Frankfurt More and more Covid 19 patients are on the wards of German clinics. Even if the number of infections stagnated immediately, this development would continue for more than a week. And already now, intensive care patients are being transferred to normal wards earlier “as medically justifiable”, said the chairman of the board of the German Hospital Association, Gerald Gaß, on Germany radio on Monday. “We know: we can no longer provide all patients with the best possible treatment (…) that we usually have available.” That is a kind of triage. Questions and answers:
The term comes from disaster medicine. There it means that in the event of a major accident, for example, patients are classified according to the urgency of their treatment. First, according to medical historians, the word was used in the French military: for the order in which wounded soldiers are treated.
In the pandemic, triage means more that a selection is made who has access to intensive care treatment or that a patient with a poor prognosis has to vacate his bed for a sick person who is given better chances. However, “no generally accepted or even binding triage scheme has emerged to this day,” said the Tübingen moral theologian Franz-Josef Bormann in March at a forum of the Ethics Council on the subject of triage.
“When we talk about triage, it’s a creeping process that is gradually becoming a harder reality,” said Gass on Monday. Patients and clinics would have to be prepared for the fact that “medically more complicated cases”, for example, would have to expect their operations to be postponed.
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What criteria would be used to decide who is to be treated?
“In the absence of appropriate governmental guidelines”, eight medical societies drew up proposals in March 2020 as to how as many people as possible can be saved when resources are scarce. “This represents an enormous emotional and moral challenge for the treatment team,” emphasize the authors.
The prioritization of patients should be based on the criterion of clinical success. “Unless otherwise avoidable, those patients who have very little chance of survival are not treated in intensive care. On the other hand, those patients who have a higher probability of survival as a result of these measures are given priority treatment. “
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It is further specified: All patients must be included in the selection to be made, regardless of which ward they are on. A selection only among Covid-19 patients would not be justifiable. A selection based solely on age, social characteristics or certain underlying diseases would also not be permitted. In an updated version of the recommendation in November 2021, the experts emphasized that the vaccination status of a patient should not play a role in the decision on further treatment.
What are the chances of survival with Covid-19 in intensive care units?
Even among patients who receive intensive care treatment, the mortality rate is 30 to 50 percent, according to the Hamburg intensive care doctor Stefan Kluge. Of the seriously ill who have to be connected to an artificial lung, more than one in two do not make it.
Is there already a triage in the clinics today?
Given the current situation in some regions, some doctors are already talking about latent or soft triage: For example, if there is no longer a free bed in a specialized house for a stroke patient in the immediate vicinity. Or if an operation planned for the next day has to be postponed by a week due to a lack of capacity, which can have negative consequences for the patient. “This is a compulsion that we are pushed into, which does not have to be that way if the pandemic were under control,” said Director of Clinic I for Internal Medicine at Cologne University Hospital, Michael Hallek, recently.
According to the German Hospital Association, three quarters of all clinics nationwide are no longer in normal operation and have to postpone operations, so mostly they are orthopedic. The current half-hearted corona policy is at the expense of thousands of necessary hospital treatments, criticized the medical lawyers association on Monday. “100,000 Covid-19 deaths are not the only deaths from this pandemic.” Necessary treatments in hospitals have been postponed for weeks. It becomes critical, for example, when lower strength chemotherapy is performed on cancer patients in order to prevent intensive care, or when tumor operations are postponed, also at the risk of metastasis.
Is there a threat of triage if the number of Covid 19 cases continues to rise?
“A triage would be a declaration of bankruptcy for the German health system,” said intensive care physician Christian Karagiannidis recently in the NDR podcast “Coronavirus Update”. “Triage would mean ending the life of one patient in favor of another patient.” In view of the large hospital capacity, this should simply not happen in Germany. “But what can happen – and what happens – is that there is a certain prioritization.”
How does this “prioritization” look in practice?
Karagiannidis gave an example: In a clinic with eight beds with artificial lungs, seven are occupied. Several hospitals in the area asked whether they could have the free bed for one of their patients, “and then of course you have to make a selection”. The higher the pressure and the lower the capacities, the more it has to be prioritized “that certain patients are treated in the large clinics and that the patients who are perhaps very old and have a bad prognosis will not get a bed there.”
Some intensive care patients would be transferred to normal wards earlier “as medically justifiable”.
(Photo: dpa)
Eugen Brysch, board member of the German Foundation for Patient Protection, points out that the proportion of intensive care patients over 80 with Covid-19 is low compared to their high proportion of corona deaths. Hospital triage is “pure theory” and remains on everyone’s lips, he says. “Elderly care triage, on the other hand, is real, but it is hardly noticed.” Brysch demands clarification: It is not enough to claim that old people basically do not want any life-sustaining measures. “Even in advance directives, a clinical stay is often not excluded per se.”
What are the consequences of the procedure for non-corona patients?
Large clinics “are currently working on priority lists,” said Jürgen Graf, medical director of the Frankfurt University Hospital and head of the planning team for inpatient care for Covid 19 patients in Hesse.
Most of the treatment cases in his home are emergencies and acute cases. As always, they would be treated according to urgency. “We are now entering an area where we have to prioritize which services we can still provide and which not.” It is expressly not about the fact that a clinic cannot or does not want to accept Covid 19 patients. The capacity problem affects all diseases. Patients who need acute medical care may not find appropriate care.
What is the legal situation like?
Lawyer Tatjana Hörnle from the Max Planck Institute for Research into Crime, Security and Law differentiates between “ex ante” triage “- two patients arrive at the same time and only one bed is free – and” ex-post triage “- one patient is already there, a second one with better chances of survival will be added. In the first case, there is no serious risk of criminal liability, said Hörnle. There was no manslaughter by omission, the selection criteria of the rescuers were not checked. In the second case, manslaughter by omission would come into question under the law. How this is assessed in individual cases, because “opinions in the criminal law discussion differ widely”.
More: RKI reports 100,000 corona deaths in Germany – the seven-day incidence is now just under 420