Intensive care and emergency medicine physicians update clinical ethical recommendations on prioritization and triage for COVID-19

26.11.2021 16:19

Given the sharp increase in COVID-19 patients with serious illnesses, emergency and intensive care physicians, as well as other healthcare disciplines, are currently faced with difficult decisions: How should the available resources be distributed in such a way that as many patients as possible in need benefit have? Since new aspects have arisen in the discussion, not least due to the vaccination, experts from seven specialist societies have updated the “Guidelines on prioritization and triage in acute resource shortages” published in spring 2020. The most important points concern the equal treatment of vaccinated and unvaccinated patients in healthcare as well as the observance of the principle of equality when increasing resources for the care of patients with COVID-19.

Lack of vaccination is not a reason for limiting health care

In the public discussion in recent weeks, it has been repeatedly suggested that vaccination status should be used as a decision criterion for prioritization when resources are limited. The frustration over some people foregoing an effective vaccination is understandable, not least given the massive burden on those working in the health system, says Prof. Uwe Janssens, former president of DIVI and head of the Ethics Working Group. However, the professional societies have made it clear in the updated guidelines that a lack of vaccination cannot represent a legitimate criterion for triage decisions.

“The obligation to provide assistance in the healthcare system exists in the case of life-threatening illnesses, regardless of the trigger or the previous behavior of the patient in need,” says Janssens, summarizing the position of the guideline.

The medical ethicist and President of the Academy for Ethics in Medicine, Prof. Georg Marckmann, adds that, for good ethical reasons, claims to benefits in our solidarity-based health system are not made dependent on criteria such as “self-inflicted” or “personal responsibility”. Firstly, in individual cases it is generally not possible to prove with sufficient certainty that the disease is caused by behavior that is harmful to health on the part of the patient. Secondly, the behavior is often not based on a free, self-determined and therefore self-responsible decision. Thirdly, there are no generally accepted standards for which self-caused and freely chosen health-endangering actions the individual should be responsible for and to what extent. This applies not only to obesity, smoking or high-risk sports, but also to the decision not to have a SARS-CoV-2 vaccination. Therefore, prioritizing scarce acute medical resources based on vaccination status is unacceptable.

Create resources for COVID-19 patients, ensure equal rights for other patients

The second major change to the guideline is aimed at the clinical and ethical foundations of resource allocation in view of the increased need for COVID-19 patients. If a shortage of resources becomes apparent, hospitals should limit regular operations in order to be able to provide capacity for the increasing number of seriously ill patients with COVID-19. For this purpose, those treatments should first be postponed if the delay does not lead to a worsening of the prognosis, no irreversible damage to health or even premature death.

In the event that a further expansion of treatment capacities for COVID-19 patients is necessary, it must be taken into account that patients with other illnesses are not disadvantaged compared to COVID-19 patients, emphasizes the doctor and medical ethicist, Prof. Schildmann, Co-author of the guideline. Equal treatment of all patients requiring care must be guaranteed even in the event of scarce resources. Negative health effects caused by the restrictions must be minimized. Patients and their relatives must be transparently informed about the reasons for any limitations in care and the possible associated health effects.

Those involved in the guideline are:

1. German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)
2. German Society for Interdisciplinary Emergency and Acute Medicine (DGINA)
3. German Society for Anesthesiology and Intensive Care Medicine (DGAI)
4. German Society for Internal Intensive Care Medicine and Emergency Medicine (DGIIN)
5. German Society for Pneumology and Respiratory Medicine (DGP)
6. German Society for Palliative Medicine (DGP) and
7. the Academy for Ethics in Medicine (AEM)