Life and death decisions – could a flowchart help ICU doctors make critical choices?

Doctors should use a flowchart to help them decide who gets intensive care if resources in ICUs reach breaking point, a leading ethicist has said.

Dr Daniel Sokol, a medical ethicist and lawyer who has previously advised government bodies in the UK on ethics, has published the flowchart to assist front-line clinicians with life and death decisions when Covid-19 patients overwhelm intensive care capacity.

The flowchart takes into account the patient’s clinical suitability for intensive care. Controversially, it also looks at their “ICU burden”, or how much intensive care resources the patient will require if admitted.

One of the key points the flowchart suggests is preferential treatment to frontline healthcare workers who are actively involved in treating Covid-19 patients.

Priority to healthcare workers

Writing in the British Medical Journal, Dr Sokol wrote that reason for giving priority to healthcare workers is “to maintain or boost morale”, as well as ensuring frontline staff can get back to work as quickly as possible to help combat the ongoing crisis.

He noted that, “Absenteeism will be lower if clinicians are assured they will jump the queue if they contract the disease. Some also argue that society has an obligation towards those who put themselves at risk when caring for the community, and many ethics experts also believe preferential treatment falls under that duty.”

The flowchart calls for the creation of ethics panels to assist clinicians in exceptional cases, or when patients or relatives wish to appeal decisions on who gets ICU treatment.

What are the criteria?

Dr Sokol does not believe a patient’s age, long-term life expectancy or social worth are criteria that should be used in determining who gets ICU care. His concern is that these would “create unnecessary complications and endless argument.” Decisions will need to be made quickly and at all times of the day and night.

This concept doesn’t mean that patients would be denied any treatment. It suggests instead that they should be cared for in other wards, with the ICU reserved for the most serious cases, as well as frontline healthcare workers. The reality, however, is that most patients denied ICU admission will succumb to the disease in a short space of time.

Ongoing assessment would be a part of all treatments, and every decision would be fully documented.

A necessary decision

Dr Sokol acknowledges that people may disagree with the content of the flowchart. However, he is in favour of complete openness and transparency when making these critical decisions. “Whatever conclusions are reached about the fair allocation of limited resources, they must be communicated to members of the public in advance of any crisis,” he explains. “To do otherwise might lead to panic and protests at the worst possible time, when hospitals are under extreme pressure.”

Ends –

Notes to editor

Dr Daniel Sokol is a medical ethicist and lawyer who has sat on committees for the UK Ministry of Defence and Ministry of Justice. He has advised military medics on ethical decision-making and published widely in the field of medical ethics and law. He is a columnist for the British Medical Journal.

The flowchart is available on

Link to BMJ article:

Funding: No specific funding

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Press release distributed by Pressat on behalf of Daniel Sokol, on Wednesday 25 March, 2020. For more information subscribe and follow

Covid-19 Coronavirus Intensive Care Triage Ethics Bioethics Doctors Critical Care Flowchart Coronavirus (COVID-19)
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Life and death decisions – could a flowchart help ICU doctors make critical choices?