Riccioni Luigi, Ingravallo Francesca, Grasselli Giacomo, Mazzon Davide, Cingolani Emiliano, Forti Gabrio, Zagrebelsky Vladimiro, Zoja Riccardo, Petrini Flavia
Anesthesia and Intensive Care, San Camillo-Forlanini Hospital, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
Legal Medicine, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
Ann Intensive Care. 2021 Jun 29;11(1):100. doi: 10.1186/s13613-021-00888-4.
In early 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published clinical ethics recommendations for the allocation of intensive care during COVID-19 pandemic emergency. Later the Italian National Institute of Health (ISS) invited SIAARTI and the Italian Society of Legal and Insurance Medicine to prepare a draft document for the definition of triage criteria for intensive care during the emergency, to be implemented in case of complete saturation of care resources.
Following formal methods, including two Delphi rounds, a multidisciplinary group with expertise in intensive care, legal medicine and law developed 12 statements addressing: (1) principles and responsibilities; (2) triage; (3) previously expressed wishes; (4) reassessment and shifting to palliative care; (5) collegiality and transparency of decisions. The draft of the statements, with their explanatory comments, underwent a public consultation opened to Italian scientific or technical-professional societies and other stakeholders (i.e., associations of citizens, patients and caregivers; religious communities; industry; public institutions; universities and research institutes). Individual healthcare providers, lay people, or other associations could address their comments by e-mail.
Eight stakeholders (including scientific societies, ethics organizations, and a religious community), and 8 individuals (including medical experts, ethicists and an association) participated to the public consultation. The stakeholders' agreement with statements was on average very high (ranging from 4.1 to 4.9, on a scale from 1-full disagreement to 5-full agreement). The 4 statements concerning triage stated that in case of saturation of care resources, the intensive care triage had to be oriented to ensuring life-sustaining treatments to as many patients as possible who could benefit from them. The decision should follow full assessment of each patient, taking into account comorbidities, previous functional status and frailty, current clinical condition, likely impact of intensive treatment, and the patient's wishes. Age should be considered as part of the global assessment of the patient.
Lacking national guidelines, the document is the reference standard for healthcare professionals in case of imbalance between care needs and available resources during a COVID-19 pandemic in Italy, and a point of reference for the medico-legal assessment in cases of dispute.
2020年初，意大利麻醉、镇痛、复苏与重症监护学会（SIAARTI）发布了关于在新冠疫情紧急情况下重症监护资源分配的临床伦理建议。后来，意大利国家卫生研究所（ISS）邀请SIAARTI以及意大利法律与保险医学学会编写一份文件草案，用于确定紧急情况下重症监护的分诊标准，以便在护理资源完全饱和时实施。
遵循包括两轮德尔菲法在内的正式方法，一个由重症监护、法医学和法律领域专家组成的多学科小组制定了12条声明，涉及：（1）原则和责任；（2）分诊；（3）先前表达的意愿；（4）重新评估和转向姑息治疗；（5）决策的合议性和透明度。声明草案及其解释性评论进行了公开咨询，咨询对象为意大利科学或技术专业协会以及其他利益相关者（即公民、患者和护理人员协会；宗教团体；行业；公共机构；大学和研究机构）。个体医疗服务提供者、普通民众或其他协会可以通过电子邮件发表意见。
八个利益相关者（包括科学协会、伦理组织和一个宗教团体）以及八个人（包括医学专家、伦理学家和一个协会）参与了公开咨询。利益相关者对声明的平均认可度非常高（在从1 - 完全不同意到5 - 完全同意的量表上，范围为4.1至4.9）。关于分诊的4条声明指出，在护理资源饱和的情况下，重症监护分诊必须旨在确保为尽可能多的能够从中受益的患者提供维持生命的治疗。该决定应在对每位患者进行全面评估后做出，要考虑到合并症、先前的功能状态和虚弱程度、当前的临床状况、强化治疗的可能影响以及患者的意愿。年龄应被视为对患者进行全面评估的一部分。
由于缺乏国家指南，该文件是意大利在新冠疫情期间护理需求与可用资源失衡时医疗专业人员的参考标准，也是纠纷案件中法医学评估的参考依据。
