Internal documents from the Madrid government show that regional officials issued protocols with criteria to exclude some nursing home residents from being transferred to hospitals at the peak of the Covid-19 pandemic.
Physicians at healthcare centers were also instructed to apply certain guidelines to determine whether sick people living in their own homes should receive home treatment instead of being taken to the hospital.
Although there are no official figures yet, this newspaper estimates that more than 19,000 people have died at social services centers – which include senior homes and centers for people with disabilities – across Spain.
In a country hit hard by Covid-19, the plight of nursing homes has been particularly shocking. Prosecutors have opened 140 criminal investigations after bodies were found on beds in understaffed and overwhelmed centers that lacked adequate protective gear for their workers.
At the 710 centers operating in the Madrid region to assist elderly people with disabilities or mental illness, at least 5,986 individuals have died of coronavirus-related problems since March 8. Since the beginning of the pandemic, 897 people have died in their homes in Madrid.
The issue has become a political football, and politicians are now threatening one another with taking it up with the courts.
The Madrid region is run by a right-of-center alliance of the Popular Party (PP) and Ciudadanos (Citizens), while the central executive is in the hands of a minority coalition made up of the Socialist Party (PSOE) and the leftist Unidas Podemos.
These opposed groups are now engaged in a public exchange of blame and disagreement over who was in charge of running the care homes during the pandemic. Healthcare is devolved to the regions, but certain powers were recentralized under the state of alarm, which was declared on March 14 in a bid to curb coronavirus contagion.
EL PAÍS recently revealed that the chief of Madrid’s Social Policy department, Alberto Reyero of Ciudadanos, had alerted colleagues in the regional government about the fact that the protocols excluding certain patients from hospital care depending on their degree of dependence or disability were “immoral” and possibly also illegal.
On Tuesday, Spain’s Deputy Prime Minister Pablo Iglesias, who is the leader of Unidas Podemos, described management of Madrid’s care homes during the Covid-19 pandemic as “an evident scandal that could have legal consequences.”
A day earlier, Iglesias had stated on the public broadcaster TVE that “people are not going to forgive what [regional premier Isabel Díaz] Ayuso has done in the Madrid region, or what has been done in other regions. It is a true scandal, if not a downright crime.”
On Tuesday, Madrid’s deputy premier, Ignacio Aguado of Ciudadanos, said it was “unacceptable” for Spain’s deputy prime minister to speak that way, and warned that the regional government was considering legal action itself.
“If anything seems criminal, it is those statements,” said Díaz Ayuso about Iglesias’ remarks, accusing the deputy PM of “not caring about politicizing pain to such an offensive and shocking degree.”
Madrid premier Díaz Ayuso and her health chief, Enrique Ruiz Escudero, have said in public that there were no orders to exclude certain dependents and people with disabilities from hospital admission, and that the document that reached care homes was a draft sent by mistake.
But several internal emails seen by EL PAÍS show that a senior official at the regional health department, Carlos Mur de Víu, signed the triage protocols and had them sent to 475 residences in the region.
These guidelines, which were used by hospitals and residences to refuse the transfer of certain patients, explained that the objective was to prevent the breakdown of Madrid’s overwhelmed healthcare system. But the children and grandchildren of these patients say that regional authorities sacrificed their relatives in order to achieve that goal.
Around mid-April, when pressure at the hospitals subsided, nursing home residents were once again admitted in a generalized way. Between March 8 and last Friday, 5,986 residents with Covid-19 or related symptoms had died at these centers, according to the most recent count by the Social Policy department. And 88% of those deaths occurred between March 8 and April 17, the period when hospitals were denying admission to some patients.
The protocol that Mur de Víu signed on March 20 contained five criteria to exclude patients with respiratory infections living at Madrid’s sociosanitary centers, including patients with disabilities.
These guidelines originally left out patients who scored 60 points on the Barthel scale for activities of daily living, where 100 points means a person is completely independent. After some strong criticism and internal debate, new versions of the protocol no longer excluded people with disabilities of any age, and the Barthel score was reduced to 25.
On May 13, Mur de Víu was replaced with Javier Martínez, one of the geriatricians who drafted the documents. Mur de Viu did not respond to several queries by this newspaper, and Martínez declined to comment.
Regional officials have noted that 10,300 care home residents were taken to hospital during the pandemic. But multiple testimonies from relatives of seniors who died at residences show that at the peak of the pandemic, between mid-March and mid-April, refusals were widespread. The director of a chain of senior homes said that at one point, people were being excluded based exclusively on age.
A protocol dated March 23 says that a rise in Covid-19 patients was expected to lead to “an exceptional, catastrophic situation.” The document offered guidelines to “prioritize assistance” and recommended that patients with possible infections and difficulty breathing remain at home and not be transferred to hospital, depending on their age and state of health.
This protocol recommended “assessing” the suitability of keeping at home patients who met some of the following criteria: being over 80 years old and having a terminal organ disease (advanced chronic cardiac failure, serious chronic obstructive disease, liver cirrhosis, serious chronic kidney failure) and/or scoring 8 or 9 on a clinical fragility scale (CFS). People with moderate to serious dementia, terminal cancer or any other disease giving them a life expectancy of under a year were also included.
José María Molero, a primary healthcare physician in Madrid, says he received the protocol. “It was a recommendation that still left the door open to sending the patient to the hospital,” he says. But another doctor who spoke on condition of anonymity says that “it was an order, and that is how those of us who do home visits on a daily basis viewed it. [...] As soon as I received it, it shook me up inside. It meant triage based on age and condition. It didn’t leave room to give those people an opportunity to be saved.”
The Spanish Geriatrics and Gerontology Society (SEGG) has come out in defense of the protocols. Its president, José Augusto García Navarro, said in a release that only coronavirus is to blame for the deaths at care homes.
Francisco Tarazona, also of SEGG, says that each patient must be assessed individually, and that those in end-of-life care may actually have benefited from not going to the hospital, especially when these centers were overwhelmed.
English version by Susana Urra.