Covert Triage During the COVID-19 Pandemic: A Qualitative Analysis of Rationing in Intensive Care

With the sudden onset of the COVID-19 pandemic, countries rushed to implement guidelines for triage. Some were unprepared. In Germany, academic discourse had focused on criteria for triage, while often neglecting their translation into clinically applicable protocols in ICUs.

How did intensivists in German ICUs experience the institutional implementation of a national triage guideline and how did they respond to the resource constraints during the initial phases of the COVID-19 pandemic?

For this qualitative study, we conducted semistructured expert interviews with 14 intensivists from various German hospitals between November 2021 and April 2022. The inclusion criteria were as follows: (1) being a senior ICU physician, (2) having worked in intensive care during the pandemic, and (3) being involved in institutional triage preparation. Transcripts were analyzed using qualitative content analysis.

Participants addressed triage preparation, implementation of triage protocols, and allocation of critical care resources. They stressed legal uncertainty as a major barrier to implementing said protocols. We identified the potentially harmful phenomenon of what we term covert triage: preemptive, nontransparent, and improvised rationing to avoid exhaustion of capacity which would have triggered official triage. To keep ICU beds free for patients with more promising prognoses, intensivists resorted to 2 main strategies: raising informal crisis standards of care (covert triage type I) and directing decision-making conversations to dissuade patients and relatives from seeking intensive care treatment (covert triage type II).

This study highlights how legal uncertainty impaired institutional pandemic preparedness and the development of actionable triage protocols, which in turn led to covert triage: a nontransparent combination of intensivist-led decision-making and bedside rationing. Allocating limited resources requires shared interdisciplinary responsibility between medical teams, scientists, health law experts, and politicians to proactively establish legal regulations, translate ethical norms into guidelines, and implement actionable protocols.