The novel coronavirus (COVID-19) outbreak in Italy has raised a number of ethical, logistic, and therapeutic dilemmas, according to a report published in the New England Journal of Medicine.

Italy’s health care system is highly regarded, having more hospital beds per capita than the United States. However, this system has been faced with a significant challenge in COVID-19, with Italy having the highest number of deaths in the world and a rapidly increasing number of cases.

Lisa Rosenbaum MD interviewed 3 physicians who have been caring for patients in Lombardy, Italy. Dr D is a middle-aged chief of cardiology at one of the biggest hospitals in northern Italy; Dr L is a staff doctor at a different hospital while Dr S is a junior attending. All 3 physicians requested anonymity, in accordance to national guidance.

The physicians reported that hospitals in Italy are approaching or beyond capacity. Even after attempting to create units specifically for patients with COVID-19, it has become increasingly difficult to protect other patients from exposure. Dr D described a situation where 5 patients were admitted to his hospital with cardiovascular disease who became infected with COVID-19 while hospitalized. Protecting healthcare workers has been equally challenging, as many of them face risk of infection when performing routine tasks such as touching computers, eating lunch, riding elevators, and seeing outpatients. “The infection is everywhere,” reported Dr. D.

Another concern is the availability of ventilator support, which has led to many ethical dilemmas for physicians. Dr. L summarizes this as having “to decide who must die and whom we shall keep alive.” The agony of these decisions has prompted the Italian College of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) to issue the guidance of “clinical reasonableness” as well as a “soft utilitarian” approach to face the crisis. Although the guidelines did not suggest that age should be a factor in determining resource allocation, it did acknowledge that an age limit may eventually be set. These recommendations have been met with wide criticism.

Yet in situations with such resource scarcity, there will be many decisions which may feel morally untenable to physicians. To deal with such instances, 3 process -related principals have been proposed: (1) separate clinicians providing care from those making triage decisions, (2) these decisions should be reviewed regularly by a centralized state-level monitoring committee, and (3) the triage algorithm should be reviewed regularly as knowledge about the disease evolves.

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Dr. Rosenbaum concluded that denial is deadly and that the “tragedy in Italy reinforces the wisdom of many public health experts: the best outcome of this pandemic would be being accused of having overprepared.”

Reference

Rosenbaum L. Facing Covid-19 in Italy-Ethics, logistics, and therapeutics on the epidemic’s front line (published online March 18, 2020). N Engl J Med. doi/full/10.1056/NEJMp2005492