ICU funnel

A Nursing technician Williane Maily Lins dos Santos, 30, was admitted since April 16 at the João Murilo hospital, in Vitória de Santo Antão, Pernambuco, with difficulty breathing and tiredness. Eleven days earlier, he had quit his job at a hemodialysis clinic due to laryngitis that took away his voice. He received antibiotics at health centers, but the condition only worsened. The mother, Maria Soares Lins Pereira, a nursing technician and physical therapist, took her daughter to the public hospital, who was already suspected of covid-19 due to respiratory distress and continued cough. Santos was placed in an isolation room. “He was unbalancing, unbalancing, the oxygen in his blood was falling, and there was no bed available.” 53 km from Recife, the city of Vitória de Santo Antão, with approximately 138 thousand inhabitants, does not have an ICU for adults.

Pernambuco has a Beds Regulation Center, one of the mechanisms capable of regulating urgent matters in times of the covid-19 pandemic: if there are no ICU vacancies for everyone, Who will be chosen and who will be ignored? What criteria will be used? And who will make this selection? In search of a ICU bed for her daughter, Pereira turned to nephrologist Suzana Melo, Santos’ boss. “Speaking with colleagues, I discovered that there were three hospitals with beds available in Recife, they said ‘the place is here, you can send it’, but the Central de Leitos reported that Williane had not been regulated, her name did not enter the process,” he said. the nephrologist. The bed was not opened until the following night, too late for the young woman’s lungs. Santos, without another disease, the mother of a 6-year-old girl, died of acute respiratory failure 33 hours after being admitted to the hospital. “I don’t know if it was the bureaucracy, if it was the lack of beds, but it didn’t flow,” laments the doctor, in a voice muffled by an N95 mask. He kept colleagues away from the contamination.

Even before the epidemic, Brazil had around 33 thousand intensive care beds for adults, but the covid-19 It consumes vacancies at a rapid rate and has led to the collapse of attention in the states. Patients die without getting places. Amazonas, Ceará, Pará and Pernambuco have announced that their public ICUs, if they have not reached 100% occupancy, are very close to that. The main reference in the treatment of covid-19 in São Paulo, the Emílio Ribas Institute, reached the end of its capacity for the second time this week. In Rio de Janeiro, 90% of ICU beds are taken for patients with coronavirus.

In a video recorded in April 2019, after participating in a forum on public and private policies on oncology, The new Minister of Health, Nelson Teich, stated that, given the limited money, it is important to make decisions and exemplified the decision between saving a teenager, who will have his whole life ahead, and an older person, who may be at the end of life. “For her [a pessoa idosa] To improve, I will spend practically the same money that I will spend to invest in a teenager. Only this person is a teenager who will have his whole life ahead of him, and the other is an older person, who may be at the end of his life. What will be the choice? With the greedy epidemic, the problem is pressing, and healthcare institutions have to make a dramatic decision in choosing who is eligible for the vacancy.

& nbsp

They don’t start from scratch. In Brazil, the reference for the distribution of vacancies in the ICU is Resolution 2,156, of 2016, of the Federal Council of Medicine (CFM). These are criteria for the admission and discharge of patients who, when created, sought to support intensive care physicians in the rational use of these limited and expensive beds. The basic admission criteria would be “clinical instability, that is, the need for support for organic dysfunctions and intensive monitoring.” Article six is ​​more specific and sets the priority scale in a somewhat complex combination for the laity. The main priority would be patients who need life support interventions, with a high probability of recovery and without any limitation of therapeutic support. Then there would be those who need intensive monitoring, due to the high risk of needing immediate intervention, also without any limitation of therapeutic support. Third, patients who need life support interventions, with a low probability of recovery or with limited therapeutic intervention. Fourth, patients who need intensive monitoring, due to the high probability of immediate intervention, but with limited therapeutic intervention. Finally, terminally ill or dying patients, with no possibility of recovery.

In summary, three basic themes come together in the evaluation. First, it is considered whether the patient needs intervention; setting for covid-19, who needs a respirator would have priority. Second, what is the probability of the patient’s recovery? High, medium, low, none? Patients with a high probability of recovery would top the list. Third, limitation of therapeutic support: case of patients who have already abandoned the directive call in advance, saying that they do not accept resuscitation maneuvers or intubation procedures. Those who do not want a more intense and invasive intervention would be referred to palliative care.

Pfor Henderson Fürst, Lawyer and chairman of the OAB Federal Council’s Special Committee on Bioethics and Bi-law, the CFM resolution may be insufficient in the face of the daily battle that covid-19 imposes on hospitals, with hundreds of cases with similar characteristics reaching a funnel . “We will need other parameters, including the performance of the bioethics councils of each health institution, to help in decision-making. ” Along the same lines, follow the general practitioner. Flávio César de Sá, emergency physician with residency in infectious diseases and post-doctorate in Bioethics at Cornell University in New York. “CFM’s recommendations are always valid, but they were not designed for this emergency situation, where we may have to leave people out of hospitalization,” he says. “To make this decision, it is important that there be some kind of prior institutional resolution so that the teams do not get lost, depending on the moment,” he says. Professor in the department of collective health in the area of ​​ethics and health at the Faculty of Medical Sciences of the State University of Campinas (Unicamp), Sá says that Brazil has to think about how to behave in the face of this dilemma.

The Ethics Committee of the Hospital of the Hospital de Clínicas da Unicamp, together with the personnel that deal with palliative care, intensive care and emergency physicians and a lawyer specialized in the area of ​​health, developed an action strategy, with the creation of a species. manual on how to act in such cases and what are the priorities. Recommendations are being disseminated to ICU staff and the hospital emergency room. The first thing, Sa says, is whether the patient has left a ready-will advance directive, indicating whether they agree to go to intensive care and whether they agree to undergo intubation and resuscitation procedures. The ER doctor acknowledges that he rarely crossed these guidelines when dealing with patients. “Even those with a chronic or life-threatening illness have probably never thought about it or thought about it. When these guidelines exist, they help a lot in decision making. ”

The Unicamp team will objectively study the criteria for the possibility of survival. “We are using a model similar to that of the Italians, an evaluation that takes into account the presence of comorbidities plus a criterion called SOFA (Sequential Evaluation of Organic Failures, or Sequential Evaluation of Organic Failures).” This index adds points related to the results of laboratory and clinical examinations and allows reaching a score, a number, which is related to the probability of the person dying when entering. The higher the score, the less chance of survival. “This index is nothing new, it has been used in intensive care for a long time and it is very consistent,” says Sá. The proposal of the Ethics Committee of the Hospital de Clínicas da Unicamp is to associate SOFA with the indications for intensive care of CFM and, from there, decide if the person should go to the ICU or not, and, once hospitalized, reevaluate every 24 hours if you benefit from intensive care. “If it is not improving or, on the contrary, it is getting worse, this is not the time to make useless extensions of people’s lives. If intensive care is not an advantage, a chance for recovery, the person may give way to someone who is more likely. “

Being intubated and going to the ICU were the most typical concerns of critically ill patients, but covid-19 changed that and brought up other problems. So even if the patient has written and sworn in his living will that he would not like to go to the ICU or be intubated, how can he say “no” to mechanical ventilation in the absence of air? “Difficulty breathing is suffocating not only for the person, but also for those around him, including the health professional, “says doctor and psychologist Vera Lucia Zaher, associate professor at the Faculty of Medicine of the University of São Paulo ( USP). Another problem is legal, because, among the legal requirements for an advance directive to be valid, content must not be considered a crime or a criminal offense, explains Marina Borba, Bioethics professor at the São Camilo University Center, in São Paulo: “A document that leads to the practice of euthanasia or assisted suicide will not be legally valid in Brazil.” To express their wishes, the person can also go to a registry office and leave everything written and authenticated.

When defining the criteria for the use of beds in the ICU, the staff of the Hospital da Unicamp also took into account the age group of the patient. “It is very impressive to establish an age criterion. But if this is a situation where there are many candidates with similar criteria for survival, age prevails, assuming that older people have less time to live, “says Sá. The team established 85 years as the upper limit of which the ICU will only happen if space is available. “It is very difficult, it is very difficult, I sincerely hope that we do not reach this limit, however, if we do, it is a criterion that we will have to use.” In the pandemic, the world was moved by the story of an Italian priest who died after handing over the respirator to a younger patient. Don Giuseppe Berardelli, 72, often surprised smiling on the streets with his red scooter, had won the respirator a few years before a believer in his parish in Casnigo, near Milan, when he suffered an asthma attack. According to reports, in the Bergamo hospital, where he had been diagnosed with the virus, he gave the valuable gift to a patient who was also infected.

TheThe criteria for the selection of beds were not always only clinical and scientific. Parameters such as religion, marital status, and economic condition were used at other times. In 1962, the Seattle Artificial Kidney Center, a high-cost dialysis center in the United States, was only able to treat the kidneys of nine patients in three beds. The Seattle Dialysis Selection Committee, better known as the God Committee or Divine Committee, was created. After the medical evaluation, this committee, made up of only lay people, selected patients using social criteria, such as sex, age, marital status, religion, number of dependents, education, occupation, and the person’s potential for future success. , whatever the future success for the group. The controversial decision sparked a reaction from Dutch Willem Kolff, Pope of hemodialysis: He created the first prototype of the kidney treatment machine in 1943: “Should we allow hemodialysis only in married patients who go to church? children, do they have a job, a good salary and collaborate with community actions? Should we accept the principle that social position should determine this selection? Only in 1971, when Washington state health insurance programs and financial support allowed all hemodialysis treatment arbitrators to be accepted, the Divine Committee did not act. Their controversial criteria motivated the creation of the Bioethics or Hospital Ethics Committees in the United States.

“Ideally, this type of decision could be shared, even with bioethics committees, but it may be that, in many situations of this pandemic, we cannot do it,” says psychologist Vera Zaher. “This moral stress ends for the intensivists.” When the fan weighs gold, who will be given preference: a mother with young children? To a health professional? A community leader? To a celebrity? And who will be at the bottom? Singles? Unemployed? Atheists? Prisoners? Fürst understands that, once the stage is set, the covid-19 itself will point out some emergencies. Will health workers be needed to combat the pandemic? They are taken care of first. Do we need labor to produce supplies and vaccines? These professionals first. And the values ​​of each society will also become more evident. “When they say that they are not going to serve people with disabilities, for whatever reason, it is very clear what that society really thinks of people with disabilities. This scenario tests our character. “In particular, it refers to the decision of the American state of Alabama, where the virus had already killed 117 people before April 21, to recommend that people with severe mental disabilities, moderate dementia to advanced and Severe traumatic brain injuries would be the least likely candidates to be on the mechanical ventilator, an orientation that ended up falling. The states of Washington and Arizona have suggested similar procedures, protesting the associations of friends of people with Down syndrome and autism.

Another option is to send the UCI supply and demand decisions to a management committee, which could regularize the situation and universalize care, including the location of beds in private hospitals. It happened in Pernambuco in the case of nursing technician Williane Maily Lins dos Santos. Mbut, at least for her, the decision came late. In a note, the Secretary of Health of the State of Pernambuco reports that the patient was admitted last Thursday 16 at the João Murilo de Oliveira Hospital, with a moderate image of Severe Acute Respiratory Syndrome (Srag). On Friday afternoon, her condition worsened and a vacancy was requested in the ICU of the Beds Regulation Center. The bed was available at night on the same day in a private hospital. “Unfortunately, the patient had a sudden worsening before the transfer was possible,” the note concludes, recalling that on Sunday the 19th, the state would have reached the mark of 646 beds dedicated exclusively to the disease, 319 of which they were in the ICU. The secretariat did not detail what time the request was made.

Two days after her daughter’s funeral, Pereira recorded a video in which she appears sitting next to her husband, also a nursing technician. She twirled her fingers in her lap, mourning the death of her daughter. “I would like to know who closed this cycle, who left this bed lost, because if it did not guarantee life, it would guarantee dignified assistance to a nursing professional, to a human being.” The coronavirus test was performed after Santos’ death. The result came out three days later. It is marked in lime green: “Detectable: Coronavirus SARS-CoV2”.