The Italian document: decisions for intensive care when there is an imbalance between care needs and resources during the COVID‑19 pandemic Luigi Riccioni1*

Background: In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI)\r\npublished clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic emergency.\r\nLater the Italian National Institute of Health (ISS) invited SIAARTI and the Italian Society of Legal and Insurance\r\nMedicine to prepare a draft document for the definition of triage criteria for intensive care during the emergency, to\r\nbe implemented in case of complete saturation of care resources.\r\nMethods: Following formal methods, including two Delphi rounds, a multidisciplinary group with expertise in\r\nintensive care, legal medicine and law developed 12 statements addressing: (1) principles and responsibilities; (2) triage;\r\n(3) previously expressed wishes; (4) reassessment and shifting to palliative care; (5) collegiality and transparency\r\nof decisions. The draft of the statements, with their explanatory comments, underwent a public consultation opened\r\nto Italian scientific or technical-professional societies and other stakeholders (i.e., associations of citizens, patients and\r\ncaregivers; religious communities; industry; public institutions; universities and research institutes). Individual healthcare\r\nproviders, lay people, or other associations could address their comments by e-mail.\r\nResults: Eight stakeholders (including scientific societies, ethics organizations, and a religious community), and\r\n8 individuals (including medical experts, ethicists and an association) participated to the public consultation. The\r\nstakeholders’ agreement with statements was on average very high (ranging from 4.1 to 4.9, on a scale from 1—full\r\ndisagreement to 5—full agreement). The 4 statements concerning triage stated that in case of saturation of care\r\nresources, the intensive care triage had to be oriented to ensuring life-sustaining treatments to as many patients\r\nas possible who could benefit from them. The decision should follow full assessment of each patient, taking into\r\naccount comorbidities, previous functional status and frailty, current clinical condition, likely impact of intensive treatment,\r\nand the patient’s wishes. Age should be considered as part of the global assessment of the patient.\r\nConclusions: Lacking national guidelines, the document is the reference standard for healthcare professionals in\r\ncase of imbalance between care needs and available resources during a COVID-19 pandemic in Italy, and a point of\r\nreference for the medico-legal assessment in cases of dispute.