Age-based triage looms in Italy and UK for allocation of ventilators and ICU beds

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Italy‘s pressured health services has issued guidelines on the rationing of ventilators and intensive care beds, as patient demand escalates, while in the former chief scientific adviser to the UK government has urged the frail elderly to considering refusing hospital treatment because their chances of survival were slim.

People over the age of 90 should think twice about going into hospital during the coronavirus outbreak to avoid “clogging up” the National Health Service (NHS), The Daily Telegraph reports that the former chief scientific adviser has suggested. Professor Sir David King urged frail elderly people to consider refusing hospital treatment during the crisis because their chances of survival were slim. But charities representing older people criticised his remarks and said patients should be offered the same standards of life-saving care regardless of their age.

The report says it comes as under-pressure hospitals across the country begin drawing up plans to ration ventilators and intensive care beds, with priority given to younger and healthier patients. “I think it’s fair to ask people in the region of 90 or 95 years old to think twice before going into hospital under the present circumstances,” Sir David said. “At the very least, they should be consulting their GP before making that decision.
“The truth is that people of that age are, in many cases, unlikely to come out of hospital once they go in. And of course, there is a risk that you are overburdening the NHS. We really don’t want 90-year-olds clogging up hospitals at this critical time.”

One senior director at a London acute trust said last week: “We are going to have to quickly agree some clinical thresholds for admissions to intensive care. This is what the Italians have had to do and, whether it’s set at 60 or whatever, we are going to have to do something similar. There’s no way we’re going to be able to scale up to the level we need otherwise.”

An NHS England spokesperson said in the report: “As the chief medical officer has said, as coronavirus expands the NHS will flex its response in line with well-established escalation plans.”

In Italy, there are now simply too many patients for each one of them to receive adequate care. Doctors and nurses are unable to tend to everybody. They lack machines to ventilate all those gasping for air. Now, writes Yascha Mounk, an associate professor at Johns Hopkins University, a senior fellow at the German Marshall Fund, and a senior adviser at Protect Democracy in The Atlantic, the Italian College of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow as these already extraordinary circumstances worsen.

Mounk writes that the document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”

The principle they settle upon is utilitarian. “Informed by the principle of maximising benefits for the largest number,” they suggest that “the allocation criteria need to guarantee that those patients with the highest chance of therapeutic success will retain access to intensive care.”

The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: “It may become necessary to establish an age limit for access to intensive care.”

Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”

In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious pre-existing health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”

Mounk writes that these guidelines apply even to patients who require intensive care for reasons other than the coronavirus, because they too make demands on the same scarce medical resources. As the document clarifies, “These criteria apply to all patients in intensive care, not just those infected with COVID-19.”

The National Institute for Health and Care Excellence in the UK is to publish rapid guidance on the diagnosis and treatment of COVID-19. According to a Health Services Journal report, the organisation expects to publish guidance on three topics per week, according to an email from out-going CEO Sir Andrew Dillon.

NICE will also free any front-line staff from its committees to support the COVID-19 effort, although it will continue to produce guidance on “therapeutically critical” topics. The body has published its first set of covid-19 guidance – on patients in critical care, on renal dialysis units and on patients undergoing chemotherapy. It is also producing rapid evidence reviews on medicine to guide NHS England’s COVID-19 commissioning policies.

The report says the first reviews will focus on the short-term use of non-steroidal anti-inflammatory drugs for acute viral respiratory infection and on angiotensin converting enzyme inhibitors.

Full report in The Daily Telegraph

Full Health Service Journal report

NICE guidance 1

Full report in The Atlantic

SIAARTI guidelines

SEE also

UK guidelines on selecting COVID-19 patients for critical care

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