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What if we run out of free intensive care units and have to prioritize patients awaiting intensive care? This moral dilemma is guided by an ethical recommendation that had not yet been used in the spring, but may now become relevant because there is an increasing likelihood that patients will need to be weighted in hospitals where there is no free intensive care unit. . If this happens, even with this guide, clinicians will be faced with terribly difficult decisions to make.
During the spring period of the coronavirus epidemic, guidance was provided on the best way to decide, in accordance with all professional, human and ethical principles, in a situation where there are more coronavirus patients than the intensive care unit or the fan. Back then, doctors didn’t have to use the 30-page document and were confident that it would no longer be needed. However, due to current data indicating the spread of the virus, the issue of the code of ethics was again discussed at the online congress of the Hungarian Society for Emergency Medicine.
We do not want to paint the devil on the wall, but it is a necessary response to the case in which the health system can no longer cope with the epidemic due to its scarce resources ”, he began his presentation. Zsolt Hegedűs physician, who, as president of the faculty of ethics of the Hungarian Medical Chamber, coordinated the drafting of a document containing important guidelines not only for doctors and nurses, but for society as a whole.
The main goal of the ethical guide, developed in the spring with more than a dozen experts, two patient organizations, translation groups, the ethics faculty and the presidency of the medical chamber, and even historical churches, is to make ethical decisions. clear and correct in the event of a coronavirus epidemic. The doctors. We wrote about the Hungarian document, which is also based on foreign protocols, in April:
As early as spring it became clear that the coronavirus epidemic could put so much pressure on even the most advanced healthcare systems that patients had to be weighed: who would receive what care if the capacity of intensive care units were full but the patients? will they arrive constantly? The experts who wrote that document consider it important to note that it is not a matter of panic: it is a real problem deciding who should be placed on a ventilator and who should not have a machine or an intensive care unit. This decision is traumatic for both the doctor and the patient’s relatives, so it is necessary to set the clearest guidelines so that they do not decide based on ad hoc ideas or order of arrival who should be ventilated and who should not, says Zsolt Hegedűs by listing the objectives of the code of ethics.
The decision seems simple on paper: if a situation is so extreme that life is opposed to life, then a more medically defensible life should be preferred to the less likely one.
Patients who are likely to survive with treatment should be given priority over patients who are unlikely to survive treatment and also those who are expected to recover without treatment. The chance of survival is the basis for prioritization, not, for example, who is old or how many more years he is expected to live.
The code’s writers emphasize that, although the epidemic is focused on patients with Covid, the patients who are not are the majority in treatment. “No distinction should be made in the distribution of resources between patients infected with the Covid-19 virus and those with other diseases,” cites Zsolt Hegedűs as one of the principles, adding that the need for a fair distribution of resources applies to all those who need them. That is, someone does not have an advantage in the care because it is a coronavirus, since in the event of an epidemic, serious accidents, cardiac arrest and stroke occur, which must be treated in the same way intensively.
Key location: the intensive care unit
The epidemic has clearly focused attention on intensive care units within healthcare. This is because some people with coronavirus infection become so severe that they need intensive care. When a hospital reaches the end of its intensive care capacity, it is forced to weigh patients, and the ranking must always take into account all patients who need intensive care in real time, the framers of the code of ethics emphasize. One of them, András Lovas An intensive care specialist at the online congress described why intensive care is needed for patients with severe covidosis – many things need to be addressed at once.
In addition to respiratory failure, circulatory and liver failure, bleeding disorders, kidney failure and disorders of the central nervous system. All of these need to be monitored, so there is more than just a ventilator next to a coronavirus patient – the doctor points out the complexity of intensive care and why this form of care is so resource and human intensive.
According to him, in Hungary, taking into account professional considerations and recommendations, it is not possible to maintain more than two thousand intensive beds because there are no staff.
Compared Viktor Orban The prime minister spoke on public radio the day after the conference, “According to our analysis, 2,240 intensive ventilator beds will be needed on November 21.” And by mid-December, 4,480 intensive care units are expected to be needed and by then 30 to 32,000 people will be hospitalized. The Prime Minister considers this to be the limit of the performance of Hungarian healthcare.
As of today, there are 391 coronavirus ventilators, but many more are in the intensive care unit due to two factors: on the one hand, the fact that there are many patients with severe coronavirus who do not require a ventilator but do receive intensive care, and there are those who were Covid patients, already virus-free, but still ventilated, and needed intensive care in the ward due to serious complications. And there are also intensive care beds for segregated Covid wards in addition to care for non-Covid intensive care units.
In the spring, András Lovas still hoped that the code of ethics was not necessary at all, but the second wave has worsened to the point that he sees that there are already several intensive departments where the document should be introduced in the supply protocol because the system it is oversaturated. and no more intensive beds.
You need a separate team to weight
About that already Tamás Berényi, the head of the Department of Emergency Care of the Master of Semmelweis University, said that the process of classification of patients, that is, triage, should be carried out by a team of several doctors and nurses. The treating physician shares the information with the triassic physician, who can make a much more objective decision about the entire system and data set than the treating physician, who is much more emotionally involved with his patient. The Triassic team in an ideal lineup is therefore an additional team, meaning that it is not the people who work on it who actually treat the patient. They would only be concerned with evaluating and then classifying the condition of patients and, more importantly, informing patients.
According to the doctor, the stone of the sages was not found by compiling ethical guidelines, but instead provide moral support along public and transparent professional principles, thus also supporting the mental integrity and unity of caregivers and society. The goal is clear: save as many patients as possible. The ER doctor commented:
Give it everything you never need to use!
Featured image: A doctor in protective gear examines a patient in an intensive care unit set up to receive coronavirus-infected patients at St. Ladislaus Hospital on April 22, 2020. Photo: Zoltán Balogh / MTI
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