The care for covid patients is reaching its limits. What happens when all the beds are occupied and caregivers have their hands full? Who will get the scarce IC bed? And who doesn’t? Six questions about this phase 3, or code black.
1 Is it already code black?
New. We have been in phase 2 d for a few days, so one more step for phase 3. Minister Hugo de Jonge announced this in a letter to Parliament. In concrete terms, this means that appointments with patients for planable care are postponed, according to the website of the National Network Acute Care.
At the moment about 1000 IC beds are occupied and only 1100 IC beds are available. So it gets tight. In phase 2d, extra beds are being sought that can be converted to an IC bed. For example, 1,350 IC beds must be available in the short term. The hospitals must work together as best as possible to be able to help every patient. If there is no room, patients are taken to another hospital, possibly abroad. The military can be deployed to provide assistance.
2 When is it code black?
If there is even more pressure on the hospitals, the minister may announce ‘phase 3’. That’s basically what ‘code black’ has come to be called. It got this menacing name because doctors have to make tough choices—they can’t help everyone anymore. There are too many seriously ill people and too few beds and care providers for that. The National Network of Acute Care has written a scaling plan for this. This plan states that phase 3 involves ‘crisis care’. The starting point is ‘doing the most for the most’, ie saving as many people as possible.
3 How are doctors going to do that?
Normally, ICU doctors make an individual assessment for each seriously ill patient. Is the IC admission necessary and will the patient recover well? This is called ‘medical selection’ and it happens every day. In phase 3 there is a crisis situation and a special form of triage takes place. Now the assessment is not per individual, but for society. How can as many people as possible be saved with scarce resources?
This crisis phase 3 also has different steps: a, b and c. In steps a and b, doctors make decisions on medical grounds about who can go to the scarce IC bed first. This is no longer possible in phase 3c, and the choice must be made on the basis of non-medical criteria. All choices in phase 3 a, b and c are pre already established by the medical associations in a script.
In June 2020, the medical specialists had already drawn up a trial protocol for this, with the proposal to select by age. Young before old. There was a lot of criticism from politicians, but it has remained in the newer version.
4 What are those criteria for who gets help?
This therefore concerns the situation where several people need IC care, but there is not enough capacity. The people have similar medical situations and chances of survival. Here are the steps:
- Step 1: Patients who need short-term IC care are allowed first.
- Step 2: People working in care are given priority if they have had contact with covid patients through their work and were unable to protect themselves.
- Step 3: Younger generations take precedence over older generations. Priority applies to patients from a younger generation: 0 to 20 years; 20 to 40 years; 40 to 60 years; 60 to 80 years and 80 years and older.
- Step 4: If none of this results in a choice, a lottery will be held for the IC bed.
5 Which criteria do not play a role?
Those are:
- Social position
- Mental or physical disability
- Personal relationships
- Ability to pay
- Social status
- ethnicity
- Nationality
- Juridical status
- Sex
- Prior quality of life
- Own fault
6 Does it matter if you are vaccinated against covid or not?
In short: no. In this podcast by NRC Professor of ethics Martine de Vries explains well whether vaccination against covid can play a role. According to her, it is about the ‘own fault’ criterion. De Vries: ‘The group of people who have not been vaccinated is lumped together, but that is not correct. They are also people from deprived areas, who have no access to health care or are suspicious of the government. Or people from a religious environment who do not get the chance to be vaccinated. Is it all ‘your own fault’? You do not want to run the risk of having to weigh those reasons if an IC bed has to be divided. There’s no time for that.’
