Age factor: struggles in the ICU to survive


Some time ago I had already commented that I did not share the position of the Spanish Scientific Societies on their recommendations for ethical decision-making on the access of patients to intensive care units (ICU) in pandemic situations.
Up To date (June 10, 20202), only 381 patients over the age of 80 have been admitted to the ICU since the start of the pandemic.

THE FACTS

Age
80-89
Confirmed
34032
Hospitalized
17610
%
20.1
ICU
312
%
4.1
Deceased
7117
%
41.3
Fatality
20.9 %
> 901593456996.5460.6349620.321.9 %
Data since February 2 up to May 7, 2020

The mortality of the ICU group is unknown. But in the group of over 80 years diagnosed with COVID-19, where the deceased reaches 41.3% all hospitalized.

That there has been a clear decision not to admitt in the ICU this group of octogenarians is clear, and I doubted and doubted whether it was ethical.

I have carefully read the cited recommendations. In addition, they were made public in the media and there was already talk of whether there was a very clear limitation by age. I do not know the acceptance or not of the doctors based on these arguments.
In it, they refer that in difficult times it is advisable to have an ethics team or committee (arduous difficult, if not impossible in most Hospitals in Spain) and less in the admission time.
We do not know many things yet. But what alerted me is that age was included as a factor in elucidating priorities and proposals for independent treatment if patients have comorbidities or not (meaning two or more chronic diseases). Directives are not included to avoid their admission, but setting specific ages and their inclusion in the recommendations with alternative treatment proposals may condition attitudes against elderly patients, such as a patient 80 years of age or older with Hypertension and type Diabetes. II, understanding that there are even young patients with two or three chronic diseases and probably with a worse quality of life.

The problem before occurring in Spain, an example was taken of what was done in Italy, with a clear position of limiting by age in their guides (although curiously their guides do not exactly put age with numbers), but the truth is that this is how did.
The problem in Spain has started and the contingency plans are in place from March 10. The recommendations of the Spanish Society of Intensive and Critical Care Medicine, together with the Spanish Society of Geriatrics and Gerontology and 20 others, are positioned to introduce the age factor. No matter how well they want to explain it, there is a bias or limitation with respect to lower age groups. I believe that, from my point of view as a doctor, specialist in Intensive Medicine, these guidelines do not represent me and I also consider them potentially reportable.

BACKGROUND LAW

Well, I have started to investigate and for example in the USA, they have multiple Universities and Bioethics centers, in addition to very powerful groups such as those of the AGD (American Geriatrics Society). Furthermore, they have had H1N1 outbreaks in many cases with situations similar to COVID-19. In fact, most of the guides were made 10 years ago.

Well, I have several lists and among them this one with some of the American Medical Societies, Universities, Departments of Critical Medicine, Ethics Groups, Disability Rights Education and Defense Fund (DREDF) and the US Office for Civil Rights. They advocate preserving civil rights, which stated relatively recently:

“Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism,” said Roger Severino, director of the US office, in a press release. His office is opening investigations to ensure that state-mandated health rationing plans “fully comply with civil rights law.”


He said his office had heard from “a wide spectrum of civil rights groups, pro-life groups, disability rights groups, from prominent members of Congress on both sides of the aisle, from ordinary people who are concerned about their civil rights in this moment of crisis ”.
Rejects rationing of disability-based health care, and age even in times of crisis.

In the face of the COVID-19 crisis, misconceptions about the quality of life of a person with a disability may also constitute an unjustified and illegal implementation of a health care rationing system. Even with a very affected Health System during these difficult times, treatment decisions and general policies still do not discriminate.



1.- Doctors cannot deny or limit care to disabled people due to their disability
2.-Doctors cannot deny or limit care due to the fact that a disabled person may have a lower probability of survival or require intensive care.
3.- Physicians should not rely on quality of life judgments when deciding whether to deny or limit COVID-19 treatment
4.-Doctors cannot deny or limit treatment to a person with a disability because they may require reasonable accommodations.


The American Geriatrics Association has given its positions that include:



(1) Avoiding age per se as a means of excluding anyone from care;
(2) Evaluate comorbidities and consider the disparate impact of social determinants of health;
(3) Encourage decision makers to focus on possible short-term (not long-term) prognostic outcomes;
(4) avoid auxiliary criteria such as “years of life saved” and “long-term expected life expectancy” that could harm older people;
(5) Form and promote triage committees to allocate scarce resources;
(6) Develop institutional resource allocation strategies that are transparent and applied uniformly; and
(7) Facilitate proper advance care planning

1. University of Utah School of Medicine, Salt Lake City, UT

2. VA SLC Geriatric Research, Education, and Clinical Center, Salt Lake City, UT

3. University of Utah Health Interprofessional Education Program

4. Section of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT

5. University of Utah S.J. Quinney College of Law, Salt Lake City, UT

6. University of Utah Department of Philosophy, Salt Lake City, UT

7. Division of Geriatrics, Department of Medicine, University of

8. California, San Francisco, San Francisco, CA

9. UT Southwestern Medical Center, Dallas, TX

10. Department of Emergency Medicine, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY

11. Cahn School of Medicine at Mount Sinai, New York, NY

12. Geriatrics Research, Education and Clinical Center, James J. Peters VAMC, Bronx, NY

13. University of California, San Francisco, San Francisco, CA

14. Good Samaritan Hospital, Vincennes IN

15. Union Hospital, Terre Haute, IN

16. Massachusetts General Hospital, Boston, MA

17. University of Michigan Medical School, Ann Arbor, MI

18. VA Ann Arbor Geriatric Research, Education, and Clinical Center (GRECC), Ann Arbor, MI

19. Baylor College of Medicine, Houston, Tx

20. Michael E. DeBakey VA Medical Center, Houston, TX

21. University of Utah College of Nursing, Salt Lake City, UT

22. UCLA Borun Center for Gerontological Research, Los Angeles, CA

23. VA Los Angeles Geriatric Research Education and Clinical Center, Los Angeles, CA

24. RAND Corporation, Los Angeles, CA

Some jurist could tell me, if in Spain, there are some laws that protect against decisions of this type. We have the Magna Carta, Decisions of the Supreme Court, etc?. I do not do this or say it to annoy, is that personally I find unethical.
No one should take a position against the right of those who live or not, even in times of crisis. If in times of no crisis, I know when I should enter someone regardless of their age and / or morbid condition.
I have made many limitations in those cases that corresponded. I have even had confrontations with the BOD of my Hospital and with colleagues based on therapeutic futility. We learn with the daily attendance.
The intensivists are already very clear about their ideas of admissions and use of available resources. We have done it all our lives. What is this position for?


And worst of all, who could have been more interested in it? The Spanish Ministry of Health? The one who says he recommended them, but only as a guide, then leaving doctors alone in their decisions when they were public in the media?



Having and working outside of Spain in different places has given me a more open mind, but my principles have never changed.

During the last days, I have read 182 articles, three almost finished articles and with some pending data, as a previous step to publish them.
The medical literature is full of these Pro-Life criteria.

The Journal of Pearls in Critical Care (JPCC)

Herrero-Varon's MD Editors. Changchun (Jilin, China) and Houston (TX, USA). Language EN/ES 2011-2020

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