Serveur d'exploration sur la COVID en France

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Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.

Identifieur interne : 000874 ( Main/Exploration ); précédent : 000873; suivant : 000875

Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.

Auteurs : Thomas Leclerc [France] ; Nicolas Donat [France] ; Alexis Donat [France] ; Pierre Pasquier [France] ; Nicolas Libert [France] ; Elodie Schaeffer [France] ; Erwan D'Aranda [France] ; Jean Cotte [France] ; Bruno Fontaine [France] ; Pierre-François Perrigault [France] ; Fabrice Michel [France] ; Laurent Muller [France] ; Eric Meaudre [France] ; Benoît Veber [France]

Source :

RBID : pubmed:32426441

Descripteurs français

English descriptors

Abstract

BACKGROUND

Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.

RATIONALE

Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.

PRIORITISATION STRATEGY

Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.

PERSPECTIVE

Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.


DOI: 10.1016/j.accpm.2020.05.008
PubMed: 32426441
PubMed Central: PMC7230138


Affiliations:


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<name sortKey="Veber, Benoit" sort="Veber, Benoit" uniqKey="Veber B" first="Benoît" last="Veber">Benoît Veber</name>
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<series>
<title level="j">Anaesthesia, critical care & pain medicine</title>
<idno type="eISSN">2352-5568</idno>
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<keywords scheme="KwdEn" xml:lang="en">
<term>Betacoronavirus (MeSH)</term>
<term>Canada (MeSH)</term>
<term>Caregivers (MeSH)</term>
<term>Continuity of Patient Care (organization & administration)</term>
<term>Coronavirus Infections (epidemiology)</term>
<term>Coronavirus Infections (therapy)</term>
<term>Critical Care (ethics)</term>
<term>Critical Care (organization & administration)</term>
<term>Critical Care (standards)</term>
<term>Critical Illness (MeSH)</term>
<term>France (epidemiology)</term>
<term>Health Personnel (MeSH)</term>
<term>Health Priorities (ethics)</term>
<term>Health Priorities (standards)</term>
<term>Health Resources (supply & distribution)</term>
<term>Health Services Accessibility (ethics)</term>
<term>Humans (MeSH)</term>
<term>Intensive Care Units (organization & administration)</term>
<term>Intensive Care Units (supply & distribution)</term>
<term>Pandemics (MeSH)</term>
<term>Patient Transfer (MeSH)</term>
<term>Pneumonia, Viral (epidemiology)</term>
<term>Pneumonia, Viral (therapy)</term>
<term>Practice Guidelines as Topic (MeSH)</term>
<term>Refusal to Treat (ethics)</term>
<term>Resource Allocation (ethics)</term>
<term>Social Justice (MeSH)</term>
<term>Switzerland (MeSH)</term>
<term>Triage (ethics)</term>
<term>Triage (organization & administration)</term>
<term>Triage (standards)</term>
</keywords>
<keywords scheme="KwdFr" xml:lang="fr">
<term>Accessibilité des services de santé (éthique)</term>
<term>Aidants (MeSH)</term>
<term>Allocation des ressources (éthique)</term>
<term>Betacoronavirus (MeSH)</term>
<term>Canada (MeSH)</term>
<term>Continuité des soins (organisation et administration)</term>
<term>France (épidémiologie)</term>
<term>Guides de bonnes pratiques cliniques comme sujet (MeSH)</term>
<term>Humains (MeSH)</term>
<term>Infections à coronavirus (thérapie)</term>
<term>Infections à coronavirus (épidémiologie)</term>
<term>Justice sociale (MeSH)</term>
<term>Maladie grave (MeSH)</term>
<term>Pandémies (MeSH)</term>
<term>Personnel de santé (MeSH)</term>
<term>Pneumopathie virale (thérapie)</term>
<term>Pneumopathie virale (épidémiologie)</term>
<term>Priorités en santé (normes)</term>
<term>Priorités en santé (éthique)</term>
<term>Refus de traiter (éthique)</term>
<term>Ressources en santé (ressources et distribution)</term>
<term>Soins de réanimation (normes)</term>
<term>Soins de réanimation (organisation et administration)</term>
<term>Soins de réanimation (éthique)</term>
<term>Suisse (MeSH)</term>
<term>Transfert de patient (MeSH)</term>
<term>Triage (normes)</term>
<term>Triage (organisation et administration)</term>
<term>Triage (éthique)</term>
<term>Unités de soins intensifs (organisation et administration)</term>
<term>Unités de soins intensifs (ressources et distribution)</term>
</keywords>
<keywords scheme="MESH" type="geographic" qualifier="epidemiology" xml:lang="en">
<term>France</term>
</keywords>
<keywords scheme="MESH" type="geographic" xml:lang="en">
<term>Canada</term>
<term>Switzerland</term>
</keywords>
<keywords scheme="MESH" qualifier="epidemiology" xml:lang="en">
<term>Coronavirus Infections</term>
<term>Pneumonia, Viral</term>
</keywords>
<keywords scheme="MESH" qualifier="ethics" xml:lang="en">
<term>Critical Care</term>
<term>Health Priorities</term>
<term>Health Services Accessibility</term>
<term>Refusal to Treat</term>
<term>Resource Allocation</term>
<term>Triage</term>
</keywords>
<keywords scheme="MESH" qualifier="normes" xml:lang="fr">
<term>Priorités en santé</term>
<term>Soins de réanimation</term>
<term>Triage</term>
</keywords>
<keywords scheme="MESH" qualifier="organisation et administration" xml:lang="fr">
<term>Continuité des soins</term>
<term>Soins de réanimation</term>
<term>Triage</term>
<term>Unités de soins intensifs</term>
</keywords>
<keywords scheme="MESH" qualifier="organization & administration" xml:lang="en">
<term>Continuity of Patient Care</term>
<term>Critical Care</term>
<term>Intensive Care Units</term>
<term>Triage</term>
</keywords>
<keywords scheme="MESH" qualifier="ressources et distribution" xml:lang="fr">
<term>Ressources en santé</term>
<term>Unités de soins intensifs</term>
</keywords>
<keywords scheme="MESH" qualifier="standards" xml:lang="en">
<term>Critical Care</term>
<term>Health Priorities</term>
<term>Triage</term>
</keywords>
<keywords scheme="MESH" qualifier="supply & distribution" xml:lang="en">
<term>Health Resources</term>
<term>Intensive Care Units</term>
</keywords>
<keywords scheme="MESH" qualifier="therapy" xml:lang="en">
<term>Coronavirus Infections</term>
<term>Pneumonia, Viral</term>
</keywords>
<keywords scheme="MESH" qualifier="thérapie" xml:lang="fr">
<term>Infections à coronavirus</term>
<term>Pneumopathie virale</term>
</keywords>
<keywords scheme="MESH" qualifier="épidémiologie" xml:lang="fr">
<term>France</term>
<term>Infections à coronavirus</term>
<term>Pneumopathie virale</term>
</keywords>
<keywords scheme="MESH" qualifier="éthique" xml:lang="fr">
<term>Accessibilité des services de santé</term>
<term>Allocation des ressources</term>
<term>Priorités en santé</term>
<term>Refus de traiter</term>
<term>Soins de réanimation</term>
<term>Triage</term>
</keywords>
<keywords scheme="MESH" xml:lang="en">
<term>Betacoronavirus</term>
<term>Caregivers</term>
<term>Critical Illness</term>
<term>Health Personnel</term>
<term>Humans</term>
<term>Pandemics</term>
<term>Patient Transfer</term>
<term>Practice Guidelines as Topic</term>
<term>Social Justice</term>
</keywords>
<keywords scheme="MESH" xml:lang="fr">
<term>Aidants</term>
<term>Betacoronavirus</term>
<term>Canada</term>
<term>Guides de bonnes pratiques cliniques comme sujet</term>
<term>Humains</term>
<term>Justice sociale</term>
<term>Maladie grave</term>
<term>Pandémies</term>
<term>Personnel de santé</term>
<term>Suisse</term>
<term>Transfert de patient</term>
</keywords>
<keywords scheme="Wicri" type="geographic" xml:lang="fr">
<term>France</term>
</keywords>
</textClass>
</profileDesc>
</teiHeader>
<front>
<div type="abstract" xml:lang="en">
<p>
<b>BACKGROUND</b>
</p>
<p>Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>RATIONALE</b>
</p>
<p>Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>PRIORITISATION STRATEGY</b>
</p>
<p>Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.</p>
</div>
<div type="abstract" xml:lang="en">
<p>
<b>PERSPECTIVE</b>
</p>
<p>Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.</p>
</div>
</front>
</TEI>
<pubmed>
<MedlineCitation Status="MEDLINE" Owner="NLM">
<PMID Version="1">32426441</PMID>
<DateCompleted>
<Year>2020</Year>
<Month>07</Month>
<Day>27</Day>
</DateCompleted>
<DateRevised>
<Year>2020</Year>
<Month>08</Month>
<Day>02</Day>
</DateRevised>
<Article PubModel="Print-Electronic">
<Journal>
<ISSN IssnType="Electronic">2352-5568</ISSN>
<JournalIssue CitedMedium="Internet">
<Volume>39</Volume>
<Issue>3</Issue>
<PubDate>
<Year>2020</Year>
<Month>06</Month>
</PubDate>
</JournalIssue>
<Title>Anaesthesia, critical care & pain medicine</Title>
<ISOAbbreviation>Anaesth Crit Care Pain Med</ISOAbbreviation>
</Journal>
<ArticleTitle>Prioritisation of ICU treatments for critically ill patients in a COVID-19 pandemic with scarce resources.</ArticleTitle>
<Pagination>
<MedlinePgn>333-339</MedlinePgn>
</Pagination>
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<ELocationID EIdType="doi" ValidYN="Y">10.1016/j.accpm.2020.05.008</ELocationID>
<Abstract>
<AbstractText Label="BACKGROUND">Relying on capacity increases and patient transfers to deal with the huge and continuous inflow of COVID-19 critically ill patients is a strategy limited by finite human and logistical resources.</AbstractText>
<AbstractText Label="RATIONALE">Prioritising both critical care initiation and continuation is paramount to save the greatest number of lives. It enables to allocate scarce resources in priority to those with the highest probability of benefiting from them. It is fully ethical provided it relies on objective and widely shared criteria, thus preventing arbitrary decisions and guaranteeing equity. Prioritisation seeks to fairly allocate treatments, maximise saved lives, gain indirect life benefits from prioritising exposed healthcare and similar workers, give priority to those most penalised as a last resort, and apply similar prioritisation schemes to all patients.</AbstractText>
<AbstractText Label="PRIORITISATION STRATEGY">Prioritisation schemes and their criteria are adjusted to the level of resource scarcity: strain (level A) or saturation (level B). Prioritisation yields a four level priority for initiation or continuation of critical care: P1-high priority, P2-intermediate priority, P3-not needed, P4-not appropriate. Prioritisation schemes take into account the patient's wishes, clinical frailty, pre-existing chronic condition, along with severity and evolution of acute condition. Initial priority level must be reassessed, at least after 48h once missing decision elements are available, at the typical turning point in the disease's natural history (ICU days 7 to 10 for COVID-19), and each time resource scarcity levels change. For treatments to be withheld or withdrawn, a collegial decision-making process and information of patient and/or next of kin are paramount.</AbstractText>
<AbstractText Label="PERSPECTIVE">Prioritisation strategy is bound to evolve with new knowledge and with changes within the epidemiological situation.</AbstractText>
<CopyrightInformation>Copyright © 2020 Société française d'anesthésie et de réanimation (Sfar). Published by Elsevier Masson SAS. All rights reserved.</CopyrightInformation>
</Abstract>
<AuthorList CompleteYN="Y">
<Author ValidYN="Y">
<LastName>Leclerc</LastName>
<ForeName>Thomas</ForeName>
<Initials>T</Initials>
<AffiliationInfo>
<Affiliation>Percy military teaching hospital, Clamart, France; Val-de-Grâce military medical academy, Paris, France. Electronic address: thomas.leclerc@m4x.org.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Donat</LastName>
<ForeName>Nicolas</ForeName>
<Initials>N</Initials>
<AffiliationInfo>
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</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Donat</LastName>
<ForeName>Alexis</ForeName>
<Initials>A</Initials>
<AffiliationInfo>
<Affiliation>Legouest military teaching hospital & Mercy regional hospital, Metz, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Pasquier</LastName>
<ForeName>Pierre</ForeName>
<Initials>P</Initials>
<AffiliationInfo>
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</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Libert</LastName>
<ForeName>Nicolas</ForeName>
<Initials>N</Initials>
<AffiliationInfo>
<Affiliation>Percy military teaching hospital, Clamart, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Schaeffer</LastName>
<ForeName>Elodie</ForeName>
<Initials>E</Initials>
<AffiliationInfo>
<Affiliation>R. Picqué military teaching hospital, Bordeaux, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>D'Aranda</LastName>
<ForeName>Erwan</ForeName>
<Initials>E</Initials>
<AffiliationInfo>
<Affiliation>Sainte Anne military teaching hospital, Toulon, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
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<ForeName>Jean</ForeName>
<Initials>J</Initials>
<AffiliationInfo>
<Affiliation>Sainte Anne military teaching hospital, Toulon, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
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<ForeName>Bruno</ForeName>
<Initials>B</Initials>
<AffiliationInfo>
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</AffiliationInfo>
</Author>
<Author ValidYN="Y">
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<ForeName>Pierre-François</ForeName>
<Initials>PF</Initials>
<AffiliationInfo>
<Affiliation>Gui de Chauliac hospital & Montpellier University, Montpellier, France; Ethics committee, French society of anaesthesia and critical care (SFAR), Paris, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Michel</LastName>
<ForeName>Fabrice</ForeName>
<Initials>F</Initials>
<AffiliationInfo>
<Affiliation>APHM, Aix Marseille Univ, UMR ADES n°7268, EFS, CNRS, Marseille, France; Ethics committee, French society of anaesthesia and critical care (SFAR), Paris, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Muller</LastName>
<ForeName>Laurent</ForeName>
<Initials>L</Initials>
<AffiliationInfo>
<Affiliation>CHU Nîmes Caremeau, Nîmes, France; Ethics committee, French society of anaesthesia and critical care (SFAR), Paris, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Meaudre</LastName>
<ForeName>Eric</ForeName>
<Initials>E</Initials>
<AffiliationInfo>
<Affiliation>Sainte Anne military teaching hospital, Toulon, France; Val-de-Grâce military medical academy, Paris, France.</Affiliation>
</AffiliationInfo>
</Author>
<Author ValidYN="Y">
<LastName>Veber</LastName>
<ForeName>Benoît</ForeName>
<Initials>B</Initials>
<AffiliationInfo>
<Affiliation>Charles Nicolle hospital & Rouen Normandie University, Rouen, France; Ethics committee, French society of anaesthesia and critical care (SFAR), Paris, France.</Affiliation>
</AffiliationInfo>
</Author>
</AuthorList>
<Language>eng</Language>
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</PublicationTypeList>
<ArticleDate DateType="Electronic">
<Year>2020</Year>
<Month>05</Month>
<Day>17</Day>
</ArticleDate>
</Article>
<MedlineJournalInfo>
<Country>France</Country>
<MedlineTA>Anaesth Crit Care Pain Med</MedlineTA>
<NlmUniqueID>101652401</NlmUniqueID>
<ISSNLinking>2352-5568</ISSNLinking>
</MedlineJournalInfo>
<SupplMeshList>
<SupplMeshName Type="Disease" UI="C000657245">COVID-19</SupplMeshName>
<SupplMeshName Type="Organism" UI="C000656484">severe acute respiratory syndrome coronavirus 2</SupplMeshName>
</SupplMeshList>
<CitationSubset>IM</CitationSubset>
<MeshHeadingList>
<MeshHeading>
<DescriptorName UI="D000073640" MajorTopicYN="Y">Betacoronavirus</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D002170" MajorTopicYN="N" Type="Geographic">Canada</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D017028" MajorTopicYN="N">Caregivers</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D003266" MajorTopicYN="N">Continuity of Patient Care</DescriptorName>
<QualifierName UI="Q000458" MajorTopicYN="N">organization & administration</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D018352" MajorTopicYN="N">Coronavirus Infections</DescriptorName>
<QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName>
<QualifierName UI="Q000628" MajorTopicYN="Y">therapy</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D003422" MajorTopicYN="N">Critical Care</DescriptorName>
<QualifierName UI="Q000941" MajorTopicYN="N">ethics</QualifierName>
<QualifierName UI="Q000458" MajorTopicYN="Y">organization & administration</QualifierName>
<QualifierName UI="Q000592" MajorTopicYN="N">standards</QualifierName>
</MeshHeading>
<MeshHeading>
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</MeshHeading>
<MeshHeading>
<DescriptorName UI="D005602" MajorTopicYN="N" Type="Geographic">France</DescriptorName>
<QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006282" MajorTopicYN="N">Health Personnel</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006292" MajorTopicYN="N">Health Priorities</DescriptorName>
<QualifierName UI="Q000941" MajorTopicYN="N">ethics</QualifierName>
<QualifierName UI="Q000592" MajorTopicYN="Y">standards</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006295" MajorTopicYN="N">Health Resources</DescriptorName>
<QualifierName UI="Q000600" MajorTopicYN="Y">supply & distribution</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006297" MajorTopicYN="N">Health Services Accessibility</DescriptorName>
<QualifierName UI="Q000941" MajorTopicYN="N">ethics</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D006801" MajorTopicYN="N">Humans</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D007362" MajorTopicYN="N">Intensive Care Units</DescriptorName>
<QualifierName UI="Q000458" MajorTopicYN="Y">organization & administration</QualifierName>
<QualifierName UI="Q000600" MajorTopicYN="N">supply & distribution</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D058873" MajorTopicYN="Y">Pandemics</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D010360" MajorTopicYN="N">Patient Transfer</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D011024" MajorTopicYN="N">Pneumonia, Viral</DescriptorName>
<QualifierName UI="Q000453" MajorTopicYN="N">epidemiology</QualifierName>
<QualifierName UI="Q000628" MajorTopicYN="Y">therapy</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D017410" MajorTopicYN="N">Practice Guidelines as Topic</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D016079" MajorTopicYN="N">Refusal to Treat</DescriptorName>
<QualifierName UI="Q000941" MajorTopicYN="N">ethics</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D040841" MajorTopicYN="N">Resource Allocation</DescriptorName>
<QualifierName UI="Q000941" MajorTopicYN="N">ethics</QualifierName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D012935" MajorTopicYN="N">Social Justice</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D013557" MajorTopicYN="N" Type="Geographic">Switzerland</DescriptorName>
</MeshHeading>
<MeshHeading>
<DescriptorName UI="D014218" MajorTopicYN="N">Triage</DescriptorName>
<QualifierName UI="Q000941" MajorTopicYN="N">ethics</QualifierName>
<QualifierName UI="Q000458" MajorTopicYN="N">organization & administration</QualifierName>
<QualifierName UI="Q000592" MajorTopicYN="Y">standards</QualifierName>
</MeshHeading>
</MeshHeadingList>
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<Keyword MajorTopicYN="Y">COVID-19</Keyword>
<Keyword MajorTopicYN="Y">Critical care</Keyword>
<Keyword MajorTopicYN="Y">Ethics</Keyword>
<Keyword MajorTopicYN="Y">Pandemic</Keyword>
<Keyword MajorTopicYN="Y">Prioritisation</Keyword>
<Keyword MajorTopicYN="Y">Triage</Keyword>
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<Month>5</Month>
<Day>20</Day>
<Hour>6</Hour>
<Minute>0</Minute>
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<li>France</li>
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<region>
<li>Aquitaine</li>
<li>Grand Est</li>
<li>Lorraine (région)</li>
<li>Nouvelle-Aquitaine</li>
<li>Provence-Alpes-Côte d'Azur</li>
<li>Île-de-France</li>
</region>
<settlement>
<li>Bordeaux</li>
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<li>Paris</li>
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<tree>
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<region name="Île-de-France">
<name sortKey="Leclerc, Thomas" sort="Leclerc, Thomas" uniqKey="Leclerc T" first="Thomas" last="Leclerc">Thomas Leclerc</name>
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<name sortKey="Donat, Alexis" sort="Donat, Alexis" uniqKey="Donat A" first="Alexis" last="Donat">Alexis Donat</name>
<name sortKey="Donat, Nicolas" sort="Donat, Nicolas" uniqKey="Donat N" first="Nicolas" last="Donat">Nicolas Donat</name>
<name sortKey="Fontaine, Bruno" sort="Fontaine, Bruno" uniqKey="Fontaine B" first="Bruno" last="Fontaine">Bruno Fontaine</name>
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<name sortKey="Meaudre, Eric" sort="Meaudre, Eric" uniqKey="Meaudre E" first="Eric" last="Meaudre">Eric Meaudre</name>
<name sortKey="Michel, Fabrice" sort="Michel, Fabrice" uniqKey="Michel F" first="Fabrice" last="Michel">Fabrice Michel</name>
<name sortKey="Muller, Laurent" sort="Muller, Laurent" uniqKey="Muller L" first="Laurent" last="Muller">Laurent Muller</name>
<name sortKey="Pasquier, Pierre" sort="Pasquier, Pierre" uniqKey="Pasquier P" first="Pierre" last="Pasquier">Pierre Pasquier</name>
<name sortKey="Perrigault, Pierre Francois" sort="Perrigault, Pierre Francois" uniqKey="Perrigault P" first="Pierre-François" last="Perrigault">Pierre-François Perrigault</name>
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