Early Formation of ICU Allocation Guidelines and Role of Palliative Care
Pre-emptive guidelines should be formulated by experts in infectious diseases, critical care, emergency medicine, clinical ethics and palliative care before the spike in demand for ICU beds (Hick et al. 2007; Biddison et al. 2018; White and Lo 2020).
This will facilitate clear communication with the public regarding the practical and ethical issues surrounding allocation of scarce ICU resources and attenuate concerns about discrimination against minority groups, boost trust in the public healthcare system, facilitate transparent, accountable and evidence-based decision making, and build solidarity within the community.
Early Exploration of Advance Care Planning (ACP), Advanced Medical Directive (AMD) and Extent of Care (EoC)
This will ensure respect of autonomy, patient preferences and respect for antecedent preferences contained within ACPs and AMDs.
Continued Transparency and Accountability
Wherever possible, triage teams or an independent interdisciplinary team of experts dedicated to deliberating complex triage decisions if the primary care team faces difficult ethical dilemmas should be established. The triage team should be available for consultation throughout the day and include at least one ethicist, two senior healthcare professionals (HCPs) and a PM physician who will offer support and experience in identifying, assessing and treating the physical and psychosocial issues of the critically ill and dying.
The triage team will help ensure accountability in care determinations and ensure these decisions are rational, transparent, inclusive, reasonable, evidence-based and practical.
Optimization and Dynamic Surveillance of Existing Resources
In Singapore, stable patients are decanted to private hospitals, community hospitals and community isolation facilities to optimize resources in public acute hospitals (Ministry of Health 2020; Channel News Asia 2020). Resources including availability of ICU beds, key medications such as sedatives and opioids, supportive treatments such as dialysis machines, and personal protective equipment within all hospitals should be closely monitored.
A clear grasp of the situation and available resources would allow for greater efficacy and quality of care across the continuum. This ensures balanced decision-making and distribution of resources, and boosts collaborations. Concurrently there should be flexibility in the deployment of manpower to Internal Medicine and ICU care to ensure resources are easily redistributed and portable across care settings.
Equitable Allocation of Scarce Resources
The Guiding Ethical Principles should be adhered to by the triage team and should be informed by evidence-based prognostic tools such as the Sequential Failure Assessment (SOFA) score, Simplified Acute Physiology Score (SAPS 3), or the Acute Physiology And Chronic Health Evaluation (APACHE) score. A multi-dimensional scale that includes measures of frailty and physical function such as age and Clinical Frailty Scale (CFS) may also be used in tandem (Poole et al. 2012; Zhou et al. 2020; Zhang et al. 2020; MDCalc 2020; Chen et al. 2020).
Understanding the potential benefits that the patient is likely to accrue from ventilatory support, their prognosis and their previously stated wishes will determine the proportionality and beneficence of an ICU admission.
Reassessment of Responses and Continued Transparency with HCPs
Strategies adopted should be rigorously reassessed and adapted as the pandemic situation evolves. The PM team must also be involved in the care of patients and their families who are allocated ICU beds, and those patients and their families who are not. In addition the PM team must be involved in supporting healthcare professionals in the ICU and those caring for patients not been allocated ICU beds. Prevailing models in Singapore have seen PM physicians integrated into the ICU care team and working together with dedicated medical social work (MSW) teams to meet the following roles.
Provision of Support and Palliative Care in ICU
PM physicians together with MSWs should be involved in the creation of early PM consultation protocols, be part of daily ward rounds with the ICU teams, participate in education sessions for the ICU multidisciplinary team and provide regular debriefs for the ICU teams.
Provision of Support and Palliative Care Where Treatment Is Withheld
For patients not allocated ICU beds, PM physicians and MSWs should be involved immediately to support the patient’s and their family’s needs. To ensure effective care of these patients and families, the PM team should formulate guidelines and decision-making algorithms for pragmatic pharmacological and non-pharmacological methods of alleviating symptoms commonly associated with COVID-19 pneumonia, such as dyspnoea, excessive respiratory secretions, delirium and pain. This will empower primary care teams to act swiftly and safely in delivering generalist palliative care in a manner that is consistent with the patient’s values, beliefs and wishes.
Specialist PM support should be available for the treatment of distressing symptoms such as dyspnoea, which may require rapid bedside titration of medications and the use of palliative sedation therapy if symptoms remain recalcitrant.
Provision of Support and Palliative Care Where Treatment Is Withdrawn
Similar care and consideration should be provided to patients whose ventilatory support is to be withdrawn as a result of progressive deterioration despite maximal ICU support. Early identification and PM involvement will help support these families and patients as well as the HCPs involved.
Psychological Support for Patients
HCPs should act as patient advocates and address their fears when deprived of traditional social networks and family support as a result of isolation protocols. Active screening for spiritual and existential distress should be carried out and provided in a timely, appropriate and personalized manner.
Psychological Support for Patients’ Families
Families suffer too and are often wrought with worry, guilt and helplessness. Concurrently as funeral rituals are shortened or disallowed in line with social distancing measures, some families may feel disenfranchised and have additional difficulty processing their grief. Flexibility in addressing these needs without compromising safety is required to support families. Here the combined PM, MSW and ICU teams should be proactive in addressing grief and bereavement needs. This may take the form of regular virtual ‘visits’, timely follow-ups and reassurances. Bereavement support should be provided in a timely, appropriate and personalized manner.
Psychological Support for HCPs
HCPs frequently experience moral distress and the decision to withhold or withdraw ventilatory support may be traumatizing especially if it results in death. It is imperative to holistically assess and support the team either individually or as a group and provide them with resources to support themselves. Here, having the triage team discuss these issues with them will certainly provide an added source of support.