of catastrophe, this attention should be reserved for those who “are more likely to survive after treatment,” he specifies.
“It is neither the age, per se, nor the order of arrival of the patient [que deve determinar a escolha da admissão em cuidados intensivos]. But this is an ethical and deontological opinion, not a technical one ”, emphasizes the president of the OM Ethics and Deontology Council, Manuel Mendes Silva. “It is clear that age is included in the evaluation, but it is not the main criterion. There are people of 70 years with a very short survival ”, he observes.
The opinion was approved by the National Council of the Order in early April, but was not released at that time because the situation improved with the general confinement. The Order of Physicians has decided to make it known now, at a time when the increase in critical patients with covid-19 hospitalized in these highly complex units continues to grow and is close to four hundred (391 this Monday, 13 more than the yesterday). “The intensive care units are in pre-rupture, especially in the north of the country, the situation is very complicated”, justifies Manuel Mendes Silva. This problem is not new, but “it has never been posed in such a sharp way, with this dimension”
“The fundamental criteria are those of proportionality and distributive justice based on the highest probability of survival after treatment and quality of life,” summarizes the doctor. In other words, “the order of arrival of the request for admission or arrival to hospital emergencies”, as well as age, “alone” cannot constitute priority criteria for the admission of patients to the ICU. Previous diseases and “multi-organ functional status” should be “carefully evaluated, along with age” and patients who “have a higher chance of survival after treatment” should be prioritized, in an extreme scenario. lack of resources in which the principles of so-called “disaster medicine” can be applied.
In addition to patients with covid-19, there are many patients with various pathologies and accident victims who require intensive care and the Order maintains that these must be evaluated in exactly the same way. Another key rule to observe is that any decision to limit access must be properly founded and result from a consensus of the health team evaluating the patient. Furthermore, in the case of a “particular clinical or moral difficulty and uncertainty”, “a second opinion from experienced colleagues” should be requested. Likewise, this decision must “be communicated to the person (whenever possible) and family members and recorded in the process.”
The Council of Ethics and Deontology also emphasizes that, when the benefit “is minimal and unlikely due to an advanced or terminal illness”, patients should not undergo intensive therapy. But the patient obviously has to continue to be monitored. When deciding to suspend treatment, the doctor “cannot abandon the patient” and must guarantee “adequate palliative care”.
It should also be verified, at the time of admission, if there are advance directives of a will (living will), and, “if a short-term agonizing period is anticipated, transfer to an environment outside the ICU and in respectful of your privacy as much as possible ”. The patient must also have “the possibility of saying goodbye, even by phone, to their relatives.”
