Journal Information
Vol. 45. Issue 6.
Pages 381-382 (August - September 2021)
Vol. 45. Issue 6.
Pages 381-382 (August - September 2021)
Letter to the Editor
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Considerations on ICU triage ethics during the COVID-19 pandemic
Algunas consideraciones sobre la ética del triaje en UCI durante la pandemia COVID-19
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J.L. Monzón Marína,
Corresponding author
jmonzn@gmail.com

Corresponding author.
, A. Couceiro Vidalb
a Médico Intensivista, Magister en Bioética, La Rioja, Spain
b Profesora de Humanidades Médicas y Bioética, Universidad del País Vasco (UPV-EHU), Bilbao, Spain
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To the Editor,

We read we great interest the article ethical recommendations for a difficult decision-making in intensive care units due to the exceptional situation of crisis by the COVID-19 pandemic: a rapid review & consensus of experts.1 Fully aware of how it will eventually impact the healthcare workers, we wish to expose some of our worries first.

There is abundant medical literature on the ethical problems regarding triage including principles, values, criteria, and methods of implementation. All this has not been presented to the reader and the reasons behind the problems discussed have not been given either (chapter C, General Recommendations).

During the current pandemic, the authors recommend the use of prioritization categories that are nothing but little changes made to the criteria that govern admissions to the Intensive Care Units (ICU) in the routine medical practice2 and based on clinical judgement, not on the triage protocols suggested by other expert working groups.3

On table 1 of this article there is a clear contradiction with respect to the statements made on such article. Age is a criterion to weigh in differently depending on the triage model selected (and there are too many of them in the medical literature available), but is not an aprioristic criterion to rule out ICU admission as this table says. This ageism is hard to defend ethically. As a matter of fact, according to the Spanish Ministry of Health medical report on ethical criteria in situations of pandemic: SARS-CoV-2, it is something to actually run away from: «what is totally unacceptable whatsoever is to deny beforehand access to these resources to anybody who is over a certain age limit».

If this table is followed, the scales and specific weight of comorbidities can lead to decisions of this sort: 81-year-old patient with diabetes or connective tissue disorder or with a previous myocardial infarction (all of them with a Charlson Comorbidity Index >3) with all-cause pneumonia and respiratory failure would not be connected to a ventilator.

We should remember that, in this pandemic, we still do not know many things about the evolution of certain groups of patients. Under normal conditions, and yet despite the higher mortality rate reported, elderly patients benefit more from ICU admission (ELDICUS study) and even more if they suffer from pneumonia,4 the main condition of patients with severe COVID-19. Also, triage proposals combining the different factors that should be taken into consideration are being published including what specific weight each factor should have and what the optimal clinical tools should be for a proper triage implementation. However, whether these triage proposals actually save lives or can make an informed decision on who should receive life-support therapies and, therefore, have higher or lower chances of living is still under discussion.

We believe that reviewing these issues would bring more validity to any recommendations made on triage practices in the current COVID-19 pandemic.5,6

Conflicts of interest

None reported.

References
[1]
O. Rubio, A. Estella, L. Cabré, I. Saralegui-Reta, M.C. Martín, L. Zapata, et al.
Recomendaciones éticas para la toma de decisiones difíciles en las unidades de cuidados intensivos ante la situación excepcional de crisis por la pandemia por COVID-19: revisión rápida y consenso de expertos.
[2]
Guidelines for intensive care unit admission, discharge, and triage. Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine.
Crit Care Med., 27 (1999), pp. 633-638
[3]
M.D. Christian, A.V. Deveraux, J.R. Dichter, L. Rubinson, N. Kissoon.
Introduction and executive summary. Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement.
Chest., 146 (2014), pp. 8S-34S
[4]
T.S. Valley, M.W. Sjoding, A.M. Ryan, T.J. Iwashyna, C.R. Cooke.
Association of intensive care unit admission with mortality among older patients with pneumonia.
JAMA., 314 (2015), pp. 1272-1279
[5]
D.B. White, B. Lo.
A framework for rationing ventilators and critical care beds during the COVID-19 pandemic.
[6]
C.L. Sprung, G.M. Joynt, M.D. Christian, R.D. Truog, J. Rello, J.L. Nates.
Adult ICU triage during the coronavirus disease 2019 pandemic: who will live and who will die? Recommendations to improve survival.

Please cite this article as: Monzón Marín JL, Couceiro Vidal A. Algunas consideraciones sobre la ética del triaje en UCI durante la pandemia COVID-19. Med Intensiva. 2021;45:381–382.

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