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

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"apellidos" => "Amblas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "k" "identificador" => "aff0055" ] ] ] ] "afiliaciones" => array:11 [ 0 => array:3 [ "entidad" => "Cuidados Intensivos, Althaia, Xarxa Assistencial Universitària de Manresa, Manresa, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Cuidados Intensivos, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Cuidados Intensivos, Comité de Bioética de Cataluña, Catalonia, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Cuidados Intensivos, Hospital Universitario de Áraba, Osakidetza Araba, Vitoria-Gasteiz, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Cuidados Intensivos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Instituto Borja de Bioética, Esplugues de Llobregat, Barcelona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Vall de Hebron, Barcelona, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] 8 => array:3 [ "entidad" => "Área de Medicina Crítica, Hospital Universitario y Politécnico La Fe, Valencia, Spain" "etiqueta" => "i" "identificador" => "aff0045" ] 9 => array:3 [ "entidad" => "Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain" "etiqueta" => "j" "identificador" => "aff0050" ] 10 => array:3 [ "entidad" => "Geriatría y Cuidados paliativos, Hospital Universitario de la Santa Creu de Vic, Central Catalonia Chronicity Research Group (C3RG), Universitat de Vic-UCC, Vic, Barcelona, Spain" "etiqueta" => "k" "identificador" => "aff0055" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "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" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1533 "Ancho" => 2513 "Tamanyo" => 381070 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Model of 4 categories for prioritizing and allocating patients based on their individual characteristics and current situation. CPR, cardiopulmonary resuscitation; OTI, orotracheal intubation. *Consider the option of admitting priority 2 patients in other health areas such as intermediate care units when available and not saturated with priority patients." ] ] ] "textoCompleto" => "IntroductionThe current pandemic due to the SARS-CoV-2 coronavirus that causes the COVID-19 disease is an unprecedented challenge for the entire healthcare system—especially for intensive care units (ICU)—because the most severe cases can develop acute respiratory distress syndrome (ARDS), sepsis/septic shock, and multi-organ failure including acute kidney injury and cardiac damage.<a class="elsevierStyleCrossRef" href="#bib0005">1</a>While most people with COVID-19 develop mild or uncomplicated disease, the early data from China show that 14% develop serious disease that requires hospitalization and 5% need to be hospitalized in an intensive care units (ICU).<a class="elsevierStyleCrossRef" href="#bib0010">2</a> In Lombardy, Italy the total ICU capacity prior to the crisis was 720 beds (2.9% of the overall number of hospital beds in a total of 74 hospitals, with an occupation rate between 85% and 90% during the months of Winter). Two weeks into the outbreak the system collapsed. The patients admitted to the ICUs due to COVID-19 disease were already 556 (equivalent to the 12% of all cases that tested positive and 16% of all hospitalized patients).<a class="elsevierStyleCrossRef" href="#bib0015">3</a>The experience gained in other countries and the reality lived daily in some of our hospitals shows the huge imbalance between the number of patients who require invasive mechanical ventilation and the actual resources available. According to data recently published by the Spanish Society of Intensive, Critical and Coronary Unit Medical Care (SEMICYUC),<a class="elsevierStyleCrossRef" href="#bib0020">4</a> the number of ICU beds in Spain is around 3600, which is a 7.7 bed ratio for every 100 000 inhabitants (compared to 29.2/100 000 inhabitants in Germany and 4.2/100 000 inhabitants in Portugal jut to mention 2 examples of neighboring countries).<a class="elsevierStyleCrossRef" href="#bib0025">5</a> To this day (March 22th, 2020), the number of patients (cumulative incidence) with COVID-19 who required ICU admission in Spain is already 1785.<a class="elsevierStyleCrossRef" href="#bib0030">6</a>The dilemma between this anticipated excessive need for invasive ventilation and the limited resources available will probably be leading us to a situation of “disaster medicine” where difficult moral decisions will need to be made for allocating resources and prioritizing patients. In the short and long-term, this reality will have a tremendous impact on the patients and their families. Also, health workers will be impacted, which may be even more catastrophic that the disease per se.<a class="elsevierStyleCrossRef" href="#bib0035">7</a>Since difficult ethical decisions will need to be made based on solid criteria and basic moral principles grounded on the equal and fair provision of services, the SEMICYUC ethics committee has promoted consensus in order to hekp healthcare workers handle this complex situation.MethodologyGiven the urgency of the current situation, an agile and resolute 3-stage methodology has been designed:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1Rapid summary of the medical literature published on the ethics behind decision-making processes under exceptional circumstances of pandemic related crises.</li><li class="elsevierStyleListItem" id="lsti0010">2Design of an online, non-systematic consensus document between health workers from SEMICYUC ethics committee and experts on bioethics, geriatrics, and palliative care.</li><li class="elsevierStyleListItem" id="lsti0015">3Consensus document including general recommendations signed by scientific societies and institutional ethics committees.</li></ul>ResultsBrief summary of the medical literatureAfter extensive search of the medical literature available, 9 especially relevant papers have been found on the ethics behind decision-making processes under exceptional situations in pandemic related crises.<a class="elsevierStyleCrossRefs" href="#bib0035">7–15</a> Three of them are articles that specifically reviewed aspects of palliative care in this context.<a class="elsevierStyleCrossRefs" href="#bib0080">16–18</a>Designing the documentBased on the actual scientific evidence available and the online work conducted by the authors of this article, the first document draft was envisioned: “Moral recommendations for decision-making processes in the exceptional situation of crisis due to the current COVID-19 pandemic in the intensive care unit setting”. Two are the objectives of this manuscript: 1) bring support to the healthcare workers in the difficult decisions they will have to make by providing them with generally agreed criteria allowing them to share responsibility in the difficult decisions made under situations that require a great emotional load, and 2) specify criteria of adequacy and resource allocation in situations of exceptionality and scarcity.General recommendationsFirst, a series of general recommendations were developed that can be grouped into 3 large categories:<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020">ARecommendations regarding organization, availability of resources and alternatives: 1) need to implement a territorial contingency plan with solidarity among different centers as the leading criterion; 2) optimization of personal, structural, and material resources; 3) consensus of common technical and ethical criteria by proposing the creation of committees including territorial experts, and 4) planning alternatives, especially for people who may need palliative care treatment.</li><li class="elsevierStyleListItem" id="lsti0025">BRecommendations regarding the patient’s individual characteristics and overall situation. Need to perform a comprehensive assessment 1) including a multidimensional assessment of the overall situation or “biological age” of the patient with his values and preferences including the possibility that he has signed an Anticipatory Last Will and Testament Document (ALWTD) or an Anticipatory Care Planning (ACP); 2) with better arrangements for ICU admissions based on a model of 4 categories of prioritizing these admissions (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>), and 3) taking into consideration the need for a dynamic adequacy of care by guaranteeing quality palliative care in cases with poor progression.<elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030">CRecommendations regarding moral decisions: 1) need to apply specific moral criteria for situations of crisis by implementing an allocation strategy to maximize survival after hospital discharge and the number of life years saved with this thought in mind: chronological age (in years) should not be the only element to take into account during the implementation of allocation strategies; 2) triage should be based on principles of distributive justice—prioritizing the best “cost/opportunity” ratio—and proportionality—by not hospitalizing patients with minimum benefits foreseen (like patients with advanced disease related limited life expectancy)—; and 3) if possible, recommendation to implement a shared decision-making process between the health team and the patient/family through respectful and transparent communication in a context of confidence.</li></ul>Beyond these 3 categories, the medical literature is very consistent on the need to plan actions to support families and healthcare workers given the emotional impact/moral distress that follows the moral decisions made and the uncertainty surrounding the entire process.Specific recommendations<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035">AIn an attempt to provide medical care to all patients with acute respiratory failure (ARF), it is advisable to prioritize the fair allocation of admission based on objective criteria of adequacy and expectations of resolution of the process with good quality of life and functionality. Based on this perspective, and in a situation of crisis and lack of resources, it is advisable that only priority 1 and 2 patients (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) should be eligible for ICU and/or intermediate/semi-critical care unit admission.</li><li class="elsevierStyleListItem" id="lsti0040">BIt is advisable to adequate the ventilation of patients with ARF to the individual characteristics of each patient (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Comorbidity here will be defined as the presence of several disease process different from the current one whose severity can be measured using the Charlson Comorbidity Index: no comorbidity (0–1); high comorbidity (>3).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul>Document consensus signed by scientific societies and institutional ethics committeesFrom the general recommendations established by SEMICYUC ethics committee, a consensus paper was designed as a draft document whose final iteration was the consensus manuscript: “General recommendations for the management of difficult moral decisions and adequacy between healthcare intensity/allocation to intensive care units in exceptional situations of crisis” shown on <a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>.<elsevierMultimedia ident="fig0010"></elsevierMultimedia>Twenty-one scientific societies, 6 ethics committees on bioethics/palliative care plus another 5 entities participated in the writing of this final consensus document (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).<elsevierMultimedia ident="tbl0010"></elsevierMultimedia>DiscussionAs far as the authors know, this is the first consensus document—an extraordinarily wide one by the way—ever published in the scientific medical literature on moral and ethical recommendations to make difficult decisions in pandemic related situations of crisis at the ICU setting. Although there may be some limitations associated with how fast it was designed and developed, the 3-step methodology used gave rise to an organized and rigorous proposal.In the first place, we saw a lack of specific papers published in the medical literature on ethics and moral under situations of epidemiological crises. Yet despite this fact, we should mention that most studies found emphasize the need to provide the resource allocation process with ethical premises. They also emphasize the need to offer quality alternatives to alleviate symptoms in cases with poor disease progression.<a class="elsevierStyleCrossRef" href="#bib0080">16</a>On the other hand, it is striking to see the need of having to apply the principle of justice to every patient uniformly, and not just selectively based on their geriatric profile or chronic health problems.<a class="elsevierStyleCrossRef" href="#bib0040">8</a> Therefore, although there is consensus that we should try to maximize the number of people that will be benefited, the disability-free survival at hospital discharge, and the number of life years saved, most papers separate the resource allocation decision from the patient’s chronological age as the only valid strategy, thus opening the door to assess other variables like the degree of frailty, which is equivalent to the patients’ “biological age”.<a class="elsevierStyleCrossRefs" href="#bib0095">19,20</a>Finally, beyond developing step-wise proactive strategies based on epidemiological assessments, clinical knowledge, and resource optimization, the process of handling a crisis of public health requires reflecting on values such as responsibility, inclusion criteria, transparency, sensitivity or rationality.<a class="elsevierStyleCrossRef" href="#bib0035">7</a> The moral frameworks such as the consensus document described above will guide the healthcare workers and authorities in the difficult decision-making process that can eventually minimize collateral damage.<a class="elsevierStyleCrossRef" href="#bib0060">12</a>Conflicts of interestNone reported." "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1394502" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1278078" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1394503" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1278077" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methodology" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Results" "secciones" => array:5 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Brief summary of the medical literature" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Designing the document" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "General recommendations" ] 3 => array:2 [ "identificador" => "sec0035" "titulo" => "Specific recommendations" ] 4 => array:2 [ "identificador" => "sec0040" "titulo" => "Document consensus signed by scientific societies and institutional ethics committees" ] ] ] 7 => array:2 [ "identificador" => "sec0045" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0050" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2020-03-26" "fechaAceptado" => "2020-04-10" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1278078" "palabras" => array:5 [ 0 => "Pandemic" 1 => "Crisis care" 2 => "ICU" 3 => "Catastrophe" 4 => "Ethics" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1278077" "palabras" => array:5 [ 0 => "Pandemia" 1 => "Atención de crisis" 2 => "UCI" 3 => "Catástrofe" 4 => "Ética" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "In view of the exceptional public health situation caused by the COVID-19 pandemic, a consensus work has been promoted from the ethics group of the Spanish Society of Intensive, Critical Medicine and Coronary Units (SEMICYUC), with the objective of finding some answers from ethics to the crossroads between the increase of people with intensive care needs and the effective availability of means.In a very short period, the medical practice framework has been changed to a ‘catastrophe medicine’ scenario, with the consequent change in the decision-making parameters. In this context, the allocation of resources or the prioritization of treatment become crucial elements, and it is important to have an ethical reference framework to be able to make the necessary clinical decisions. For this, a process of narrative review of the evidence has been carried out, followed by unsystematic consensus of experts, which has resulted in both the publication of a position paper and recommendations from SEMICYUC itself, and the consensus between 18 scientific societies and 5 institutes/chairs of bioethics and palliative care of a framework document of reference for general ethical recommendations in this context of crisis." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Ante la situación excepcional de salud pública provocada por la pandemia por COVID-19, desde el grupo de ética de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) se ha promovido un trabajo de consenso con el objetivo de encontrar algunas respuestas desde la ética a la encrucijada entre el incremento de personas con necesidades de atención intensiva y la disponibilidad efectiva de medios.En un periodo muy corto de tiempo, se ha cambiado el marco de ejercicio de la medicina hacia un escenario de «medicina de catástrofe», con el consecuente cambio en los parámetros de toma de decisiones. En este contexto la asignación de recursos o la priorización de tratamiento pasan a ser elementos cruciales, y es importante contar con un marco de referencia ético para poder tomar las decisiones clínicas necesarias. Para ello, se ha realizado un proceso de revisión narrativa de la evidencia, seguida de uconsenso de expertos no sistematizado, que ha tenido como resultado tanto la publicación de un documento de posicionamiento y recomendaciones de la propia SEMICYUC, como el consenso entre 18 sociedades científicas y 5 institutos/cátedras de bioética y cuidados paliativos de un documento marco de referencia de recomendaciones éticas generales en este contexto de crisis." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Rubio O, Estella A, Cabre L, Saralegui-Reta I, Martin MC, Zapata L, 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. Med Intensiva. 2020;44:439–445." ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1533 "Ancho" => 2513 "Tamanyo" => 381070 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "Model of 4 categories for prioritizing and allocating patients based on their individual characteristics and current situation. CPR, cardiopulmonary resuscitation; OTI, orotracheal intubation. *Consider the option of admitting priority 2 patients in other health areas such as intermediate care units when available and not saturated with priority patients." ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2940 "Ancho" => 3119 "Tamanyo" => 1517548 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "General recommendations on difficult moral decisions and adequacy between healthcare intensity/allocation to intensive care units in exceptional situations of crisis." ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "IMV, invasive mechanical ventilation; NIMV: non-invasive mechanical ventilation.Charlson Comorbidity Index >3." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Individual characteristics of each patient \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Proposal for mechanical ventilation for the management of COVID-19 related respiratory failure \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>80 years old with comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient will receive an oxygen mask at high concentrations of oxygen, high-flow oxygen therapy or NIMV (the last 2 procedures will be considered on a risk/benefit ratio due to the production of aerosols in shared rooms and depending on the availability of monitorization in the conventional hospitalization floor). \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>80 years old without comorbidities \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Patient will receive an oxygen mask at high concentrations of oxygen, high-flow oxygen therapy or NIMV (the last 2 procedures will be considered on a risk/benefit ratio due to the production of aerosols in shared rooms and based on the availability of monitorization in the conventional hospitalization floor). The indication for IMV will be carefully and individually assessed based on each particular case on a risk/benefit ratio. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Between 70 and 80 years old \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Without significant pre-existing conditions \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IMV treatment is advised here. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">With moderate-severe comorbidities<a class="elsevierStyleCrossRef" href="#tblfn0005">a</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">The indication for IMV will be assessed individually and carefully and the patient will be treated with NIMV or a similar therapy preferably, when available. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dementia and/or neurodegenerative disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IMV treatment is ill-advised. \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">In all the cases mentioned above \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IMV will be withdrawn based on the evolution of the daily SOFA score, complications, and by establishing a judgement of futility. \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2393273.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "DCM, dilated cardiomyopathy, COPD, cirrhosis, chronic kidney disease, etc." ] ] ] "descripcion" => array:1 [ "en" => "Indications for IMV y NIMV based on the individual characteristics of each patient." ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Scientific societies \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Other societies \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society for Family and Community Medicine (CAMFIC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Bioethics Chair. University of Vic-UCC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society of Anesthesiology, Resuscitation and Pain Therapy (SCART) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Borja Bioethics Institute, Universitat Ramon Llull \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society of Emergency Medicine (SOCMUE) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">College of Physicians of Catalonia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society of Geriatrics and Gerontology (SCGG) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Foundation for Research, Teaching and Innovation in Patient Safety (FIDISP) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society of Intensive and Critical Care Medicine (SOCMIC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Francisco Vallés institute of Ethics. European University \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society of Pediatric Nurses (ACIP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Grup de recerca en cronicitat de la Catalunya central (C3RG) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan-Balearic Society of Internal Medicine (SCMI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Nurses of Catalonia \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Family and Community Nursing Association of Catalonia (AIFiCC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Observatory of Bioethics and Rights, University of Barcelona \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Federation of Associations of Community Nursing and Primary Care (FAECAP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Palliative Care Chair. University of Vic-UCC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Palliative Care Society of Catalonia and the Balearic Islands (SCBCP) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Medical Colleges Organization (OMC) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Palliative Care Nurses Association (AECPAL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society for Family and Community Medicine (SEMFYC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Emergency Medicine (SEMES) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Geriatric Medicine (SEMEG) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Geriatrics and Gerontology (SEGG) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Intensive Nursing and Coronary Units (SEEIUC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Intensive, Critical and Coronary Unit Medical Care (SEMICYUC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Internal Medicine (SEMI) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Palliative Care (SECPAL) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Spanish Society of Shared Care Plan (AEPCA) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Catalan Society for Family and Community Medicine (CAMFIC) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2393272.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Societies participating in the consensus document (in alphabetical order)." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:20 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "X. 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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

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

O. Rubioa,

Corresponding author

orubio@althaia.cat

Corresponding author.

, A. Estellab, L. Cabrec, I. Saralegui-Retad, M.C. Martine, L. Zapataf, M. Esquerdag, R. Ferrerh, A. Castellanosi, J. Trenadoj, J. Amblask

a Cuidados Intensivos, Althaia, Xarxa Assistencial Universitària de Manresa, Manresa, Barcelona, Spain

b Cuidados Intensivos, Hospital Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain

c Cuidados Intensivos, Comité de Bioética de Cataluña, Catalonia, Spain

d Cuidados Intensivos, Hospital Universitario de Áraba, Osakidetza Araba, Vitoria-Gasteiz, Spain

e Servicio de Medicina Intensiva, Hospital Universitario de Torrejón, Torrejón de Ardoz, Madrid, Spain

f Cuidados Intensivos, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain

g Instituto Borja de Bioética, Esplugues de Llobregat, Barcelona, Spain

h Servicio de Medicina Intensiva, Hospital Universitario Vall de Hebron, Barcelona, Spain

i Área de Medicina Crítica, Hospital Universitario y Politécnico La Fe, Valencia, Spain

j Servicio de Medicina Intensiva, Hospital Universitario Mútua de Terrassa, Terrassa, Barcelona, Spain

k Geriatría y Cuidados paliativos, Hospital Universitario de la Santa Creu de Vic, Central Catalonia Chronicity Research Group (C3RG), Universitat de Vic-UCC, Vic, Barcelona, Spain

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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Model of 4 categories for prioritizing and allocating patients based on their individual characteristics and current situation&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CPR&#44; cardiopulmonary resuscitation&#59; OTI&#44; orotracheal intubation&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#42;Consider the option of admitting priority 2 patients in other health areas such as intermediate care units when available and not saturated with priority patients&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The current pandemic due to the SARS-CoV-2 coronavirus that causes the COVID-19 disease is an unprecedented challenge for the entire healthcare system&#8212;especially for intensive care units &#40;ICU&#41;&#8212;because the most severe cases can develop acute respiratory distress syndrome &#40;ARDS&#41;&#44; sepsis&#47;septic shock&#44; and multi-organ failure including acute kidney injury and cardiac damage&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">While most people with COVID-19 develop mild or uncomplicated disease&#44; the early data from China show that 14&#37; develop serious disease that requires hospitalization and 5&#37; need to be hospitalized in an intensive care units &#40;ICU&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> In Lombardy&#44; Italy the total ICU capacity prior to the crisis was 720 beds &#40;2&#46;9&#37; of the overall number of hospital beds in a total of 74 hospitals&#44; with an occupation rate between 85&#37; and 90&#37; during the months of Winter&#41;&#46; Two weeks into the outbreak the system collapsed&#46; The patients admitted to the ICUs due to COVID-19 disease were already 556 &#40;equivalent to the 12&#37; of all cases that tested positive and 16&#37; of all hospitalized patients&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The experience gained in other countries and the reality lived daily in some of our hospitals shows the huge imbalance between the number of patients who require invasive mechanical ventilation and the actual resources available&#46; According to data recently published by the Spanish Society of Intensive&#44; Critical and Coronary Unit Medical Care &#40;SEMICYUC&#41;&#44;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the number of ICU beds in Spain is around 3600&#44; which is a 7&#46;7 bed ratio for every 100&#8239;000 inhabitants &#40;compared to 29&#46;2&#47;100&#8239;000 inhabitants in Germany and 4&#46;2&#47;100&#8239;000 inhabitants in Portugal jut to mention 2 examples of neighboring countries&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> To this day &#40;March 22th&#44; 2020&#41;&#44; the number of patients &#40;cumulative incidence&#41; with COVID-19 who required ICU admission in Spain is already 1785&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The dilemma between this anticipated excessive need for invasive ventilation and the limited resources available will probably be leading us to a situation of &#8220;disaster medicine&#8221; where difficult moral decisions will need to be made for allocating resources and prioritizing patients&#46; In the short and long-term&#44; this reality will have a tremendous impact on the patients and their families&#46; Also&#44; health workers will be impacted&#44; which may be even more catastrophic that the disease <span class="elsevierStyleItalic">per se&#46;</span><a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Since difficult ethical decisions will need to be made based on solid criteria and basic moral principles grounded on the equal and fair provision of services&#44; the SEMICYUC ethics committee has promoted consensus in order to hekp healthcare workers handle this complex situation&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Methodology</span><p id="par0030" class="elsevierStylePara elsevierViewall">Given the urgency of the current situation&#44; an agile and resolute 3-stage methodology has been designed&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1</span><p id="par0035" class="elsevierStylePara elsevierViewall">Rapid summary of the medical literature published on the ethics behind decision-making processes under exceptional circumstances of pandemic related crises&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2</span><p id="par0040" class="elsevierStylePara elsevierViewall">Design of an online&#44; non-systematic consensus document between health workers from SEMICYUC ethics committee and experts on bioethics&#44; geriatrics&#44; and palliative care&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3</span><p id="par0045" class="elsevierStylePara elsevierViewall">Consensus document including general recommendations signed by scientific societies and institutional ethics committees&#46;</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Brief summary of the medical literature</span><p id="par0050" class="elsevierStylePara elsevierViewall">After extensive search of the medical literature available&#44; 9 especially relevant papers have been found on the ethics behind decision-making processes under exceptional situations in pandemic related crises&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;15</span></a> Three of them are articles that specifically reviewed aspects of palliative care in this context&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">16&#8211;18</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Designing the document</span><p id="par0055" class="elsevierStylePara elsevierViewall">Based on the actual scientific evidence available and the online work conducted by the authors of this article&#44; the first document draft was envisioned&#58; &#8220;Moral recommendations for decision-making processes in the exceptional situation of crisis due to the current COVID-19 pandemic in the intensive care unit setting&#8221;&#46; Two are the objectives of this manuscript&#58; 1&#41; bring support to the healthcare workers in the difficult decisions they will have to make by providing them with generally agreed criteria allowing them to share responsibility in the difficult decisions made under situations that require a great emotional load&#44; and 2&#41; specify criteria of adequacy and resource allocation in situations of exceptionality and scarcity&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">General recommendations</span><p id="par0060" class="elsevierStylePara elsevierViewall">First&#44; a series of general recommendations were developed that can be grouped into 3 large categories&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">A</span><p id="par0065" class="elsevierStylePara elsevierViewall">Recommendations regarding <span class="elsevierStyleItalic">organization</span>&#44; <span class="elsevierStyleItalic">availability of resources</span> and <span class="elsevierStyleItalic">alternatives</span>&#58; 1&#41; need to implement a territorial contingency plan with solidarity among different centers as the leading criterion&#59; 2&#41; optimization of personal&#44; structural&#44; and material resources&#59; 3&#41; consensus of common technical and ethical criteria by proposing the creation of committees including territorial experts&#44; and 4&#41; planning alternatives&#44; especially for people who may need palliative care treatment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">B</span><p id="par0070" class="elsevierStylePara elsevierViewall">Recommendations regarding the patient&#8217;s <span class="elsevierStyleItalic">individual characteristics</span> and <span class="elsevierStyleItalic">overall situation</span>&#46; Need to perform a comprehensive assessment 1&#41; including a multidimensional assessment of the overall situation or &#8220;biological age&#8221; of the patient with his values and preferences including the possibility that he has signed an Anticipatory Last Will and Testament Document &#40;ALWTD&#41; or an Anticipatory Care Planning &#40;ACP&#41;&#59; 2&#41; with better arrangements for ICU admissions based on a model of 4 categories of prioritizing these admissions &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#44; and 3&#41; taking into consideration the need for a dynamic adequacy of care by guaranteeing quality palliative care in cases with poor progression&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">C</span><p id="par0075" class="elsevierStylePara elsevierViewall">Recommendations regarding <span class="elsevierStyleItalic">moral decisions</span>&#58; 1&#41; need to apply specific moral criteria for situations of crisis by implementing an allocation strategy to maximize survival after hospital discharge and the number of life years saved with this thought in mind&#58; chronological age &#40;in years&#41; should not be the only element to take into account during the implementation of allocation strategies&#59; 2&#41; triage should be based on principles of distributive justice&#8212;prioritizing the best &#8220;cost&#47;opportunity&#8221; ratio&#8212;and proportionality&#8212;by not hospitalizing patients with minimum benefits foreseen &#40;like patients with advanced disease related limited life expectancy&#41;&#8212;&#59; and 3&#41; if possible&#44; recommendation to implement a shared decision-making process between the health team and the patient&#47;family through respectful and transparent communication in a context of confidence&#46;</p></li></ul></p><p id="par0080" class="elsevierStylePara elsevierViewall">Beyond these 3 categories&#44; the medical literature is very consistent on the need to plan actions to support families and healthcare workers given the emotional impact&#47;moral distress that follows the moral decisions made and the uncertainty surrounding the entire process&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Specific recommendations</span><p id="par0085" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">A</span><p id="par0090" class="elsevierStylePara elsevierViewall">In an attempt to provide medical care to all patients with acute respiratory failure &#40;ARF&#41;&#44; it is advisable to prioritize the <span class="elsevierStyleItalic">fair allocation of admission</span> based on objective criteria of adequacy and expectations of resolution of the process with good quality of life and functionality&#46; Based on this perspective&#44; and in a situation of crisis and lack of resources&#44; it is advisable that only priority 1 and 2 patients &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; should be eligible for ICU and&#47;or intermediate&#47;semi-critical care unit admission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">B</span><p id="par0095" class="elsevierStylePara elsevierViewall">It is advisable to adequate <span class="elsevierStyleItalic">the ventilation of patients with ARF</span> to the individual characteristics of each patient &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Comorbidity here will be defined as the presence of several disease process different from the current one whose severity can be measured using the Charlson Comorbidity Index&#58; no comorbidity &#40;0&#8211;1&#41;&#59; high comorbidity &#40;&#62;3&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></li></ul></p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Document consensus signed by scientific societies and institutional ethics committees</span><p id="par0100" class="elsevierStylePara elsevierViewall">From the general recommendations established by SEMICYUC ethics committee&#44; a consensus paper was designed as a draft document whose final iteration was the consensus manuscript&#58; &#8220;General recommendations for the management of difficult moral decisions and adequacy between healthcare intensity&#47;allocation to intensive care units in exceptional situations of crisis&#8221; shown on <a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">Twenty-one scientific societies&#44; 6 ethics committees on bioethics&#47;palliative care plus another 5 entities participated in the writing of this final consensus document &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Discussion</span><p id="par0110" class="elsevierStylePara elsevierViewall">As far as the authors know&#44; this is the first consensus document&#8212;an extraordinarily wide one by the way&#8212;ever published in the scientific medical literature on moral and ethical recommendations to make difficult decisions in pandemic related situations of crisis at the ICU setting&#46; Although there may be some limitations associated with how fast it was designed and developed&#44; the 3-step methodology used gave rise to an organized and rigorous proposal&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the first place&#44; we saw a lack of specific papers published in the medical literature on ethics and moral under situations of epidemiological crises&#46; Yet despite this fact&#44; we should mention that most studies found emphasize the need to provide the resource allocation process with ethical premises&#46; They also emphasize the need to offer quality alternatives to alleviate symptoms in cases with poor disease progression&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">On the other hand&#44; it is striking to see the need of having to apply the principle of justice to every patient uniformly&#44; and not just selectively based on their geriatric profile or chronic health problems&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> Therefore&#44; although there is consensus that we should try to maximize the number of people that will be benefited&#44; the disability-free survival at hospital discharge&#44; and the number of life years saved&#44; most papers separate the resource allocation decision from the patient&#8217;s chronological age as the only valid strategy&#44; thus opening the door to assess other variables like the degree of frailty&#44; which is equivalent to the patients&#8217; &#8220;biological age&#8221;&#46;<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19&#44;20</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">Finally&#44; beyond developing step-wise proactive strategies based on epidemiological assessments&#44; clinical knowledge&#44; and resource optimization&#44; the process of handling a crisis of public health requires reflecting on values such as responsibility&#44; inclusion criteria&#44; transparency&#44; sensitivity or rationality&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The moral frameworks such as the consensus document described above will guide the healthcare workers and authorities in the difficult decision-making process that can eventually minimize collateral damage&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of interest</span><p id="par0130" class="elsevierStylePara elsevierViewall">None reported&#46;</p></span></span>"
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">In view of the exceptional public health situation caused by the COVID-19 pandemic&#44; a consensus work has been promoted from the ethics group of the Spanish Society of Intensive&#44; Critical Medicine and Coronary Units &#40;SEMICYUC&#41;&#44; with the objective of finding some answers from ethics to the crossroads between the increase of people with intensive care needs and the effective availability of means&#46;</p><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">In a very short period&#44; the medical practice framework has been changed to a &#8216;catastrophe medicine&#8217; scenario&#44; with the consequent change in the decision-making parameters&#46; In this context&#44; the allocation of resources or the prioritization of treatment become crucial elements&#44; and it is important to have an ethical reference framework to be able to make the necessary clinical decisions&#46; For this&#44; a process of narrative review of the evidence has been carried out&#44; followed by unsystematic consensus of experts&#44; which has resulted in both the publication of a position paper and recommendations from SEMICYUC itself&#44; and the consensus between 18 scientific societies and 5 institutes&#47;chairs of bioethics and palliative care of a framework document of reference for general ethical recommendations in this context of crisis&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Ante la situaci&#243;n excepcional de salud p&#250;blica provocada por la pandemia por COVID-19&#44; desde el grupo de &#233;tica de la Sociedad Espa&#241;ola de Medicina Intensiva&#44; Cr&#237;tica y Unidades Coronarias &#40;SEMICYUC&#41; se ha promovido un trabajo de consenso con el objetivo de encontrar algunas respuestas desde la &#233;tica a la encrucijada entre el incremento de personas con necesidades de atenci&#243;n intensiva y la disponibilidad efectiva de medios&#46;</p><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">En un periodo muy corto de tiempo&#44; se ha cambiado el marco de ejercicio de la medicina hacia un escenario de &#171;medicina de cat&#225;strofe&#187;&#44; con el consecuente cambio en los par&#225;metros de toma de decisiones&#46; En este contexto la asignaci&#243;n de recursos o la priorizaci&#243;n de tratamiento pasan a ser elementos cruciales&#44; y es importante contar con un marco de referencia &#233;tico para poder tomar las decisiones cl&#237;nicas necesarias&#46; Para ello&#44; se ha realizado un proceso de revisi&#243;n narrativa de la evidencia&#44; seguida de uconsenso de expertos no sistematizado&#44; que ha tenido como resultado tanto la publicaci&#243;n de un documento de posicionamiento y recomendaciones de la propia SEMICYUC&#44; como el consenso entre 18 sociedades cient&#237;ficas y 5 institutos&#47;c&#225;tedras de bio&#233;tica y cuidados paliativos de un documento marco de referencia de recomendaciones &#233;ticas generales en este contexto de crisis&#46;</p></span>"
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        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as&#58; Rubio O&#44; Estella A&#44; Cabre L&#44; Saralegui-Reta I&#44; Martin MC&#44; Zapata L&#44; et al&#46; Recomendaciones &#233;ticas para la toma de decisiones dif&#237;ciles en las unidades de cuidados intensivos ante la situaci&#243;n excepcional de crisis por la pandemia por COVID-19&#58; revisi&#243;n r&#225;pida y consenso de expertos&#46; Med Intensiva&#46; 2020&#59;44&#58;439&#8211;445&#46;</p>"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Model of 4 categories for prioritizing and allocating patients based on their individual characteristics and current situation&#46;</p> <p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">CPR&#44; cardiopulmonary resuscitation&#59; OTI&#44; orotracheal intubation&#46;</p> <p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">&#42;Consider the option of admitting priority 2 patients in other health areas such as intermediate care units when available and not saturated with priority patients&#46;</p>"
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          "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">IMV&#44; invasive mechanical ventilation&#59; NIMV&#58; non-invasive mechanical ventilation&#46;</p><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Charlson Comorbidity Index &#62;3&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Individual characteristics of each patient&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Proposal for mechanical ventilation for the management of COVID-19 related respiratory failure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#62;80 years old with comorbidities</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Patient will receive an oxygen mask at high concentrations of oxygen&#44; high-flow oxygen therapy or NIMV &#40;the last 2 procedures will be considered on a risk&#47;benefit ratio due to the production of aerosols in shared rooms and depending on the availability of monitorization in the conventional hospitalization floor&#41;&#46;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">&#62;80 years old without comorbidities</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Patient will receive an oxygen mask at high concentrations of oxygen&#44; high-flow oxygen therapy or NIMV &#40;the last 2 procedures will be considered on a risk&#47;benefit ratio due to the production of aerosols in shared rooms and based on the availability of monitorization in the conventional hospitalization floor&#41;&#46; The indication for IMV will be carefully and individually assessed based on each particular case on a risk&#47;benefit ratio&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Between 70 and 80 years old</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Without significant pre-existing conditions&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">IMV treatment is advised here&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>With moderate-severe comorbidities<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">The indication for IMV will be assessed individually and carefully and the patient will be treated with NIMV or a similar therapy preferably&#44; when available&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">Dementia and&#47;or neurodegenerative disease</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">IMV treatment is ill-advised&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">In all the cases mentioned above</span>&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">IMV will be withdrawn based on the evolution of the daily SOFA score&#44; complications&#44; and by establishing a judgement of futility&#46;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Scientific societies&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Catalan Society for Family and Community Medicine &#40;CAMFIC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">Bioethics Chair&#46; University of Vic-UCC&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Catalan Society of Anesthesiology&#44; Resuscitation and Pain Therapy &#40;SCART&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Borja Bioethics Institute&#44; Universitat Ramon Llull&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Catalan Society of Emergency Medicine &#40;SOCMUE&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">College of Physicians of Catalonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catalan Society of Geriatrics and Gerontology &#40;SCGG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Foundation for Research&#44; Teaching and Innovation in Patient Safety &#40;FIDISP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catalan Society of Intensive and Critical Care Medicine &#40;SOCMIC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Francisco Vall&#233;s institute of Ethics&#46; European University&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catalan Society of Pediatric Nurses &#40;ACIP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Grup de recerca en cronicitat de la Catalunya central &#40;C3RG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catalan-Balearic Society of Internal Medicine &#40;SCMI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Nurses of Catalonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Family and Community Nursing Association of Catalonia &#40;AIFiCC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Observatory of Bioethics and Rights&#44; University of Barcelona&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Federation of Associations of Community Nursing and Primary Care &#40;FAECAP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Palliative Care Chair&#46; University of Vic-UCC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Palliative Care Society of Catalonia and the Balearic Islands &#40;SCBCP&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Medical Colleges Organization &#40;OMC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Palliative Care Nurses Association &#40;AECPAL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society for Family and Community Medicine &#40;SEMFYC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Anesthesiology&#44; Resuscitation&#44; and Pain Therapy &#40;SEDAR&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Emergency Medicine &#40;SEMES&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Geriatric Medicine &#40;SEMEG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Geriatrics and Gerontology &#40;SEGG&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Intensive Nursing and Coronary Units &#40;SEEIUC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Intensive&#44; Critical and Coronary Unit Medical Care &#40;SEMICYUC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Internal Medicine &#40;SEMI&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Palliative Care &#40;SECPAL&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Spanish Society of Shared Care Plan &#40;AEPCA&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Catalan Society for Family and Community Medicine &#40;CAMFIC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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                0 => "xTab2393272.png"
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        "descripcion" => array:1 [
          "en" => "<p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Societies participating in the consensus document &#40;in alphabetical order&#41;&#46;</p>"
        ]
      ]
    ]
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      "titulo" => "References"
      "seccion" => array:1 [
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            0 => array:3 [
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan&#44; China&#58; a single-centered&#44; retrospective&#44; observational study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "X&#46; Yang"
                            1 => "Y&#46; Yu"
                            2 => "J&#46; Xu"
                            3 => "H&#46; Shu"
                            4 => "J&#46; Xia"
                            5 => "H&#46; Liu"
                          ]
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                      ]
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                  ]
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                    0 => array:2 [
                      "doi" => "10.1016/S2213-2600(20)30079-5"
                      "Revista" => array:3 [
                        "tituloSerie" => "Lancet Respir Med"
                        "fecha" => "2020"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24429275"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
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                ]
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            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Characteristics of and important lessons from the coronavirus disease 2019 &#40;COVID-19&#41; outbreak in China"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "Z&#46; Wu"
                            1 => "J&#46;M&#46; McGoogan"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/jama.2020.2648"
                      "Revista" => array:3 [
                        "tituloSerie" => "JAMA"
                        "fecha" => "2020"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/9676687"
                            "web" => "Medline"
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                0 => array:2 [
                  "contribucion" => array:1 [
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                      "titulo" => "Critical care utilization for the COVID-19 outbreak in Lombardy&#44; Italy"
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                          "autores" => array:3 [
                            0 => "G&#46; Grasselli"
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1001/jama.280.3.292"
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                        "tituloSerie" => "JAMA"
                        "fecha" => "2020"
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                          0 => array:2 [
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                      "titulo" => "Plan de contingencia para los servicios de medicina intensiva frente a la pandemia COVID-19"
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                          "etal" => true
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                            3 => "L&#46;F&#46; CarrascoRodr&#237;guez-Rey"
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                      "doi" => "10.1016/j.enfi.2020.03.001"
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                        "tituloSerie" => "Enferm Intensiva"
                        "fecha" => "2020"
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              "etiqueta" => "5"
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                      "titulo" => "Recursos estructurales de los Servicios de Medicina Intensiva en Espa&#241;a"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "M&#46;C&#46; Mart&#237;n"
                            1 => "C&#46; Le&#243;n"
                            2 => "J&#46; Cu&#241;at"
                            3 => "F&#46; del Nogal"
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                    0 => array:2 [
                      "doi" => "10.1016/j.medin.2013.06.002"
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                        "tituloSerie" => "Med Intensiva"
                        "fecha" => "2013"
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                        "paginaInicial" => "443"
                        "paginaFinal" => "451"
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                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24011639"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Actualizaci&#243;n n&#46;o 52&#46; Enfermedad por el coronavirus &#40;COVID-19&#41;"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "Ministerio de Sanidad"
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                    0 => array:1 [
                      "WWW" => array:2 [
                        "link" => "https&#58;&#47;&#47;www&#46;mscbs&#46;gob&#46;es&#47;en&#47;profesionales&#47;saludPublica&#47;ccayes&#47;alertasActual&#47;nCov-China&#47;documentos&#47;Actualizacion&#95;52&#95;COVID-19&#46;pdf"
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            6 => array:3 [
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                      "titulo" => "Pandemic influenza preparedness&#58; an ethical framework to guide decision-making"
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                          "etal" => false
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                            0 => "A&#46;K&#46; Thompson"
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                    0 => array:2 [
                      "titulo" => "Who should receive life support during a public health emergency&#63; Using ethical principles to improve allocation decisions"
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                          "etal" => false
                          "autores" => array:4 [
                            0 => "D&#46;B&#46; White"
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                            2 => "J&#46;M&#46; Luce"
                            3 => "B&#46; Lo"
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                    0 => array:2 [
                      "doi" => "10.7326/0003-4819-150-2-200901200-00011"
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                        "tituloSerie" => "Ann Intern Med"
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Article information

ISSN: 21735727
Original language: English

DOI:10.1016/j.medine.2020.06.002

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2024 September	92	39	131
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2023 June	97	26	123
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