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Table 1 Summary of the statements

From: The Italian document: decisions for intensive care when there is an imbalance between care needs and resources during the COVID-19 pandemic

Principles and responsibilities
1. The increase in demand for health care (at the three levels of hospitalization: ordinary, semi-intensive, intensive), due to a situation such as the pandemic, does not reduce the necessary adherence, as regards the protection of health, to the constitutional and founding principles of the National Health Service and to deontological principles, particularly universality, equality (non-discrimination), solidarity and self-determination
2. It is the responsibility of the healthcare organization, at every decisional level, to adapt the response in terms of logistics, technological and human resources to face the crisis
3. In the event of an imbalance between the need for and the supply of care, the healthcare organization is always responsible locally for all the organizational strategies aimed at providing patients with the appropriate treatment (increase in the number of beds in both ordinary and intensive care, increase/redistribution of human and technological resources, implementation of the system for transferring patients between healthcare facilities). Healthcare professionals shall—as effectively as possible—report any shortcomings that make it impossible to implement these strategies to the competent institutions
Triage
4. At every level of intensity of care, should care resources become saturated, making it impossible to guarantee each sick person the recommended treatment, it is necessary to resort to triage rather than to a “first come, first served” or random (lottery) criterion
5. The purpose of intensive care triage is, in accordance with the above principles, to ensure life-sustaining treatments to as many patients as possible who may benefit from them
6. Triage should be based on defined clinical–prognostic parameters that are as objective and shared as possible. The assessment, aimed at stratifying the likelihood of overcoming the current critical condition with the support of intensive care, should be based on an overall evaluation of each individual patient, using the following parameters:
 Number and type of comorbidities
 Previous functional status and frailty relevant to the response to care
 Severity of the current clinical condition
 Presumable impact of intensive treatments, also taking the patient's age into account
 The patient's wishes with regard to intensive care, which should be explored as early as possible in the initial triage stage.
7. Age should be considered as part of the global assessment of the patient and not on the basis of pre-set cut-offs
Previously expressed wishes
8. If a patient lacks decision-making capacity, a careful check should be made for any previous wishes expressed through advance directive or shared care planning. Shared care planning should be offered to all patients likely to require intensive care in the future
Reassessment and shifting to palliative care
9. All access to care should be scrutinized on the basis of daily reassessment of the clinical indication, goals of care and proportionality
10. Patients for whom intensive care is not possible must receive—in relation to their clinical and healthcare related situation and their wishes—the most appropriate treatments, including palliative care, which must always be guaranteed at all levels of hospitalization and in all care settings
11. Should a patient not respond to treatment or severely worsen the decision to discontinue intensive care (withdrawing futile treatments) and to shift to palliative care must not be postponed
Collegiality and transparency of decisions
12. Compatibly with human resources and actual circumstances, decisions should not be left to a single provider, but should be the result of collective evaluation by the medical and care team, which may, if necessary, also call on outside professionals (for a “second opinion”). The decision to limit intensive care must be adequately justified reported and documented in the medical record