(QCOSTARICA) Faced with the unstoppable increase in patients hospitalized by COVID-19, public hospitals are preparing in the event that they have to make the most difficult and painful decision of the entire pandemic: select who gets a respirator and who doesn’t.
The Caja Costarricense de Seguro Social (CCSS) or “Caja” published, for the knowledge of all its workers, the second version of the Bioethical Guidelines for the SARS-CoV-2 Pandemic (Lineamientos Bioéticos ante la Pandemia por SARS-CoV-2 in Spanish).
A third version will be presented next week.
The document, which has been circulating since June 9, recommends the general actions that health personnel should carry out in different scenarios; including the collapse of hospital services, when human resources, equipment, and beds become insufficient to care for the sick.
This is a guide that aims to prevent, in crisis situations, unfair decisions, inadequate management of limited resources, and errors when prioritizing the admission of patients to the Intensive Care Unit (ICU) and assigning devices, such as respirators.
The head of the Bioethics Area of the Center for Strategic Development and Information on Health and Social Security (Cendeisss), Sandra Rodríguez Ocampo, ensures that this guide seeks respect for the dignity of the person, and the defense of the rights to health and life.
In borderline situations, such as those that could be approaching if the tendency of the exponential increase in contagion cannot be stopped, Rodríguez affirms that every possible effort will be made to save as many people as possible with the resources that are available.
In this sense, it promises that there will be no discrimination based on age, social condition, nationality, ideology or sex; and she anticipates that priority will be given to those who have the best chance of survival.
According to data from the Caja, as of July 17 hospitals had 720 ventilators to provide mechanical respiratory assistance. The number of beds available for COVID-19 Intensive Care patients was 308.
The figures, the CCSS clarified, vary as the so-called Expansion Plan, announced on July 9, progresses. In three phases, it is intended to add quotas in the main national hospitals (San Juan de Dios, Mexico and Calderón Guardia), up to 159 ICU beds and 134 intermediates.
However, CCSS projections indicate that, if the current growth trend continues, by August 14 there will be a decrease in the capacity to serve patients in intensive care.
“So that people do not feel anguish to think that in a situation where the Caja’s capacity to respond is exceeded, arbitrary decisions will be made, that dignity will not be taken into account, or that they will discriminate against people.
“In this type of situation, what is intended is to maximize the benefits to patients with the available resources, and seeking to save as many lives as possible. This includes people who get sick from other pathologies and who also need care in hospitals,” said Rodríguez.
The exponential growth of COVID-19 daily cases in Costa Rica, which multiplied by 20 in a matter of a month (it went from 33 new patients a day on June 9 to 649 a month later), directly hits hospital services.
This situation was repeatedly warned by Health authorities since the beginning of the national emergency in March and amid insistent calls to the population to respect the sanitary measures.
This Saturday, 225 people hospitalized; 41 of them in ICU. A month earlier, the figures were diametrically opposed: 22 hospitalized patients registered on June 17; three of whom were in ICU.
In the 24 hours between the Friday noon report by the Ministry and Saturday, seven deaths were reported, the highest for a single day, for an accumulated total of 54; the number of confirmed cases rose to 10,551 on Saturday, of which 7,595 are active, that is they can spread the virus.
For Carlos Valerio Monge, lawyer for the Ombudsman’s Office and specialist in Public Health, Bioethics and Health Law, one of the strengths of the CCSS guidelines is that they allow covering other care scenarios, in addition to the most critical ones.
For Valerio, the CCSS document is clear and becomes a good tool for health personnel who must make these decisions, generating what is known as ethical or moral stress.
“When things get difficult, which is very possible in the face of the current crisis, the document is clear for making decisions, as they say, in times of war. The prioritization of the guideline is based on the probability of life expectancy.
“It establishes several clinical elements to consider of the patient: condition, morbidity, age, but above all it is a clinical analysis to assess the survival of a person and decide whether or not to be admitted to an ICU or put on a respirator,” he told La Nacion.
“It contains the bioethical elements necessary for a bioethical crisis like the current one, respecting the value of life, justice and equity in the distribution of resources. Respect the issue of the autonomy of the will of the people. Its content is correct from the bioethical and clinical point of view,” added Valerio.
Among the core aspects, the guidelines recommend prioritizing the care of those patients with a greater probability of recovery, this according to the best scientific evidence available, and without making any type of discrimination.
The guide is especially clear on the subject of age, one of the most worrisome worldwide, transcending cases in which patients have been left out of the ICU just because they are seniors.
For this population group, also considered to be at the highest risk of complications from the new coronavirus, treatment equal to that of other people is recommended, based on clinical criteria.
Ernesto Picado Ovares, coordinator of the palliative and community care unit of the National Hospital for Geriatrics and Gerontology (Hospital Nacional de Geriatría y Gerontología), considers that this group is protected in the guidelines.
“Older adults are one of the most at-risk populations in the pandemic, but they are also one of the most at risk for exclusions from a bioethical point of view. These guidelines mention that you have to take into account the person, ask for their opinion, respect their dignity,” said the specialist.
The CCSS guide also recommends applying these guidelines to all people uniformly, and not selectively, as well as knowing, respecting and taking into account in the clinical approach, the values and preferences of patients who reject “invasive measures”.
Hazel Gutiérrez, pediatric specialist in Palliative Care of the National Children’s Hospital (HNN) and bioethicist, maintains that a situation like the one that is coming was expected since March.
“This was inevitable, one wants to maintain that hope that everything turns out well, but when faced with something medical, so new to humanity, we had to be prepared for decision-making in difficult scenarios, such as those we observed a few months ago in Spain or Italy.
“We knew that we were not going to be free (of such a decision) as a country. But if we had to face it, we had to generate a guide so that professionals had clear the most important principles on that decision-making,” acknowledged the specialist.
Gutiérrez considers that the guide is very well defined, especially to avoid discrimination of patients by age, social status or nationality, and contemplates the assessment of vulnerable people at the extremes of life: minors and older adults.
“There is this clarity that there will never be institutional abandonment of the patient, whose needs will always be met to promote the greatest possible well-being. Each case will be assessed individually, comprehensively and not as a set of isolated risk factors because we deal with human beings,” added the pediatrician.
Protect the most vulnerable
Many of the actions that the CCSS has developed in recent weeks are linked to the bioethical principles defined in its guide for hospitals.
One of the first measures was to restrict the outpatient consultation so that only priority patients, such as people with cancer, saw a medical specialist. This, in order to avoid the spread of the virus.
Another action has been to promote solidarity and cooperation between the different health centers, with the transfer of patients to those with response capacity, as has been done between regional hospitals and the COVID-19 Specialized Center for Patient Care (CEACO).
This has been achieved through a centralized health system like the Caja, as explained by the president of the CCSS, Roman Macaya, on Saturday.
Efforts have also been made to optimize the resources of all services, recently including 48 beds from the Institution Nacional de Seguros (INS) Trauma Hospital, a medical center by the national insurer to serve its insured patients and of traffic accidents. Last week, Macaya announced the cooperation agreement between the CCSS and the INS, to attend to patients with the new coronavirus.
In addition, it was decided that the new teams from the new east tower of the Calderón Guardia Hospital would go on to support the care of patients in CEACO.