Preparing for the Worst-Case Scenario in a Pandemic: Intensivists Simulate Prioritization and Triage of Scarce ICU Resources.

OBJECTIVES: Simulation and evaluation of a prioritization protocol at a German university hospital using a convergent parallel mixed methods design. DESIGN: Prospective single-center cohort study with a quantitative analysis of ICU patients and qualitative content analysis of two focus groups with intensivists. SETTING: Five ICUs of internal medicine and anesthesiology at a German university hospital. PATIENTS: Adult critically ill ICU patients ( n = 53). INTERVENTIONS: After training the attending senior ICU physicians ( n = 13) in rationing, an impending ICU congestion was simulated. All ICU patients were rated according to their likelihood to survive their acute illness (good-moderate-unfavorable). From each ICU, the two patients with the most unfavorable prognosis ( n = 10) were evaluated by five prioritization teams for triage. MEASUREMENTS AND MAIN RESULTS: Patients nominated for prioritization visit ( n = 10) had higher Sequential Organ Failure Assessment scores and already a longer stay at the hospital and on the ICU compared with the other patients. The order within this worst prognosis group was not congruent between the five teams. However, an in-hospital mortality of 80% confirmed the reasonable match with the lowest predicted probability of survival. Qualitative data highlighted the tremendous burden of triage and the need for a team-based consensus-oriented decision-making approach to ensure best possible care and to support professionals. Transparent communication within the teams, the hospital, and to the public was seen as essential for prioritization implementation. CONCLUSIONS: To mitigate potential bias and to reduce the emotional burden of triage, a consensus-oriented, interdisciplinary, and collaborative approach should be implemented. Prognostic comparative assessment by intensivists is feasible. The combination of long-term ICU stay and consistently high Sequential Organ Failure Assessment scores resulted in a greater risk for triage in patients. It remains challenging to reliably differentiate between patients with very low chances to survive and requires further conceptual and empirical research.

Transparent entscheiden im moralischen Dilemma : Ethische Entscheidungsempfehlungen zu Besuchsregelungen im Krankenhaus während der COVID-19-Pandemie

Zutrittsbeschränkungen in Krankenhäusern in der COVID-19-Pandemie führen zu großen Belastungen bei Patienten, ihren Angehörigen und Mitarbeitenden. Für die Kliniken stellen sie eine komplexe organisationsethische Herausforderung dar. Die vorliegenden prozeduralen Empfehlungen sollen die Entscheidungsfindung auf Meso- und Mikroebene unterstützen.

[Recommendations for ethical decision making regarding hospital visitation during the COVID-19 pandemic]. / Ethische Entscheidungsempfehlungen zu Besuchsregelungen im Krankenhaus während der COVID-19-Pandemie.

Visitation restrictions in hospitals during the COVID-19 (coronavirus disease 2019) pandemic led to great psychological burden for patients, their relatives and employees. For hospitals, they represent a complex organizational challenge with respect to ethics. The present recommendations are intended to support decision-making at the meso- and microlevels.

Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic : Clinical and ethical recommendations of DIVI, DGINA, DGAI, DGIIN, DGNI, DGP, DGP and AEM.

In view of the globally evolving coronavirus disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary group of authors with the support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethicolegal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supraindividual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. The assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient's general health status prior to the current illness.

[Moral distress in medical students and young professionals: research desiderata in the context of the COVID-19 pandemic]. / Moralischer Stress bei Medizinstudierenden und ärztlichen Berufseinsteigenden: Forschungsdesiderate im Rahmen der COVID-19-Pandemie.

BACKGROUND: The COVID-19 pandemic poses particular challenges for people working in the medical sector. Some of the medical students and young medical professionals who are starting their work in healthcare facilities during this time are confronted with extraordinary moral challenges. A portion of them does not yet have sufficient coping skills to adequately deal with these challenges. This can lead to so-called moral distress (MoD). Permanent or intensive exposure to MoD can have serious consequences. Appropriate support services have the potential to improve the handling of MoD. OBJECTIVE: This article aims to provide an overview of the current state of research on MoD among medical students and young medical professionals in order to sensitize lecturers with responsibility for education and training and doctors in leading positions to the problem. MAIN PART: This article presents the scientific concept of MoD, known triggers, and options for prevention and intervention. The topic is presented with reference to the changes in patient care in the context of the COVID-19 pandemic and research needs are presented. CONCLUSION: The article illustrates the necessity of a German-language, interdisciplinary discourse on MoD among medical students and young professionals.

[Decisions on the allocation of intensive care resources in the context of the COVID-19 pandemic : Clinical and ethical recommendations of DIVI, DGINA, DGAI, DGIIN, DGNI, DGP, DGP and AEM. German version]. / Entscheidungen über die Zuteilung intensivmedizinischer Ressourcen im Kontext der COVID-19-Pandemie : Klinisch-ethische Empfehlungen der DIVI, der DGINA, der DGAI, der DGIIN, der DGNI, der DGP, der DGP und der AEM.

In view of the globally evolving Coronavirus Disease (COVID-19) pandemic, German hospitals rapidly expanded their intensive care capacities. However, it is possible that even with an optimal use of the increased resources, these will not suffice for all patients in need. Therefore, recommendations for the allocation of intensive care resources in the context of the COVID-19 pandemic have been developed by a multidisciplinary authors group with support of eight scientific medical societies. The recommendations for procedures and criteria for prioritisations in case of resource scarcity are based on scientific evidence, ethico-legal considerations and practical experience. Medical decisions must always be based on the need and the treatment preferences of the individual patient. In addition to this patient-centred approach, prioritisations in case of resource scarcity require a supra-individual perspective. In such situations, prioritisations should be based on the criterion of clinical prospect of success in order to minimize the number of preventable deaths due to resource scarcity and to avoid discrimination based on age, disabilities or social factors. Assessment of the clinical prospect of success should take into account the severity of the current illness, severe comorbidities and the patient's general health status prior to the current illness.