Failing to understand that the first come first serve principle does not work in a pandemic like this can lead to really catastrophic consequences.
Hello. I'm Katrien Devolder. This is thinking out loud conversations with leading philosophers from around the world on topics that concern us all.
This is a special edition on ethical questions raised by the Corona pandemic.
In this video, I talk to Dr. Marco Vergano. Intensive care specialist in Turin northern Italy.
Dr. Vergano is also first author of the recently published clinical ethics
recommendations for allocating intensive care treatments when resources are limited.
In other words, recommendations about who to give access to potentially lifesaving treatments and who to let die.
You worked during the night. Say yes, and I'm working tonight as well as well.
I'm between two night shifts. And I slept one hour after lunch.
Oh, wow. It's OK. Thank you very much for giving up some of your very precious time for their Thinking Out Loud video series.
And I realise very well how little time off work you have. Maybe to start with,
Could you describe a little bit the current circumstances in your hospital?
The situation is changing almost every day for sure, every week.
We started a little less than one month ago to admit the first severe cases of COVID-19 patients, a sorry in my ICU.
And now after a month, it looks like we need, some commentators,
they say that the one month of COVID life equals to, probably a couple of years of normal life,
because you learn a lot of things and things it changes so quickly that it's really when you think about your previous two weeks,
it looks like really very remote time in the past. When we issued this recommendation
with the Italian Society on Anaesthesia and Intensive Care at the beginning of March.
Now, the situation was already an emergency in some so-called red zones in Lombardia
In the areas around Milan. But still it was manageable.
In Chiaramonti and Turin where I live. Now, we are very under pressure and we worked a lot
with a really huge force in order to increase our ICU bed capacity and also hospital ordinary work capacity.
But still, we are admitting more and more patients every day.
But the situation is still it is not so difficult.
And compared to Lombardia and compared especially with the some hospitals and
some provinces in Lombardia. So you mentioned the recommendations,
can you give us a little bit more insight into these recommendations?
Well it is a pretty short document and with an introduction and then fifteen short recommendations.
So just a few pages. Because also our aim was to,
to develop a tool that could be easily accessed by colleagues in a time where your personal time is extremely, very limited.
And we produced this document in just a few days.
And it was not an easy process and very short time by the very I mean, a lot of discussion and some disagreement.
Because, for example, professors and people and colleagues in Central and South of Italy really
didn't grasp at the time the severity of the situation that is in Lombardia.
And so now I realise that it's happening everywhere. And then what were sort of the major disagreements?
Do you remember these debates or disagreement?
Well, some colleagues say, yeah, they're probably well written and that we agreed general principles about.
It's a matter of opportunity because we we issue a document like this.
Now, this can depict a more catastrophic situation than the real situation.
But then after just a couple of weeks, all of this sort of a, I would say,
negationism of the crisis and the severity really dissipated more and more silent.
And I have a colleague that he wrote an article comparing this sort of negation ism that still is present in Italy in some environments.
And so I think that, compared to the plague in Milan, in it might be 620 that Alesandro Manzoni described from a supposedly famous novel.
And where where the authorities in Milan, where indicating the existence of the plague.
Even after establishing this site, I think the neighbourhoods where thousands of people were dying because of the plague.
But do they use different names? Because they were scared of admitting that the that the city was really hard hit by the plague.
Well, what did your recommendation say? How to decide between patients?
And presumably it's not on a first come, first serve basis?
No, that's exactly what we wanted to avoid,
because the usual attitude in admitting patients to the ICU's in a pandemic like this would result in such rating immediately.
Your ICU, with the very old and frail people who are the most vulnerable,
who are the first who get sick with a severe form of COVID-19 interstitial pneumonia.
And that you are probably able to keep them alive for many days or for weeks because
we have a lot of Know-How and the technology and the skills in order to do this.
But it's very unlikely that those people will survive the ICU because are too severe and because we learnt that this a severe form or COVID-19,
that is really deadly for elderly, frail people.
And while you keep them alive without reasonable hope of recovery and survival,
the risk is that many more people with much greater chances of survival will die outside of your ICU door.
You have to understand that you are responsible in a pandemic, not only for your single patient you admitted,
but also for everyone else that it is outside of your door and that that probably
is they will not receive intensive care treatment then that lifesaving treatment,
these fifteen recommendations that they set some triage criteria for admission to the ICU and also for the withdrawal of life sustaining treatment.
The principles used that are basically the same over some past documents about by our society at a different threshold.
So we stated that the combination of a functional status age chronically in this and Frazey in general,
combined with other steps like, for example, the surprising question of asking yourself or your colleagues,
would you be surprised that if your patients, your patient would be dead in just a few weeks or a few months,
just as a trigger of your approach and your decision making process?
And so we use this basically these principles that are shared.
Then in the medical literature, it's all over the world.
And just with more focus on the need to be very stringent in your criteria and to
focus on the shortage and under these exceptional shortage of ICU resources in this current pandemic,
some of the principles are the same. So many critics of our recommendations criticise us and accuse us of being discriminatory,
unconstitutional ageist without realising that the modern medicine and intensive care medicine in general is already
full of priorities and and their prioritisation of patients, transplant medicine and access to emergency departments.
What changes here is just the general framework and the and the scale of this,
because this does not involve just a few recipients of lifesaving organ transplants, but maybe a large part of the population.
So the criteria are the same and about. But the threshold, it could be a little different.
And it's flexible and must be flexible. And the people involved are
Many more. what I would like to underline is that it is a clinical decision before being an ethical decision,
because if you think that that admission to the ICU is inappropriate because that patient has really unreasonable chances of survival,
it is not a value judgement or it's not deciding to save a just a young patient because they think his life is worth more than the
life of an elderly patient. It is just because he gets much more chances of survival from this severe form of COVID 19 pneumonia.
And also, not only he has much more chances of survival, but all things equal
You save a much more life years. So I know this is a hard statement but failing to understand that the first come first serve
principle does not work in a pandemic like this can lead to really catastrophic consequences.
And so does age play a more important role in this pandemic?
Yes, it plays a more important role, especially for the characteristics of this pandemic, because it could be different.
For example, now we know that many children just get sick and remain asymptomatic and get infected and remain as symptomatic or experience
Just the sort of mild flu. And also teenagers, for example.
But we know that is almost deadly for the elderly.
If the severity of the disease reaches this A.R.D.S acute respiratory distress syndrome, a clinical stage.
So you can have elderly people with COVID-19 that stay at home and do not require oxygen.
And in that case, they deserve all of the treatment they receive.
But if their respiratory failure worsens and they need oxygen and in danger, if it worsens again, they need non-invasive ventilation.
And if even if non-invasive ventilation is not enough for probably under threat of intubation,
that would be inappropriate because it could be just the prolonging their agonal phase and then that dying process.
So to be clear, it's not age in itself, but it's because age in this pandemic is associated with very low chance of survival.
Yes. Yes. This was one of the main misunderstandings of our recommendations in the media. It's a bit of a controversial question.
I think within amongst ethicists about whether health care workers,
doctors and nurses and so on should get priority access to essentially life-saving resources,
because after all that, they are needed to keep other patients alive.
And yeah, from what I read, a lot of health care workers are already ill themselves.
Right. Yeah, you are right. Of course. Yeah, we are at risk.
Of course, we have a lot of exposure to the virus. And we cannot do anything else because that's our job.
And I think we should get the priority for testing.
And that's the safety of the healthcare staffing. Hospitals should be a priority for hospitals.
I have to admit that, of course, this situation.
This is really heavy. Sometimes everyday because we have exhausting shifts and we've doubled our shifts.
And we have a lot of course,
we have an emotional burden and colleagues that sometimes are really collapse and then they need support by psychologists.
And there are psychologists that probably will need support by their colleagues because we will need psychologists for psychologists.
And when you treat your colleagues in the ICU are in high dependency units, a colleague said, be your age.
And that we're working with you the previous week.
Sometimes you are scared and you think that maybe your roles could be easily exchanged in just a couple of days.
But we did strengthen a lot of our connexions,
our sense of belonging to a community of healthcare workers in the ICU, especially since doctors and nurses.
And even if we don't have an official priority,
everyone knows that if one of us gets sick and needs a [INAUDIBLE] intubation, that, for example, we remain in our hospital.
So we will try to do that extra bed.
And just for us, because this gives you a sort of safety net, and not only because you access you have access to a bed an ICU bed,
but also because you know that you or your colleagues that are your friends in a certain sense, your brothers.
We take care of you. So we will not be transferred to another hospital either other 200 kilometres away from the
hospitals because our hospitals are becoming a second sort of a house and their home.
Their home. Because. Yes, I mean, because you spend so much time, so much time.
Equity said I tried to protect their families. And so they might even go home.
OK. So it becomes your home. Yeah.
in some senses. That's tough. It's one of the less criticised recommendations.
But I think one is becoming one of the most important thing is that is the focus on the on the moral injury of healthcare workers.
Moral distress and the burnout, not only physical exhaustion, but also emotional and moral exhaustion.
Because when you have to face the heart of the allocate allocating choices for many weeks or for months.
Of course, you will need support because you will remember a lot of faces of patients that you are not able to treat.
And so this becomes a real burden. And that makes a difference.
So I got a little bit angry with some commentators because they think there's a real,
real, real difference between the armchair philosophers and the people on the front line.
I mean, not in your case, not because you are interested in the reasons of the recommendations,
the people that started criticising and with very harsh criticism and with really venomous words and terms,
without even that interested in that, in asking our reasons.
And that is really difficult to bear.
And because of that, the main difference thing that we try to reflect on these principles and treating these patients at the same time.
And it's not the same as just reflecting on the principles and then having someone else and
nobody of us would be would like to be in that trolley problem scenario with the trolley.
With the lever in your hand. Exactly. And that the people that negate that were still negation of the severity of this epidemic.
They didn't want to make a choice not pull the lever or let the trolley just go.
They just refused the that that you could be there.
So just refused the idea that you could be in a position of having to
Make these choices. It's like they're denying that there is the scarcity of healthcare resources.
Yeah.
It's just a simple fact. I mean, yeah, that that is what it is.
Yes. Unrealistic solutions. Like, for example, not let's build or buy.
Five thousand ventilator's. They people do not understand it.
A life saving treatment is not just the bed and the ventilator and a couple of syringe pumps.
You need the skilled professionals. They do not get sick.
And they they they that they are able to treat you for weeks.
And and you cannot just build these resources, human resources from scratch just in a few days.
So that's what also was misunderstood by many commentators.
Currently, any support because you as doctors and the nurses, you're all working basically round the clock almost?
Yeah, it seems like now there's not even time probably to go and see a psychologist.
It seems like it's all building up. Yeah. we are living in a bubble now?
Yeah. We are all hoping that all this will really end pretty soon and then we will have to we will need a sort of huge debriefing.
And and to heal also the emotional and moral injury after this from.
I also wanted to just ask how you feel when you see people not complying with their rules of social distancing because
you're in the middle of the crisis and I can imagine you walk on the street or you're in your car or something.
And then a group. I have to recognise that in Turin
I think that there is a good compliance to this containment and social distancing measures.
So we cannot complain. Maybe a couple of weeks ago, still, there were a lot of people that used to underestimate the severity now.
People understood. I think it's very difficult to enforce these measures at the beginning of the
epidemic surge because they are very unpopular and people do not realise it.
So it's difficult to to just force them to stay at home if they do not understand exactly what is happening and and how bad is the situation.
Of course, many of my colleagues, they get angry of people just go go running in the parks or go for a walk.
And so these stay at home mothers become a sort of mantra. But I think that the things are working.
I'm not sure they will be able. The government and the authorities will be able to implement these measures for a very long period of time.
So people are expecting just this quarantine to end in a couple of weeks.
But probably we will need to to keep it for at least a couple of months, probably.
So I'm not sure there is a lot of uncertainty about the future.
Do you think Italy and other countries will be more prepared for the next time?
There will be for the next one? Yeah, for sure. We are learning things week after week.
Clinical treatments, experimental drugs and ventilations strategies.
We are sharing a lot of information on these days. We have weekly webinars.
We have networks with colleagues from China, United States, UK, everywhere, because we are learning very quickly at this change completely the speed.
Also the sharing of medical information, scientific information.
You are learning a lot for the next one. I don't know. I think that this COVID 19 pandemic really changed a lot of things so deeply.
Also, people, people around me and myself, I really felt so,
really so bad after this criticism that with a couple of colleagues who strengthen you, it's a joke about the president of our society.
She's a professor, almost retired, just about to retire.
So and and I had a lot of distance from her a couple of months ago, of course, because she's and now we exchange e-mails.
So where we are sort of like in the Caulkins how to say Lord of the Rings, we are the Fellowship of the Ring.
And she put her signature in the emails. is Galadriel, the president of the society.
And I am Frodo because I carry that the ring for three weeks.
And I have colleagues who are Aragon. And I mean that this strengthens our relationship.
And. And also I think our characters. Because now we we are really.
I will be heard by in a couple of weeks by the National Committee of Bioethics in Italy.
That remains the sort of of a castle like in reading a sort of filter bubble,
because they really do not even acknowledge the fact that there are recommendations that were cited all over the world,
probably sometimes criticise. But they just that a lot of those conservative members of the committee,
they just do not even want to recognise the fact that we issued those recommendations.
So I read a couple of e-mails and they they there are people there in there in the committee that refused to participate in
the discussion because they say that our our principles and our criteria are a new form of defining Untermensch.
OK, so that this is the level of the discussion in those places. it's like they're living in a different world like a bubble.
Yeah. Like a bubble. Like. Like. Like a fairy tale.
like the plague in Milan for four centuries ago.
I was scared at the beginning. And now I'm really I just I like to be there tomorrow because I feel that much stronger than one month ago.
So because I think I have good reasons to. We just want to save lives.
Exactly, I mean, you're there. People that. Yeah. Then there are people there that say it's better.
Two people dead. Than the one homicide. And then this pandemic that it would also mean like it may.
Or 2000 people. Yeah. Yeah. We're like. Yeah. Yeah, that's.
Yes. Yeah. Also because the numbers are totally positive when you read it.
We have 1000 deaths in Italy today.
It is probably between four and eight thousand because we don't have enough testing capacity to test leaving patients, not the dead patient.
Not all of the patients in the red zone started dying outside the hospitals because they don't have even gets an ambulance or something.
So this is what's happening. Yeah. Thanks so much for sharing your thoughts on this.
Thank you. And I hope the situation in Italy will improve.
Very soon. Yes. And I also wanted to say how many grateful we all are, of course, for all the work that you do.
And I'm sure that's not what this video will be extremely grateful just so much right now.
I hope that the situation in the U.K. will not reach the intensity and the severity of our.
So I really hope. Yes. Thank you. OK. Thank you very much.
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