By Emilio Parodi, Silvia Aloisi and Pamela Barbaglia
MILAN, Mar 16 (Reuters) – The fight against death stops every day at 1pm.
At that time, the ICU doctors at the San Donato Polyclinic telephoned the relatives of the 25 critically ill coronavirus patients in this intensive care unit, all sedated and intubated with respirators, to update the families.
It used to be lunchtime during visiting hours at this Milan hospital. But now, as the country faces a coronavirus outbreak that has killed more than 2,000 people, visitors are not allowed in. And no one in Italy leaves their homes anymore.
When the doctors make the calls, they try not to give false hope. They know that one in two intensive care coronavirus patients is likely to die from the disease.
As the COVID-19 epidemic expands and the disease progresses, these beds are in increasing demand, especially for the respiratory problems caused by the virus. Every time a bed becomes free, two anesthesiologists consult a resuscitation specialist and an internal medicine doctor to decide who will occupy it.
The patient’s age and medical history are important factors. So is having a family.
“We have to consider if older patients have families who can take care of them once they leave the ICU, because they will need help,” says Marco Resta, deputy director of the ICU at the San Donato Polyclinic.
Even when there are no possibilities, you have to “look the patient in the face and say, ‘Everything is going well.'” And this lie destroys you. “
The most devastating health crisis in Italy since World War II is forcing doctors, patients and their families to make decisions that Resta, a former military doctor, said he had not even experienced in war.
As of Monday, 2,158 people had died and 27,980 had been infected with the coronavirus in Italy. It is the second highest number of recorded cases and deaths in the world after China.
Resta says 50% of people with COVID-19 who are accepted into intensive care units in Italy die, compared to a typical death rate of 12% to 16% in ICUs across the country.
Doctors have warned that northern Italy – where the universal health system is ranked among the most efficient in the world – is a pioneer in the crises that the disease is causing around the world. The outbreak, which first affected the northern regions of Lombardy and Veneto, has paralyzed the local network of hospitals, putting their ICUs under brutal pressure.
In three weeks, 1,135 people have needed intensive care in Lombardy, but the region only has 800 beds of this type, according to Giacomo Grasselli, head of the intensive care unit at the Milan Polyclinic Hospital, which is separate from San Donato. Grasselli coordinates all ICUs in the public system throughout Lombardy.
Such dilemmas are not new to the medical profession. When treating patients with respiratory difficulties, intensive care physicians always assess their chances of recovery before intubation, an invasive procedure that involves inserting a tube into the throat and airways.
But such high numbers mean that doctors must choose more often, and more quickly, who deserves a better chance of survival, a protocol that is particularly heartbreaking in a Catholic country that does not allow assisted death and where the population is, according to the statistics agency Eurostat, the oldest in Europe with one in four people aged 65 and over.
“We are not used to such drastic decisions,” says Resta, a 48-year-old anesthesiologist.
Italian doctors say so many older patients with COVID-19 and respiratory problems prefer not to try their luck with those with little hope of recovery.
Alfredo Visioli was one of those patients. When he was diagnosed with the disease, this 83-year-old man from Cremona led an active and busy life at home with a German shepherd, Holaf, that the family had given him. He was caring for his 79-year-old wife, Ileana Scarpanti, who had suffered a stroke two years ago, said her granddaughter Marta Manfredi.
At first, he only had intermittent fever, but two weeks after he was diagnosed with COVID-19, he developed pulmonary fibrosis, a disease that results from damage and scarring of the lung tissue and progressively worsens breathing.
Doctors at the Cremona hospital, a city of about 73,000 inhabitants in the Lombardy region, had to decide whether to intubate him to help him breathe.
“They said it didn’t make sense,” said Manfredi.
Her granddaughter would have liked to have shaken her grandfather’s hand during morphine-induced sleep before she died, Marta Manfredi said.
Now she is worried about her grandmother. Ileana was also infected with COVID-19 and is hospitalized, although she is responding well to the help of an artificial respirator. No one has told Ileana that her husband is dead.
Lombardy Intensive Care Coordinator Grasselli said he believed that, until now, all patients with a reasonable chance of recovering and living an acceptable quality of life had been treated.
However, he added that this argument is in question. “Before, with some people we would have said, ‘Let’s give them a chance for a few days.’ Now we have to be more strict.”
These kinds of decisions are also being made outside of hospitals.
On Friday, the mayor of Fidenza, a city bordering the Lombardy region, closed access to his local hospital for 19 hours.
It was crowded with COVID-19 patients and hospital staff had been working 21 days without a break. Although the closure was intended to keep the hospital running, it meant that some people “died at home,” said the mayor, Andrea Massari.
The new coronavirus first appeared in Italy in January, but the outbreak soared in February in the small town of Codogno, about 60 kilometers southeast of Milan. Some medical experts believe it may have come through someone who traveled to Italy from Germany.
Rome hastened to isolate the north of the country, first closing 10 cities in Lombardy and one in Veneto. But that did not stop the virus. In one week, 888 people tested positive for the disease and 21 died. The cases grew exponentially. Small towns were the first to be affected, immediately straining small hospitals.
Since last week, Italy has been in complete confinement. It has closed all schools, offices and services and has ordered all citizens to remain at home unless they have a convincing authorization or reason. These measures are being followed by other European countries, in their attempt to stop the epidemic.
“GREATEST LIFE EXPECTATION”
All infected people who come to the hospital with respiratory distress receive oxygen, Grasselli says. The question is to what extent, and for how long, to keep them breathing artificially.
Those with milder respiratory problems are connected to an external machine with a mask or, if the patient does not respond, a protective helmet. If their health deteriorates, doctors must decide whether to admit them to intensive care, where they would be intubated.
But there is a problem: intubation can come at a physical cost, especially for older patients, Grasselli says. Even if some elderly people survive, many may develop other problems, such as motor or cognitive difficulties.
In the past, doctors tended to try to intubate even older patients, generally because they had the resources to do so, Grasselli said, clarifying that he would never intubate his 84-year-old father.
Before the coronavirus outbreak, “we could more often try to intubate patients who were on the edge,” said Mario Riccio, head of anesthesiology at the Oglio Po hospital near Cremona.
Now that has changed. The Italian Association for Anesthesia, Analgesia, Reanimation and Intensive Care released new guidelines on March 7 because it expects a “huge imbalance” between the population’s clinical needs and intensive care resources in the coming weeks.
This said to the doctors on the front line: give priority to those with “higher life expectancy.”
The massive quarantine of the Italian population adds emotional stress to suffering. Family members are not allowed to travel by ambulance with their relatives, and coronavirus units are closed to anyone other than a doctor or patient.
Some patients who are not at the point of needing intensive care feel like prisoners in overflowing wards.
“Get me away from here. I want to die at home. I want to see you one more time,” Stefano Bollani, a 55-year-old department store worker, said in a text message to his wife from the ICU at the San Donato Polyclinic, where he is being treated for pneumonia after contracting the virus.
The couple have not seen each other since she drove him to the Milan hospital nearly two weeks ago. All he knows, he says, is that his condition appears to have improved in recent days. “These are things that a husband should not (have) to write to a wife who is away, who cannot see him,” she adds.
Former military medic Resta says the situation in Lombardy is worse than the 1999 war in Kosovo, where he served on the air rescue team that was transporting patients from Albania to Italy.
Every time a coronavirus patient is admitted to his hospital, he says, staff write an email to family members assuring them that their loved ones will be treated “like family.” He says the hospital is trying to activate a video conferencing system, so that patients can see their relatives during the 1 p.m. call.
A doctor, and not a relative, is often and inevitably the last person to see a dying COVID-19 patient. Loved ones can’t even get close to coffins for fear they’ll get the virus.
The last time Mara Bertolini learned of her father Carlo, a 76-year-old agricultural engineer from Cremona who is locally known for being a historian of his vineyards, was when someone from the morgue called another member of the family to say they had his body.
Mara does not hold a grudge against health workers, she said.
What impressed him most about the last week of his father’s distress was the look on the doctor’s face when he met him.
“I couldn’t tell if it was worry or sadness,” he said.
“All he said to us was, ‘Stay home.'”
(By Emilio Parodi, Silvia Aloisi and Pamela Barbaglia; additional information by Giselda Vagnoni in Rome; written by Alessandra Galloni; translated by Jose Elías Rodríguez)