Hidden coronavirus tragedies: Dutch elderly forgotten in pandemic

Doctors advised against admitting elderly people to ICU, but have authorities underestimated their resilience?

Rie van der Have was admitted to a nursing home to recover from cancer when everyone on the first floor of Flevohuis, the institution in Amsterdam, fell ill with COVID-19.

By the time she tested positive, 31 patients had already died. Her doctor told her she would not be admitted to an intensive care unit and had to stay in the nursing home instead.

Rie told me she had already heard on television that old people would not be admitted to the ICU. At 88 and with her bad lungs, she did not think she would have survived a ventilator anyway.

When he heard she had the disease, Helmut, her 91-year-old husband of 67 years, felt like the earth disappeared under his feet.

Holding back tears, he said: "I did not want her to die this way." 

In late March, the Dutch Federation for Medical Specialists advised medical professionals to be more selective in sending COVID-19 patients to the ICU. 

The Netherlands, which has a population of 17 million, only has 1,150 ICU beds and is traditionally more conservative in sending patients to intensive care wards if there is a realistic chance they will not survive the invasive treatment.

With infections spreading around the country and ICU beds running out, authorities have tried to prevent the Italian scenario, which saw many elderly people die in hospitals on ventilators alone, without their relatives by their side.

Doctors were asked to use the fragility scale looking at the overall condition of patients and their ability to take care of themselves. They held conversations with elderly patients discussing the options in case they got infected.

Helmut said he was also asked the painful question.

"I called my doctor for something else but suddenly she asked me if I still wanted to go to the ICU in case I got corona. The way she did this so abruptly and expecting an answer right away felt quite harsh to me," he said.

The fit-looking nonagenarian told his doctor he was not planning to die soon and if needed, he would choose to go to the ICU.

Marike de Meij, a palliative care doctor in Amsterdam, says these are very difficult conversations.

"You don't want to give people a feeling that we don't value their lives. You have to explain that it will be a shared decision," she said.

It is not clear yet how many elderly patients have died at home; as in many other countries, these deaths have not been added to the official death toll mainly because many COVID-19 patients in the Netherlands have died without being tested. 

But statistics show that the largest age group of people admitted to the ICU dropped by 10 years, from 60 to 65 in April compared with 70 to 75 in March - a sign that many elderly patients decided to stay home.

Doctors have now started to register these so-called hidden coronavirus deaths.

De Meij estimates that the real death toll - which currently stands at about 5,500 people - could be twice as high. 

She set up a palliative care unit in the hospital where she works to offer elderly patients more care than what they would receive at home.

"I think we have been too rigid in telling patients that they only had two options, the ICU or staying at home. We have offered them a third option where we have given them oxygen to be more comfortable," she said.

While preparing to die, some of her patients have managed to recover, much to her surprise. She believes survival chances of elderly coronavirus patients might have been too pessimistic.

"We know so little about this disease, we are learning and adjusting every day," she said. "We should stop focusing on people in the ICU but pay more attention to elderly patients in nursing homes or at home that are often forgotten."

To everyone's surprise, Rie survived coronavirus and has even returned home.

"You can see that doctors are making a selection and if they think you don't stand a chance, they won't admit you to the ICU," said her husband Helmut. "But even in her condition my wife managed to survive. Something we did not expect at all."

Helmut is already making plans on how to spend his extra time with Rie.

If she is well enough he wants to take her on a boat ride, like the couple has done most summers of their marriage.

by Step Vaessen

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