DEVELOPING GUIDELINES FOR THE DISTRIBUTION OF SCARCE MEDICAL RESOURCES DURING THE COVID-19 PANDEMIC. THE ESTONIAN CASE.

• Author: Sutrop, Margit

1. Introduction

   March 2020 witnessed an unprecedented level of global bioethics activity, both in professional as well as in mainstream media and networks. Amongst the most challenging of these debates during the COVID-19 pandemic were attempts to formulate clinical ethics guidelines on how limited medical resources and services ought to be allocated should the needs exceed availability. By mid-April most European countries had at least some form of ethical guidance in place regarding these difficult decisions.

   Was such a flurry of activity necessary? Few have doubted the importance of such debates in mainstream media, blogs and online deliberations, because they contributed to informing the public about the stark choices involved in triage. In some countries the debates may even have indirectly influenced a more rapid adoption of emergency measures in order to avoid the necessity to make such choices in the first place. Some have questioned whether medical professionals actually needed such guidance, due to the fact that emergency and disaster physicians have regular experience with critical situations, and the existing clinical guidelines might be extended to cover the new pandemic (McCullough 2020). Indeed, it is the case that there has been a proliferation of guidance documents on international, national, professional and local levels, resulting in potential inconsistencies, plenty of duplication and general information overload targeted at clinical decision-makers (Huxtable 2020).

   However, not all countries had previously formulated written clinical guidelines for the allocation of intensive care treatments that could also have been used in exceptional, resource-limited circumstances. For example, the Estonian Society of Anaesthesiologists recognised during the Covid-19 pandemic the need to formulate exact triage rules for intensive care units. According to the oral communication the anaesthesiologists appreciated the work on the recommendations and welcomed additional support in thinking through the ethical basis of difficult decisions in emergency situations. In the following we will describe the process of compiling recommendations for Estonian hospitals regarding the distribution of limited health care resources during the Covid-19 pandemic, including stakeholder involvement, engagements with comparable international documents, major internal debates and lessons learned for the future.

2. Timeline and stakeholders

   The Estonian Government declared an emergency situation on 12 March 2020 in order to respond to the spread of the coronavirus in Estonia. At first, the situation was meant to last until 1 May 2020, but on 24 April the emergency situation was extended until 17 May because of ongoing spread of the virus.

   The initiative for drafting the recommendations for Estonian hospitals for distribution of limited health care resources during the Covid-19 pandemic came from the Crisis Management Committee at the North Estonia Medical Centre (NEMC). The Republic of Estonia's Health Board had on 24 March made the two largest hospitals, NEMC in Tallinn and Tartu University Hospital (TUH) responsible for the management of Covid-19 treatment in all hospitals in either the northern or the southern regions of Estonia. The Crisis Management Committee at NEMC asked the hospital's ethics council to work out guidelines for the allocation of health care resources in the Covid-19 pandemic. The Ethics Council of NEMC met on 25 March and discussed the then already available Italian guidelines (Vergano et al 2020) and some scholarly articles (Rosenbaum 2020 and Ezekiel et al 2020) addressing the fair allocation of medical resources in a situation of high demand for intensive care beds and respirators. That day the first patient with Covid-19 diagnosis had died and 404 cases had been diagnosed; 28 people were hospitalized and 7 needed intensive care. The worst-case scenario forecast the overwhelming of ICUs across the country within 2-3 weeks. The ad hoc Covid-19 Scientific Council was formed to advise the Estonian Government, and on 24 March the council predicted that in two weeks more than 100 patients, after three weeks even a total of 200-300 patients might need intensive care. The estimated maximum national capacity of ventilated ICU beds was 130 (+75 more ventilators available, but lacking adequately trained staff). At the moment, occupancy of the 3rd level intensive care beds in Estonia was 49%.

   After the discussion of the first draft at the extraordinary meeting (25 March) of the Ethics Council of NEMC, the decision was made that instead of a regional document pertaining only to hospitals belonging to the northern region of Estonia, coordinated by NEMC, it would be better to address recommendations for all Estonian hospitals; therefore, an invitation was sent to Tartu University Hospital, which is responsible for all hospitals in the southern part of Estonia, with the goal of preparing a joint document. After the heads of the two hospitals' crisis committees, Professor Peep Talving (Medical Director ofNEMC) and Professor Joel Starkopf (Head of the Clinic of Anaesthesiology and Intensive Care at UTH), had agreed that we should prepare a joint document, the Clinical Ethics Committee at Tartu University Hospital became a second partner in this process. The third partner who helped draft this document was the interdisciplinary Centre for Ethics at the University of Tartu who, in cooperation with some external experts in medicine, ethics and law volunteered to study other available international documents and prepare an ethical and legal analysis of the recommendations. The initial draft of the document was written during the last week of March by members of the two hospital ethics committees and the Centre for Ethics, and then submitted for consultation to experts in medicine, bioethics and law, and edited accordingly. The draft was then worked on and shared via Google docs, with hours-long Skype audio sessions facilitating the joint formulation. The responsibility for the analysis in clinical medicine was assumed by Dr Jaan Tepp and Dr Kristo Erikson from NEMC. The legal analysis was prepared by Professor Jaan Ginter (UT) and the ethical analysis by Professor Margit Sutrop (UT) and Associate Professor Kadri Simm (UT). The process was coordinated by Andra Migur from NEMC.

   Estonia is a small country (population 1.3 million), and most of its medical practitioners have been trained in one medical school, at the University of Tartu. Thus, there were numerous existing personal contacts and overlapping institutional affiliations between the members of the three partner institutions that facilitated the cooperation. The ethics committees of both medical centres (the two largest in Estonia) are interdisciplinary and, in addition to physicians, they also include representatives from nursing, midwifery, philosophy/ethics, counselling, and patient advocacy.

   The final version of the Recommendations was coordinated with the Health Board and the President of Estonia. A press release announcing the availability of the guidelines on the NEMC homepage and their distribution to all Estonian hospitals was published on 6 April 2020 and an article in the major daily newspaper "Postimees" explained the ethical approach (Sutrop 2020). The press release stressed that these instructions should be taken as preventive measures, which hopefully would not be necessary, but which, should the situation deteriorate, would ensure that doctors know on what to base their decisions.

   The media response was quite lively (around 20 items of media coverage); the recommendations were mentioned by all daily newspapers and various radio and TV channels. On 13 April, the Committee of Social Affairs of the Estonian Parliament discussed the recommendations at their online meeting. Dr Kristo Erikson (NEMC) and Professor Margit Sutrop (UT) explained the process of drafting the recommendations and answered questions from MPs and representatives of the Estonian Ministry of Social Affairs. Although the joint initiative of two major hospitals' ethics committees and the Centre for Ethics was appreciated and viewed as a good example of cooperation, there was some criticism from the representatives of the ministry that they had not been involved in the process. Also, there were questions about the timing of the recommendations, since by the time the document was published, it had already become clear that the lockdown measures enforced by the government to control the virus had been effective, and that the number of patients needing hospital treatment, especially intensive care, was much lower than expected (on 6 April Estonia had 1108 confirmed diagnosed cases, 129 were hospitalized, including 14 in intensive care). It is important to stress that already during the guideline compilation process Estonian intensive care units were not overwhelmed; in fact, these critical prognoses never materialised. The highest number of ventilated patients was 20 (on 3 April), and the highest number of hospitalisations was 157 (on 12 April).

   Thankfully, the pandemic in Estonia has so far not overwhelmed the health care system and the emergency situation ended on Sunday at midnight (17 May) when there were still 44 people hospitalised, 4 in intensive care and Estonia overall had had 64 Covid-19-related deaths. Estonia's southern neighbour, Latvia, was even less affected (19 deaths as of 18 May) while in Finland, Estonia's northern neighbour, the infection rates and casualties were slightly higher (Hayry 2020). Estonia has not had excess death rate due to Covid-19 in March-April 2020.

3. A moral compass for doctors in making difficult decisions

   During these few intensive weeks of global bioethical deliberation, synchronised work on various national and professional guidelines was accomplished through the sharing, debating, as well as criticizing of numerous documents. For the...