Table 1

Summary of guidelines for allocating limited intensive care resources during the COVID-19 pandemic during periods of high demand for intensive care

GuidelineArea1. Development of guidelines process2. Ethical Framework3. Criteria for admission4. Criteria adapt as demand changes5. Criteria for discharge6. Equality across conditions7. Equality across healthcare system8. Decision-making processes and support9. Communication of decision
Toolkit for COVID-19—Kansas Department for Health and Environment (28 February 2020)21 Kansas, USABased on guidance produced by expert panel (doctors, hospital managers, state officials) in 2013—few adaptations for COVID-19.Not explicitly stated, but emphasises maximising lives saved. For patients of similar risk-benefit category, allocation should be at random or first come, first served.Primarily medical survivability determined by clinical judgement or formal means (eg, SOFA score).
Additional explicit exclusion criteria for severe conditions (eg, metastatic disease with poor prognosis, end-stage organ failure).
Yes. Hospitals should adapt based on resources.Yes. Reassess every 48 hours, with step down if exclusion criteria are met.Not discussed.Yes. Patients using ventilators in chronic care facilities would not be subjected to acute care triage guidelines. Uniform policies are required to avoid inequalities.Triage team (medically led and independent of treating doctor) will make decisions on resource allocation for individual patients, and its decision-making scrutinised by a ‘review committee’.Not discussed.
Clinical ethics recommendations for the allocation of intensive care treatments in exceptional resource-limited circumstances—Italian Society of Anaesthesia, Analgesia and Intensive Care (SIAARTI)
(16 March 2020)19
ItalyNot stated. Written by panel of experts.Maximise benefits for the greatest number of people. Discusses possible need of using first come, first served during resource saturation.Age (with possible upper limit); comorbidities; functional status.Yes. Criteria need to be flexible and locally adapted based on resource availability.No explicit criteria, but de-escalation decisions should not be postponed.Yes.Partially—principles established but anticipate different thresholds locally based on local capacity and demand.Decision-making responsibility is for doctors managing care—suggests second opinion for challenging cases. Recommends systems put in place to support healthcare workers to debrief.Yes. Communicate decisions with patients and obtain their wishes.
The Australian and New Zealand Intensive Care Society COVID-19 Guidelines v1
(16 March 2020)18
Australia and New ZealandConsensus-based guidelines drawing on previous experience and literature.Not explicitly stated, but emphasises maximising lives saved.Probable outcome of the patient’s condition; burden of ICU treatment; comorbidities; likelihood of response to treatment.Yes, described as ‘a living document that will be continually revised’.Not discussed.Yes.Yes. While similar criteria should apply across all jurisdictions, the ultimate decision-making is at discretion of senior intensive care medical staff.Treating clinician responsible for decision-making. Shared decision-making with other clinicians.Yes. Shared and transparent decision-making process with patients and relatives.
Ethical principles concerning proportionality of critical care during the COVID-19 pandemic: advice by the Belgian Society of Intensive Care Medicine
(18 March 2020)17
BelgiumNot stated. Written by a panel of experts.Not explicitly stated, but emphasises maximising lives saved.Probable outcome of patient’s condition; frailty in elderly patients (eg, Clinical Frailty Score); cognitive impairment in elderly patients; comorbidities (particularly severe or life-limiting conditions); age alone should not be used.Not discussed.Not discussed.Yes.Not explicitly discussed. Each hospital drafts their own ethical guideline.Decision to deny or prioritise treatment made by two or three doctors in consultation. Psychological support offered to clinicians making triage decisions. Keep register of all triage decisions.Yes. Open communication with patient and family.
Department of Defense COVID-19 practice management guide
(23 March 2020)22
US military hospitalsNot stated. Written by a panel of experts.Not discussed.Each hospital should provide a specific plan regarding ICU admission/exclusion criteria.
Age and comorbidities should be a factor for provision of (any form of) care for older patients.
Yes. Recommends having different criteria for different levels of capacity/need.Not discussed.Not discussed.Yes. Each hospital should have their own criteria and implement based on their own resources.Not discussed.Providers should avoid discussing rationing of care at the bedside.
COVID-19 pandemic: triage for intensive care treatment under resource scarcity—Swiss Academy of Medical Sciences
(24 March 2020)14
SwitzerlandBased on previous pandemic guidelines. Adapted by four experts, reviewed by ethics committee, ratified by professional bodies for medicine and intensive care.Maximising lives saved is a decisive factor for purposes of triage.
Acknowledges importance of equity and protecting healthcare professionals.
Patients who are most likely to survive to discharge.
Specific exclusion criteria given, primarily related to severe life-limiting underlying conditions; when no ICU beds available, a broader set of conditions and any patient aged >85 years, regardless of underlying health.
Two sets of criteria for different bed availability: (A) capacity limited, (B) no beds available.Yes. Reassess every 48 hours with specific clinical discontinuation criteria given.Yes.Yes. Uniform criteria across the country.Decisions to be made by multidisciplinary team, which may include input from ethicists. Most senior clinician takes responsibility. Deviation from guidance possible but must be clearly stated why.Not explicitly discussed but must be transparent.
COVID-19 rapid guideline: critical care in adults—National Institute for Health and Care Excellence (NICE)
(27 March 2020)16
UKDeveloped using existing national and international guidance, advice from specialists and a rapid guideline process.Not stated.Based on likelihood of recovery. Frailty (using Clinical Frailty Score or individualised assessment of frailty if score not appropriate); comorbidities; patient wishes.Not discussed.No explicit criteria but acknowledge need for regular review and stop when not achieving outcomes.Yes.Yes. Hospitals should discuss sharing of resources and transfer patients between units in other hospitals to ensure best use of critical care within the National Health Service.Not explicit. Decision-making is by the critical care team.Encourages open communication with patient and family and shared decision-making.
Provisional clinical practice guidelines on COVID-19 suspected and confirmed patients—Ministry of Health Sri Lanka
(31 March 2020)20
Sri LankaNot stated. Written by a panel of experts.Not stated. Appears to suggest prioritising saving lives.Admission rather than triage criteria, which are: acute and potentially reversible organ dysfunction; adequate physiological reserve; and goals of ICU admission defined.Not discussed.Patients with poor physiological reserve or comorbidities are prioritised for step down to ensure ICU not overwhelmed.No. Guidance specific to patients with COVID-19.Not explicitly discussed, but guidance is national.Decision made by senior member of intensive care team.Not discussed.
  • ICU, intensive care unit; SOFA, Sequential Organ Failure Assessment.