By Benjamin Herreros, Pablo Gella, Diego Real de Asúa
In the wake of the first COVID-19 wave, the latest news media cycles in Spain have been filled with alarming headlines on the need to investigate the triage criteria used during the epidemic. The State’s Attorney’s Office is undertaking preliminary investigations into several hospitals in the Madrid region (the Comunidad Autónoma de Madrid), asking for their institutional ICU triage protocols. Although the investigation is prompted by an unrelated question -whether elderly individuals living in residential facilities were denied hospital transfer during the epidemic-, it has stirred a painful uneasiness among clinicians, with whom we’ve tirelessly worked arm in arm these trying months.
As physicians working at two academic medical centers in Madrid we share our colleagues’ sense of feeling judged for some of the most difficult decisions we’ve had to make in our careers. And yet it is also understandable that society might hold us accountable for our decisions, questioning how we reached them. Indeed, it might be necessary for us all, as a society, to review how these were made in order to be able to move forward. We might need it to put behind all the pain caused by those that died.
During the pandemic, we have strongly advocated for the need to open our decision-making processes to the general public. Transparency can foster trust, not only among healthcare professionals but also between these professionals and their patients and families. As such, we have shared in two articles, one of which was recently published in this journal, how triage criteria for the use of advanced life support (ALS) and/or access to ICU beds had been developed in Madrid, Spain. We evaluated the moral grounding of those criteria, highlighting our missed opportunities by comparing these criteria to those used in organ transplantation protocols and criticising the problems posed by subjective, non-clinical criteria such as setting an age cut-off value for unilaterally withholding ALS, using ‘social utility’ criteria, prioritising healthcare professionals or using ‘first come, first served’ policies.
As participants in the task force for the elaboration of general guidelines for hospital triage in the Madrid region, we have had the opportunity to review many protocols and proposals on triage. Although most protocols shared many commonalities, all criteria were not homogeneous. In fact, we have defended that the application of diverging criteria between institutions might have led individual patients to be considered for admission to the ICU at one particular hospital, while at another nearby institution their admission (to the ICU) could have been denied. Because this fractionation might have been detrimental to patients, a deeper analysis by a public third party might be useful.
Although the State Attorney’s Office investigation might clarify the role of these inter-institutional differences, judging each protocol individually might easily overlook two relevant aspects that substantially influenced the drafting of all of them: the absence of supra-institutional guidance and the lack of collaboration between healthcare institutions at a regional and national level.
Most of the general recommendations stemming out from scientific societies, the National Bioethics Committee or the Ministry of Health appeared in late March or April, when the epidemic was already at its worst. For the better part of March, most institutions had to develop and adjust their triaging protocols as best as they could. Furthermore, the delayed publication of these guidelines might have been of little use for clinicians because they were eminently theoretical, lacking the granular practicality required for clear, rapid decisions in clinical practice.
In addition, as flawed as each triage protocol may be, a general insisted-upon aspect was the need to increase the availability of ALS resources by ensuring inter-institutional or inter-regional patient mobility. Unfortunately, we have seen neither. Patient transfers have been very scarce with the notable exception of those moved to the large, improvised field hospital established at IFEMA Convention Center in Madrid. Although most hospitals were equally crowded during the epidemic, we fail to believe that a better collaboration between healthcare institutions, coordinated at the regional level by the Consejería de Sanidad of each Autonomous Community, and at the national level by the Ministry of Health, would not have helped save more lives.
COVID-19 has taught us that triaging protocols should be systemic. They should be developed and implemented jointly between institutions and authorities, both locally and nationally. Regardless of whether the focus now lies on individual institutions, we should not miss this opportunity to increase supra-institutional transparency and collaboration as a better way for all to heal from the COVID-19 wounds.
Paper title: Triage during the COVID-19 epidemic in Spain: better and worse ethical arguments
Authors: Benjamín Herreros 1, 2, Pablo Gella 2, Diego Real de Asúa 3, 4
1 Unidad de Medicina Interna, Hospital Universitario Fundación Alcorcón, Madrid, Spain
2 Instituto de Ética Clínica Francisco Vallés, Universidad Europea, Madrid, Spain
3 Servicio de Medicina Interna, Hospital Universitario de La Princesa, Madrid, Spain
COMPETING INTERESTS: None to disclose