After 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.7–15 Three of them are articles that specifically reviewed aspects of palliative care in this context.16–18

Based 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.

First, a series of general recommendations were developed that can be grouped into 3 large categories:

• A

  Recommendations 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.

• B

  Recommendations 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 (Fig. 1), and 3) taking into consideration the need for a dynamic adequacy of care by guaranteeing quality palliative care in cases with poor progression.

  
  

  Figure 1.

  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.

  (0.36MB).
• C

  Recommendations 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.

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.

• A

  In 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 (Fig. 1) should be eligible for ICU and/or intermediate/semi-critical care unit admission.

• B

  It is advisable to adequate the ventilation of patients with ARF to the individual characteristics of each patient (Table 1). 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).

  Table 1.

  Indications for IMV y NIMV based on the individual characteristics of each patient.

  Individual characteristics of each patient	Proposal for mechanical ventilation for the management of COVID-19 related respiratory failure
  >80 years old with comorbidities	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).
  >80 years old without comorbidities	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.
  Between 70 and 80 years old
  Without significant pre-existing conditions	IMV treatment is advised here.
  With moderate-severe comorbiditiesa	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.
  Dementia and/or neurodegenerative disease	IMV treatment is ill-advised.
  In all the cases mentioned above	IMV will be withdrawn based on the evolution of the daily SOFA score, complications, and by establishing a judgement of futility.

  IMV, invasive mechanical ventilation; NIMV: non-invasive mechanical ventilation.

  Charlson Comorbidity Index >3.

  a

  DCM, dilated cardiomyopathy, COPD, cirrhosis, chronic kidney disease, etc.

From 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 Fig. 2.

Figure 2.

General recommendations on difficult moral decisions and adequacy between healthcare intensity/allocation to intensive care units in exceptional situations of crisis.

(1.45MB).

Twenty-one scientific societies, 6 ethics committees on bioethics/palliative care plus another 5 entities participated in the writing of this final consensus document (Table 2).