A doctor asked him in tears on Tuesday: who should I cancel? The breast cancer patient or the colon cancer patient? Hospital director David Jongen tries to outline the situation in his hospital. The answer? “Call off both patients.”
The influx of Covid patients in the Limburg Zuyderland hospital is so great that they decided on Tuesday to postpone all critical planable care. Cancer operations, heart operations: interventions that should actually be done within six weeks. “That talk about whether code black or not code black,” says Jongen over the phone. He finds it incomprehensible. “We are already making choices that lead to health damage. We are already in our shoes.”
The protocol for ‘code black’, drawn up last year by doctors and ethicists, will only officially go into effect when all ICU beds are full and choices have to be made about who receives life-saving treatment and who does not. Outgoing minister Hugo de Jonge (Public Health, CDA) has said in recent days that the care there is “a long way off”. But Diederik Gommers, head of the IC doctors, said in the House of Representatives on Tuesday evening that code black could be on the agenda within ten days. The cabinet clearly does not speak the same language as the care providers in the workplace.
Critical limit IC in the picture?
This Tuesday, according to the National Center for Patient Distribution, 943 patients were in the ICUs. The total capacity is currently being expanded to 1,150 beds. According to Gommers, this is already “very difficult”. Because the infection figures are still not falling, many hospitals fear that the critical IC limit will come into view in the coming weeks.
The Ministry of Health and the National Acute Care Network (LNAZ) have agreed that a further upscaling to 1,350 IC beds for four weeks should be possible, although Gommers called this “unfeasible” due to the large staff shortage in the House of Representatives.
If the maximum IC limit is exceeded, the code black protocol comes into effect and special triage committees in hospitals must determine who will still be admitted to the ICU and who will not. In the triage, medical factors such as survival rate and frailty are first considered, but ultimately non-medical criteria may also play a role, such as the age and expected length of stay of a patient. Patients who can no longer go to the ICU still receive care and end up in the nursing ward, for example, or receive oxygen at home. As a result, they do not receive the best possible care and could die as a result.
To avoid a black scenario, it has been agreed that hospitals will first postpone all planable care, including cancer and heart operations that can be crucial for a patient’s chances of survival. Only in this way can staff be released and the 1,350 IC beds can be manned. The Dutch Healthcare Authority reported on Tuesday that the situation is now “serious”. Just like the Limburg Zuyderland, fourteen hospitals are no longer able to deliver critical, planable care on time.
The crisis week of hospital director David Jongen: ‘I think we have to close two more operating rooms’
Anyone who follows the strict definition of code black concludes: there are still IC beds available in the Netherlands. But locally, says hospital director Peter Langenbach, there are days when that is not the case. Last week, all seventeen ICU beds in the Maasstad Hospital in Rotterdam were occupied. “If an accident happens on the A16, or if Covid patients in the nursing department suddenly deteriorate sharply, there will be no bed in the hospital. That feeling is very uncomfortable. Code black feels very close.”
On Thursday, a team from the Rotterdam hospital will already go through the scenarios as an exercise. Like David Jongen, Langenbach emphasizes that choices are already being made that go against professional ethics. “Doctors and nurses are trained to help everyone. Any surgery you postpone is a tragedy for the patient.”
President of the professional association for nurses V&VN Bianca Buurman says that we are already on a ‘sliding scale’ on the way to code black, the quality of care is deteriorating step by step. “In a normal situation, for example, each ICU nurse takes care of one or two patients. Now there have been three or sometimes four for a long time.” Buurman is concerned about aggression towards care providers, which increases when care becomes poorer. For example, ambulance workers who are rudely spoken to because they first want to put on their protective clothing before entering.
Hospital director Ernst Kuipers, responsible for the scaling up of ICU care, said on Monday that he thinks it is risky that healthcare directors are now “tumbling over each other”. He fears that the term ‘code black’ will no longer make an impression if this extreme scenario gets really close.
A version of this article also appeared in NRC in the morning of November 24, 2021
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