With the number of infected people practically reaching 20 thousand, with 1141 patients in intensive care and the number of deaths passing the barrier of 1000, Spain puts on the table the possibility that health services are unable to respond to the situation pandemic.
A Bioethics working group from the Spanish Society of Intensive Care, Critical and Coronary Units (Semicyuc), which worked in collaboration with the Spanish Society of Internal Medicine (SEMI), developed an ethical guide to help healthcare professionals make decisions, if there is a scenario of scarcity of resources for all patients.
The text, available on the society’s website, recommends that before two people in a similar situation, priority should be given to those with “higher quality life expectancy”. In elderly people, adds the text, one must be against “survival without disabilities” at the expense of survival considered in isolation. That is, age should not, in itself, be a criterion for prioritizing one patient over another. The guide states it clearly: “It is important to note that chronological age (in years) should not be the only element to consider”.
Lluis Cabré, a member of the Semicyuc Bioethics working group and one of the authors of the guide, tells the newspaper El País: “We can have an 80-year-old person with a good quality of life, who is well intellectually, who goes out, plays tennis, and a 60-year-old person with chronic kidney failure, diabetes. Usually people over 80 have more comorbidity, But it’s not always so”.
“Many of these patients have to be intubated and mechanically ventilated. Before doing so, we have to think about what will happen and what quality of life they will have”, adds this expert, stressing that this is an evaluation that is already being done usually in hospitals. “We know that patients with other chronic conditions do not respond [aos tratamentos] and in cases, I don’t know what to call it, war, like the current one, you have to make decisions: I don’t intubate the first one who arrives, but the one who has the best chance of going ahead “. This is, in fact, a principle that is written in the document: “Bear in mind that admitting an entry [nos cuidados intensivos] it may involve refusing entry to another person who may benefit most. Avoid the ‘first come, first come’ criterion.
“Social value” and “dependents as a criterion”
The document defines four levels of priority. The first is critical, unstable patients who need monitoring and treatment that has to be given in intensive care. On the second level are patients who need monitoring and may need immediate intervention. The third is critical patients with little chance of survival due to other acute diseases. In the fourth are patients with terminal and irreversible disease in a situation of imminent death.
“In a situation of lack of resources, priority is given to entering intensive care for patients with priority 1”, leaving intermediate care for patients with priority two. “Patients with priority 3 and 4, without a crisis situation, are not admitted to intensive care units”, says the document.
However, the guide prepared by the Bioethics working group does not only present strictly medical criteria to prioritize the treatment of patients. “Taking into account the social value of the sick person” is one of the listed criteria, without specifying what exactly this means. Another of the mentioned parameters goes through “take into account other factors such as, for example, people in charge of the patient, to make decisions maximizing the benefit of as many people as possible “.
In a previous document, the same company had already prepared a contingency plan for the response to Covid-19.
The document defines four phases of the epidemic outbreak, forecasting the various possible scenarios, including the blackest ones: the beginning, the saturation of intensive care, the collapse of intensive care and the hospital and, finally, the phase of control of the epidemic.
In the second phase, of saturation of intensive care, the contingency plan already pointed to “strict criteria” for admission to intensive care units, guided by “objective scales” that are previously defined and limitation of the life support treatment, with assistance , if necessary, from the Ethics Committee.
In phase three, corresponding to a collapse situation, it is suggested to “use all available beds in the hospital to give priority to patients who are more likely to recover”. “At this stage, the principle of prioritizing the global benefit over the particular should be established”, taking the decisions that follow.
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