COVID-19 forces Italian doctors to make life-and-death choices about rationing care

In northern Italy, medical resources are stretched so thin by the COVID-19 pandemic that doctors are facing hard choices about who gets priority access to potentially life-saving resources such as intensive care beds and ventilators and who does not.

According to Politico, new "marching orders" advise doctors to prioritize "scarce resources" for patients with "the greatest chances of survival."

That means a younger, otherwise healthy patientwho tests positive for the novel coronavirus might win priority for an intensive care unit bed over, for example, an older patient with several pre-existing conditions.

Marco Vergano, a Turin-based doctor involved in developing ethical guidelines for how to deal with these kinds of scenarios, said that given the overwhelming volume of coronavirus cases, a first-come, first-served protocol for intensive care unit beds could end up costing lives.

"Admitting an elderly patient, frail with comorbidities with very low chances of survival, even without any shortage of intensive care (ICU)beds, I think is unethical and inappropriate from a clinical point of view for that single patient," Vergano told Day 6 host Brent Bambury.

Vergano is also chair of the ethics working group for Siiarti, the Italian Society of Anesthesiologists, and Emergency and Intensive Care physicians.

The number of confirmed cases of COVID-19 in Italy neared 13,000 on Friday, with over 1,000 deaths. The entire country is effectively under lockdown, with most businesses other thanpharmacies and food shops shuttered.

In Milan, said Vergano, health officials are planning to open hundreds of ICU beds in other public gathering spaces like convention centres because hospitals are inundated with patients.

"This is an extraordinary and unprecedented emergency situation," he said.

Vergano said the flow of patients has slowed somewhat compared to the first spike in cases, but added that "nobody is really sure" whether the trend will continue.

"Even epidemiologists and virologists aren't sure what will happen in Italy the next week or in a couple of weeks," he said.

Lombardia, the wealthy region at the heart of Italy's outbreak, is still struggling to find beds, ventilators and other resources for the "overwhelming flow of patients with respiratory failure and distress" that began weeks ago, said Vergano.

He said that the acute shortage of resources, and the life-or-death decisions doctors are being forced to make, share some similarities with wartime triage but with one important difference.

"In this case, the bomb is inside the hospitals," he said.

"You don't have the bomb outside and then a flow of patients to hospitals. ... patients usually come with mild respiratory distress, and then they deteriorate in the next few hours."

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The number of COVID-19 cases in Canada is nowhere near what Italy is currently facing.

But Dr. Anand Kumar, a critical care physician at Winnipeg's Health Sciences Centre, says Canada would likely be faced with the same dilemmas if we were to see a "worst-case scenario" spike in COVID-19 cases.

"There's no question we would exceed our health care capacity whether it be for hospital beds or for ICU beds," he said.

But he stressed that Canada is currently well-prepared for any "large epidemic event," thanks in part to lessons learned during the 2003 SARS outbreak.

Social distancing 'number one'

When asked what he would advise doctors to do if he could go back in time a few weeks, knowing what he now knows, Vergano said social distancing would be "number one" on his list.

"It is really weird and surreal, I would say, in our hyper connected society. ... But for the population I would say social distancing is the only way to prevent situations like this," he said.

Kumar said that educating the Canadian public on "mitigation" strategies like social distancing and self-isolation are key tools to avoid an Italy-like worst case scenario.

"What they do as a community will have a big impact on what the final outcome of this epidemic is," he said.

"But I think we're in pretty good shape, as far as most countries go."

Written by Jonathan Ore. Interviews produced by Pedro Sanchezand Mouhamad Rachini.

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