'Act so that most people survive'
March 24, 2020
DW: Doctors and nurses from Italy are reporting, appalled, that they are no longer able to care adequately for all of their patients during the coronavirus crisis. What guidelines are there for physicians who have to make a decision about who they can help?
Prof. Dr. Georg Marckmann: We have guidelines for classic triage situations in disaster medicine, i.e. when there's a mass influx of injured people, and affected patients are screened and separated into treatment categories. What we don't yet have are recommendations for the situation like the one that has arisen in Italy, where the spread of COVID-19 has left us with so many patients requiring intensive care and ventilation that the capacity of intensive care units is no longer sufficient.
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Triage, a word used in military medicine, means classification. What groups do you classify the patients into?
There are several categories. Critically-ill patients are treated immediately, the treatment of seriously-ill patients is delayed, and patients who are slightly ill are treated later. Patients with no chance of survival receive purely palliative care.
The crucial element of situations involving a large number of sick people that we can no longer care for adequately is that we have to switch from a patient-centered approach to a group- or population-oriented approach. In a patient-centered approach, we try to adjust treatment as best we can to ensure the well-being of the individual patient and accommodate their wishes.
In a group-centered approach, we try to ensure that the incidence of illness and death within a population group is as low as possible. This places a strain on those making these decisions, because they're not used to it.
As a basic rule, we try to act in such a way that the largest number of people survive, because that is in the public interest.
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In a crisis, when there's a shortage of ventilators and intensive care beds, should those who need help most urgently be treated, or those with the best chances of survival?
In normal circumstances, we always allocate on the basis of urgency. Those who are most seriously ill have access to the most intensive resources. In situations where we no longer have sufficient capacity, we increasingly switch to success-oriented allocation.
Our priority must always be to try to expand capacity. This is being done intensively in Germany. This is just as ethically imperative as making optimum use of the capacity available, for example by coordinating intensive care beds and possibly also by switching patients.
COVID-19 patients requiring ventilation are not equally distributed across the regions. It's a principle of solidarity that we make the best possible joint use of the resources available, and that there are no conflicts over allocations.
How is it possible to determine quickly and beyond doubt which patient belongs to which group?
Intensive care medicine has a long tradition of assessing patients' prognoses. Where there is still some uncertainty is in the prognosis of COVID-19 patients. We do, however, have initial data from Italy, where attempts have been made to establish criteria to help estimate the probability of a critically ill patient dying.
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What needs to be done for doctors and nurses?
It is very important to protect health workers. We depend on having healthy healthcare staff to provide adequate care for the large number of COVID-19 patients.
As far as the psychological burden of allocation decisions on health personnel is concerned, it's important that there be guidelines on the criteria by which these decisions are made. There should be collegial support so that individuals don't have to make decisions alone. Ethical advisory bodies can't take the decisions away, but they can relieve the burden on teams. It's also important to provide support for those who can't cope with the burden, like an emergency telephone line staffed by psychologists or pastoral workers trained in emergency pastoral care or emergency assistance.
In Germany, we do everything we can to avoid making tragic decisions, or to have to make as few tragic decisions as possible. But if it does come to that, we have to be prepared and support health workers in making those decisions.
It's also important to communicate better with relatives, and it promotes confidence among the population to know that these decisions, if they can't be avoided, will be made in a transparent, fair, well-founded, medically and ethically based manner.
What are the criteria?
It will be necessary to assess the prospect of success of intensive care treatment. The severity of acute respiratory distress is one criterion. It will also have to be taken into account whether relevant concomitant diseases worsen the patient's prognosis, and also what their general condition is – for example, whether someone is very frail. It's also important to define which criteria should not play a role: marital status, social status, cultural background. No one is privileged or disadvantaged from the start – that's decided according to medical and ethical criteria.
Prof. Dr. med. Georg Marckmann is the director of the Institute for Ethics, History and Theory of Medicine at the Ludwig Maximilian University of Munich, and the president of the Academy of Ethics in Medicine.