DOI: https://doi.org/10.4414/smw.2021.20472
In spring 2020, the Swiss Academy of Medical Sciences (SAMS) issued specific guidelines on triage for intensive-care treatment in the context of the COVID-19 pandemic, which are regularly updated [1]. We conducted a qualitative study to explore the acceptance and perceived implementation of the SAMS guidelines among senior physicians involved in treatment and care of COVID-19 patients in the Canton of Ticino, where the hospital and health system were purposely reorganized to increase and adapt capacity. Between April and July, 2020, we conducted face-to-face and telephone interviews with a purposive sample of nine senior physicians employed in either one of the two COVID-19 hospitals in Ticino. Interviews were transcribed verbatim and thematically analysed using an inductive approach. The Ethics Committee of the Canton of Ticino issued a favourable opinion on the study (Req-2020-01307).
We identified several themes. First, participants held different views regarding the nature of the guidelines. Some viewed them as a source of direction, legitimisation and protection, whereas others stated that they should only serve as a general framework subject to interpretation and changes according to patients’ values and preferences, and to the physician’s evaluation. This points to the need for hospital leadership to ensure legal safeguards prior to establishing a triage system, in order to ensure consistent application of triage protocols [2]. Second, we found that professional, collaborative decision making facilitated choices on intensive care unit (ICU) admission. Our participants saw decisions on admission as a matter of collective responsibility and reported having involved external, senior physicians in the decision-making process on whether to accord priority to patients for intensive care. This can be a result of awareness of the psychological implications of making ICU admission decisions, which have been previously described as being extremely difficult and emotionally burdensome [3]. Third, participants shared the view that age should not be a criterion for limiting intensive care. This reflects the principle that scarce resources should be fairly allocated regardless of age, sex or gender identity, race or ethnicity, and similar individual factors [4], and that priority decisions should be primarily based on medical criteria [5]. Fourth, our participants referred to a revival of the paternalistic model, as physicians could not always carefully ascertain the patients’ and their families’ wishes, because of logistic and emotional barriers, many of which were unprecedented and conceivably exceptional during the first wave of the epidemic. Previous evidence has shown that end-of-life decisions were perceived as more complex in the absence of family or of information about patients’ end-of-life preferences, and when there was time pressure and a lack of training in end-of-life decision making [6]. To give precedence to respecting a distributive justice principle, our participants reported having downgraded principles of autonomy and beneficence.
We conducted in-depth interviews with senior physicians who were confronted with unprecedented treatment and care decisions during the first wave of the COVID-19 epidemic. Our results highlight the importance of sensitising both healthcare professionals and the general population regarding the nature, purpose and intended application of these guidelines. Explicit information and clarifications are needed, in particular to address issues of authority and responsibility during triaging decisions, the benefits of discussing and compiling advance directives, and including family members as much as possible in the decision-making process regarding a patient’s ICU admission and stay. Integrating these findings into future versions of the guidelines will help case management systems cope with patient inflow, fairly allocate limited medical resources, support critically ill patients and their families, and protect the safety of healthcare providers.
This study was conducted with funding of the Commission of Clinical Ethics of the Ente Ospedaliero Cantonale (COMEC). The authors certify that there is no actual or potential conflict of interest in relation to this article.
1Swiss Academy of Medical Sciences. Intensive care medicine: triage under resource scarcity. Intensive care medicine: triage under resource scarcity. [Accessed 2020 November 11.] https://www.samw.ch/en/Ethics/Topics-A-to-Z/Intensive-care-medicine.html
2 Aziz S Arabi YM Alhazzani W Evans L Citerio G Fischkoff K Managing ICU surge during the COVID-19 crisis: rapid guidelines. Intensive Care Med. 2020;46(7):1303–25. doi:.https://doi.org/10.1007/s00134-020-06092-5
3 Escher M Cullati S Hudelson P Nendaz M Ricou B Perneger T Admission to intensive care: A qualitative study of triage and its determinants. Health Serv Res. 2019;54(2):474–83. doi:.https://doi.org/10.1111/1475-6773.13076
4 Kirkpatrick JN Hull SC Fedson S Mullen B Goodlin SJ . Scarce-Resource Allocation and Patient Triage During the COVID-19 Pandemic: JACC Review Topic of the Week. J Am Coll Cardiol. 2020;76(1):85–92. doi:.https://doi.org/10.1016/j.jacc.2020.05.006
5 Oerlemans AJM Wollersheim H van Sluisveld N van der Hoeven JG Dekkers WJM Zegers M . Rationing in the intensive care unit in case of full bed occupancy: a survey among intensive care unit physicians. BMC Anesthesiol. 2016;16(1):25. doi:.https://doi.org/10.1186/s12871-016-0190-5
6 Rosca A Krones T Biller-Andorno N . Shared decision making: patients have a right to be informed about possible treatment options and their risks and benefits. Swiss Med Wkly. 2020;150(2728):w20268. doi:.https://doi.org/10.4414/smw.2020.20268
This study was conducted with funding of the Commission of Clinical Ethics of the Ente Ospedaliero Cantonale (COMEC). The authors certify that there is no actual or potential conflict of interest in relation to this article.