As COVID-19 wreaks havoc on the Italian health system, doctors are forced to decide who gets intensive care based on life expectancy.
ROMEIn the northern Italian region of Lombardy, the epicenter of the novel coronavirus outbreak that erupted on Feb. 21, doctors say they are now practicing disaster medicine.
The term comes from wars and natural disasters, when emergency doctors use triage, prioritizing the order of treatment to decide who they will use scarce resources to try to save, and who they will let go.
This surely is not meant to be applied in modern hospitals in the economic powerhouse of the fourth largest economy in Europe, but such are the times.
Doctors in Lombardy are now disastrously short of intensive care beds and respirators to treat the worst cases of COVID-19, the disease caused by the novel coronavirus. So they are no longer doling out intensive care beds to the first to arrive, but to those expected to live the longest. Age is not the only factor, but roughly speaking the older you are, the lower you are on the priority list.
Confirmed infections across Italy are shockingly high, with 10,149 cases as of Tuesday and 631 deaths, second only to China where the outbreak began. But even more alarming is the fatality rate, which is running at 5 percent nationwide and 6 percent in Lombardy, compared to the World Health Organizations global average of 3.4 percent.
Italys head of the National Institutes of Health, Dr. Giovanni Rezza, says the high rate comes down to math. Since Italy has the second oldest population after Japan, and the coronavirus is particularly hard on the elderly, they are hard to save. Of Italys 631 deaths so far, the median age is 80.
But increasingly over the last few days, those who die are younger. People in their fifties are now on the list. Even though almost everyone who perishes with the virus has underlying conditions, the health care system is now forced to look, essentially, at who is worth saving.
Take the case of Patient One, the 38-year-old Unilever worker who was the first in Lombardy to contract COVID-19 on Feb. 21 after trying desperately to get someone to test him. Because he had no ties to China, he went from clinic to clinic until someone took him seriously, spreading the virus as he went. He got out of intensive care on Monday after nearly three long weeks. He is still testing positive for the virus, but he is no longer on a respirator. He has no underlying conditions and the disease nearly killed him.
Dr. Guido Giustetto, the head of the medical association of Piedmont, another hard-hit area in the north, suggested that choosing not to give an elderly person with a complicated medical history an ICU bed often happens. Its a reasoning that our colleagues make, he said at a press conference Monday. It becomes dramatic if, rather than doing it under normal situations, they do it because the beds are so scarce that someone might not have access to medical care, like now.
Italys Society of Anesthesiology and Intensive Care sent out 15 ethical recommendations for the virus when considering who to prioritize. One recommendation is that, in a situation like Lombardys where there are severe shortages of health resources, doctors must aim to ensure intensive treatments for patients with greater chances of therapeutic success: it is therefore a matter of prioritizing the greatest life expectancy. The need for intensive care must therefore be integrated with other elements of clinical suitability.
The fear now is that if the draconian measures Italy is taking to try to contain the virus fail, the spread will be far more deadly in Italys poorer southern regions, where health care facilities are far less developed. The Lombardy region already has borrowed beds, and converted operating rooms and even hallways into intensive care units to try to treat the now 466 patients who need ICUs. They are still grotesquely unable to keep up with the growing number of afflicted.
Italys Society of Anesthesiology and Intensive Care guidelines also include a pragmatic, albeit worst case scenario. The availability of resources does not usually enter the decision-making process and the choices of the individual case until the resources become so scarce that they do not allow to treat all patients who could hypothetically benefit from a specific clinical treatment, the guidelines state. Patients and their relatives concerned by the application of the criteria must be informed of the extraordinary nature of the measures in place, as a matter of transparency and maintaining trust in the public health service.