At the end of March, the elderly residents who received the green light from the hospital were found within a few minutes with another red light. The 061 did not come to collect them despite the fact that the liaison geriatricians had authorized the transfer. These people in charge of filtering the entrances from residences to avoid the collapse protested to the Community of Madrid because these people were supposed to meet the hospitalization requirements of the protocol designed for the coronavirus crisis.
Frustrated, a geriatrician of this group expressed his frustration with the Summa (the Madrid emergencies) with a play on words that evokes an old motto of the Community: “More than everyone’s summa there are people who seem to be left”.
It was one of many complaints to the Ministry of Health of this group of 22 liaison geriatricians who are now under scrutiny for their role in designing the triage policy for nursing homes, the main focus of death in the pandemic. When the ambulance problem arose, they had already faced the difficult task of preparing protocols, an extraordinary document inspired by disaster medicine, which in its final version recommended not admitting terminally ill or heavily dependent patients to hospitals. They had to decide on a large scale who would benefit from scarce medical resources, perhaps the greatest ethical dilemma of their entire careers. It reminded some of them to the theoretical exercises of the Faculty of Medicine, such as when two trains collided and they had to put green and red stickers on the victims.
Anticipating that Madrid hospitals could collapse, the Ministry of Health created this group on March 13. The residences were surprised because before that day they did not have to get the approval of any intermediary to refer their patients to the hospital. It was a filter that according to the Spanish Geriatrics Society was only installed in the Community of Madrid.
The socio-sanitary coordination directorate initially assigned this work to 10 geriatricians distributed in an equal number of hospitals throughout the region. On the 16th the group was expanded to 22 hospitals, according to medical sources detailed to this newspaper. Each liaison geriatrician was assigned dozens of nursing homes in the Community, where there are a total of 475 such centers.
In addition to responding to referrals, up to 200 inquiries a day from nursing homes, and continuing their normal work, were ordered to prepare the triage document. They wrote up to seven versions, according to the Ministry of Health. They agreed electronically and were signed by the director of socio-sanitary coordination, Carlos Mur de Víu.
The first versions were more restrictive. People with moderate dependency were left out of the hospital, and one of the documents rejected people with disabilities of any age. Geriatrists lowered those requirements and also modified the crudest language. They replaced “exclusion criteria” with “hospital referral criteria”.
“It was never intended to exclude anyone, but also not to fall into the therapeutic frenzy. When a resident has been tried to drive at his residence, it was because the referral to the hospital was not going to provide him with a benefit in his life prognosis, ”Mur de Víu tells this newspaper.
However, families and residences report that hundreds of people who had benefited from hospital treatment, including people fit under the protocols, were rejected.
Triage is common in the medical profession, for example when deciding on transplant preferences or ICU care after a multiple accident. What is new is that geriatricians denied access to a hospital bed, a broader resource.
According to experts in bioethics, the risk of these situations of scarcity is that priority be given to a utilitarian criterion, by which the collective good prevails over the needs of the individual. The usual thing when resources are left over is that equity prevails in the distribution, according to which the neediest groups should have priority, just contrary to what the families claim happened.
“Everyone can understand that a terminally ill patient is not being transferred because they are not going to benefit from anything other than palliative care, but the elderly dependents are something else. I cannot deny them an available bed just because a younger person may need it in a matter of hours, ”said Aurelio Luna, professor of legal medicine at the University of Murcia.
Protests
The geriatricians realized with the passing of the days that the medicalization of residences announced for the Community of Madrid it was not reality and they protested for it. It was the other leg of the care plan for the residences. If they were denying hospital care to the elderly, it was because they were supposed to be cared for on-site.
Very early on March 14, they had agreed with the Ministry of Health to increase medical support in the residences because they were limited and could not offer such basic treatments as oxygen therapy or intravenous therapy. But on April 10 they had to reiterate those demands. They asked the Community for a medical reinforcement in the residences through the Spanish Society of Geriatrics and the Spanish Society of Geriatric Medicine.
They also complained to the Ministry that the patients had not been adequately separated in the residences. “There is a high percentage of residences (around 50%) in which the proposed isolation measures have either not been carried out correctly or have not been effective,” says a draft of the liaison geriatricians seen by this newspaper.
The pressure, the drama in the residences, and the obstacles of the Summa, undermined the morale of the geriatricians. During the worst of the crisis they were available 14 hours a day, from 08:00 to 22:00, from Monday to Sunday. On April 11 they organized to throw in the towel. They asked Mur de Viú to end his role, since it did not make sense in the terms it was designed for.
“This activity lacks the support of the corresponding ministries, it is being interpreted in an equivocal way and at the present time it is no more than a bureaucratic obstacle rather than slowing down (sic) the transfers. It should return to the system prior to March 13 in which the residence doctor requests the transfer directly without intermediaries, when he sees fit, ”says the draft seen by this newspaper.
Madrid hospitals alleviated their situation in mid-April and geriatricians were able to admit more sick people to nursing homes. By then, more than 5,200 people had died in nursing homes from covid-19 or with symptoms, almost 90% of the total to date.
The authors of the selective policy and its advocates today argue that hospitalization would not have saved those lives. Mur de Viú, who was fired last month, says that his council’s shock plan contained the tragedy. He defends his performance that even led him, a psychiatrist, to contribute as a volunteer in the most urgent residences. “I am very sorry that everything that was achieved is not recounted so that, at least, the drama was not even greater.” But he acknowledges that medicalization did not work, largely because of the large number of casualties who became infected. He emphasizes that his counseling sent massive amounts of medications and oxygen to nursing homes, but for the families of the deceased, this is proof of an insufficient and unfair policy.
Other Ethical Guidelines Questioned
In the first days of the pandemic, the ethical documents of different scientific societies and administrations proliferated. Some documents have been widely criticized as immoral and possibly illegal. As this newspaper has revealed, the Community of Madrid also distributed in March a protocol to the doctors of the health centers that care for patients in homes that also established exclusion criteria for hospital admission of patients who were in their houses. “Being over 80 years old” was a reason for rejection. The Spanish Bioethics Committee, an independent organ of the Government, and the Ministry of Health, published documents warning that doctors should prevent the spread of a utilitarian mentality or, worse still, of contrary prejudices towards the elderly or disabled.
Do you know of discrimination or irregularities in a residence in the Community of Madrid? Contact the reporters of the Madrid section [email protected] or [email protected] or send a message via Twitter to @FernandoPeinado or @jdquesada
Information about the coronavirus
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