Summary of guidelines for allocating limited intensive care resources during the COVID-19 pandemic during periods of high demand for intensive care
| Guideline | Area | 1. Development of guidelines process | 2. Ethical Framework | 3. Criteria for admission | 4. Criteria adapt as demand changes | 5. Criteria for discharge | 6. Equality across conditions | 7. Equality across healthcare system | 8. Decision-making processes and support | 9. Communication of decision |
| Toolkit for COVID-19—Kansas Department for Health and Environment (28 February 2020)21 | Kansas, USA | Based 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 | Italy | Not 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 Zealand | Consensus-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 | Belgium | Not 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 hospitals | Not 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 | Switzerland | Based 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 | UK | Developed 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 Lanka | Not 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.