OLDER PERSONS & THE PANDEMIC 2 And They Died by the Thousands ...

INTRODUCTION

In my previous post “Older Persons & The Pandemic 1 – Surprise, Seniors Have Rights Too!”, we saw that the human rights of older persons must also be respected, and that Governments have a legal duty to eliminate age discrimination. This was the positive side of the story. However, we also began to address its sad side, with the intolerable widespread elder abuse around the world.

Then, like a lightening from a clear blue sky, humanity was faced with the first violent wave of the Covid-19 pandemic, which havocked our beautiful planet and brought additional death, pain, confusion and worry to humanity. People began to die by the thousands and, as of November 2020, they still do. Many of the dead have been residents of care homes, to which family members were for a long time refused access in order to help protect their loved ones. But many care homes and residencies for the elderly became a death trap.

It is all linked. If we don’t respect peoples’ dignity and rights in normal times, we are unlikely to do so in times of crisis. As we will see in this post, older people suffer greatly from the Covid-10 pandemic. But this is not all. WHO reports that, during the pandemic, there has also been an increase of elder abuse, among other kinds of abuse, such as child maltreatment, youth violence, intimate partner violence and sexual violence.[1] Older people are thus in a very real sense doubly affected by hardship. However, there is yet another important dimension of violence: Its negative impact on society itself, an aspect that we may explore in some further depth in the future.

For now, let’s return to the Covid-19 pandemic and the tragedy of how it has struck our seniors: How could this happen?

In this particular context, we will take a closer look at the situation of older persons by giving selected examples from Spain, Sweden, and Switzerland. This is not an academic analysis of what has happened during the pandemic and still is happening at the time of writing this post. However, to the extent possible – and given the information readily available - problems and concerns urgently need to be highlighted and considered within the legal human rights framework applicable also to older persons. Governments are not necessarily responsible for nature’s wrath (although they might be in some cases) – but they are clearly responsible for how they prepare for the possible occurrence of pandemics and how they manage their countries when the pandemic hits.

We are now in the midst of the throes of the second wave of the pandemic, and the number of people ill with the Covid-19 virus, or who have died from it, change by the day. In some countries it is easier than in others to get clear and reliable data. Uncertainties exist everywhere, if only because not all persons are tested, and others may have passed away without any diagnosis being certified. Yet, given this uncertainty, the figures and stories presented below are sufficiently serious to give rise to a profound concern about older peoples’ human right to have effective access to adequate medical care at all times, including during pandemics.

Let’s take a look!

SPAIN

Basic statistics: As of 10 November 2020, 22.081 elderly persons had died from Covid-19 or compatible symptoms in the approximately 5.457 care facilities in Spain, whether public, officially approved, or private.[2] This information is based on a compilation of data provided by the autonomous regions of Spain. The corona-related deaths in residential homes would thus amount to more than 55 % of the total 39.756 deaths officially notified by the Ministry of Health as of 10 November 2020.[3] This is a considerable number although less than the over 63 % of total deaths a month earlier.[4] It is likely that the primary reason for this decrease is the fact that the most vulnerable persons in residential care died during the first wave, and that those who survived have contributed to an improved immunity in the care homes; yet, as of November 2020, the outbreaks in these homes continue to be more frequent and intense than in the general population.[5]

The situation in Madrid and Cataluña: Some autonomous regions in Spain have faced higher death rates in care homes than others, with Madrid and Cataluña together accounting for more than 10.300 deaths, or over half of the deaths in Spanish care homes as of 10 November 2020. On the same date, the reported deaths due to Covid-19 and compatible symptoms in the 710 residences in the Community of Madrid, for instance, were 6.038 of a total 10.859, and in Cataluña the corresponding numbers were 4.267 of 7.299 deaths.[6] It is noted that, for whatever reason, the number of deaths in Madrid care homes did not appear to have changed between 8 October and 10 November.

Why have so many people died in Spanish care homes? Could at least some of these deaths possibly have been avoided had these persons had better access to adequate medical assistance?

Spanish media has in particular given much attention to the situation in Madrid where, during a few weeks in March and April 2020, it appears to have been exceedingly difficult for people with the corona virus in care homes to be transferred to hospitals. In order to prevent a collapse of the public hospital system, the local government had then reportedly imposed a system of triage (selection) of those who could be so transferred and those who could not. However, it would appear that this system was only implemented with regard to transfers to public hospitals, and elderly who had a private health insurance had an “escape route” by being treated in private hospitals.[7] According to information submitted by the regional Government on 11 June 2020 and reported by the Spanish daily El País, only 921 persons 70 years or older had been admitted to intensive care units in Madrid since 1 March 2020. As stated by El País, this number “contextualises the magnitude of a tragedy which has especially ravaged the seniors, penalised by protocols and systems of triage at the time of being treated in hospitals”; barely 25 % of the persons admitted to the intensive care units “had turned 70 years – 921 of a ... total of 3.694 – while this age group concentrated 87% of those dead by the virus.”[8] However, Ms. Ayuso, President of the Community of Madrid, denied that there had been any public or political instructions with regard to the transfer of people from the residences to hospitals.[9]

Yet, the dramatic situation in Madrid is illustrated by a chilling video from a teaching session in the Madrid university hospital Infanta Cristina. The session was aimed at preparing for the imminent collapse of the intensive care units in Madrid. The chief medical doctor informed his hospital team that the health authorities would oblige them to reserve the beds in the intensive care units not for the most seriously ill people, but for those who would have more years to live. They would thus have to deny beds to persons in their 80s and 90s. In order to save these lives the only choice for them would be to be stricter with the admission of young people having a good prognosis. This was in his view “drastic” and “dreadful”, and he wished that they would not have had to experience this situation. In the video, the doctor confirmed that they were already denying treatment to elderly from care homes, adding that “they are giving them treatment for bacterial infection and if it is a COVID, bad luck.”[10] Reacting to this video in a tweet, Ms. Ayuso again denied that the doctors were following political directives, arguing that it was only a session between doctors to assess all possible scenarios of the pandemic ...[11]

Hopefully, independent investigations into the situation in Spain, and in particular in Madrid, will eventually clarify how and to what extent the elderly in general, and in care homes most particularly, were effectively guaranteed their human right to adequate medical care during the pandemic.

We now turn to find out whether the residents in care homes possibly fared better in Sweden, earlier widely known for its excellent health care system, including its elder care...

SWEDEN

Basic statistics: According to the Public Health Authority in Sweden, there were, as of 10 November 2020, 21.370 confirmed cases of Covid-19 among persons 70 years and older, of which a mere 720 persons had received intensive care; on the same date, there was a total of 6.082 known Covid-19 deaths, of which 5.421 were people 70 years or older.[12] In other words, the age group 70 years and above represented at this particular time just a little less than 90% of all corona deaths in Sweden!

The question that must be asked is: What kind of medical attention and treatment did the persons in the age group 70 plus get, ... if any at all?

Interestingly, the statistics of the National Board of Health and Welfare show that, if you are 70 years or older, there is an advantage of living at home if you want to avoid the coronavirus. As of 9 November 2020, there were thus 7.086 confirmed Covid-19 cases among persons 70 years or older living in retirement facilities, and 5.214 persons who were receiving home care.[13] With regard to Covid-19 deaths on the same date, 2.774 persons 70 years and older had died in retirement facilities, while 1.539 persons receiving home care had died.[14]

This discrepancy may to some extent be explained by the fact that people in care homes are more fragile than people getting help at home. However, this may not explain everything, and the difference is sufficiently important to justify that an investigation be made so as to allow the health authorities to define better strategies to protect the elderly in future pandemics. This is supported by a further significant difference between people in care homes as compared to those receiving assistance at home: The number of deaths in hospital and hospitalisations between the two groups ...

Relevant statistics regarding deaths in hospitals of elderly with Covid-19 did not appear to have been updated as of the writing of this blog post. The most recent document found, dated 20 August 2020, does however have startling statistics with regard to hospital admissions of persons in care homes as compared to those receiving help in their homes. It shows that, as of 12 August 2020, the 2.630 persons who had died while living in care homes, a mere 17% had been admitted to hospital at the earliest two weeks prior to the date of their death. On the other hand, of the 1.498 deaths among persons with home care, the corresponding number was 78%![15] It is noteworthy that these statistics include all people in care homes and who receive assistance at home, that is to say, also those younger than 70 years.

However, there was also a difference between the age groups in that people below the age of 70 years were more likely to be transferred to hospital than those 70 years and older. And, yet again, persons receiving assistance at home were much more likely to be transferred to hospital for treatment than persons in care homes.[16]

These differences cast further doubt on the provision of adequate and non-discriminatory medical treatment to persons in particularly vulnerable situations in Sweden. It also adds weight to the imperative need for a thorough independent investigation into the provision of medical care of in particular people 70 years and older during the pandemic.

Without affirming that there has necessarily been a general policy to deny intensive care to older Covid-19 patients, there are reliable reports about people having been refused transfer to hospital and denied intensive care during the first wave, and this independently of whether they lived at home or at care facilities. This is what happened to Gösta and Hamed ...

Refusing elderly intensive care: The case of Gösta, 81 years, is a particularly striking case. Three days after it was confirmed that Gösta had Covid-19, his daughter received a telephone call from the hospital to inform her that her father’s health had deteriorated and that a decision had been taken not to give him intensive care.[17] In his patient journal, seen by the Swedish daily Dagens Nyheter, it was noted: “Position on life-sustaining treatment: Zero intensive care, zero cardiopulmonary resuscitation, no respirator”![18]

The fact is that Gösta was in very good health when he fell ill with Covid-19. He had recently walked in the Alps with his family and was preparing to participate in his 33rd annual bicycle race around Vättern, one of Sweden’s biggest lakes. In addition, his own father only died when he was 104 years old. His children thus pleaded with the responsible medical team to change their decision, and a hospital finally accepted to provide Gösta with intensive care. After eight days on a respirator, he could again breathe on his own, and was back home after one month. He is alive and in good health thanks to the intervention of his children.

And Gösta makes an appeal: “Change the rules. Age must not decide the possibilities to get care.”[19]

Hamed, 87 years, who was living in a residence for elderly in the northern part of Stockholm, was not as lucky as Gösta, although his family appears to have done what it could to convince the doctors to give him the necessary care. The responsible doctor did not even see Hamed. After reading the patient journal she decided that he was not a priority patient and that he would get palliative care with morphine instead. The hospital beds were needed for other cases. In a mail-exchange with the family seen by Dagens Nyheter, the Director of the responsible care unit at the Stockholm City Administration, replied: “It is unfortunately as the doctor informed you, that your father does not belong to a priority group. The emergency hospitals are overfull. As I wrote. The world is in a terrible situation”. Hamed died the same day in the residence where he was living...

However, when later questioned by Dagens Nyheter on her statement that the emergency hospitals were full, the Director admitted that maybe it was “dumb” of her to reply like this, and that maybe it was “her own personal view”.[20] Meanwhile, a field hospital had been built outside Stockholm all set to provide bed places for 140 Covid-19, including 30 patients needing intensive care; it was later dismantled without ever being used...[21]

What the legislation says: In Sweden, the priorities with regard to health care are at least relatively clear in theory. First of all, the Health and Medical Care Act of 2017 (2017:30) provides that the purpose of the health and medical care in Sweden is “good health and a care on equal conditions for the entire population” (Ch 3, § 1(1)). Moreover, the care shall be provided “with respect for all persons’ equal value and for the dignity of the individual human being”; the person having the “greatest need of health and medical care shall be given precedence to the care” (Ch. 3, § 1(2)). The health and medical services shall also “work in order to prevent ill health” (Ch.3, § 2).[22]

Faced with the pandemic, the Swedish National Board of Health and Welfare adopted “National principles for prioritisation within intensive care during extraordinary circumstances” in March 2020, which were followed by the “National principles for prioritisation of routine health care during the covid-19 pandemic” in April 2020. According to the preface to the principles for intensive care prioritisation, they are only intended to be applied in case the spread of the virus would lead to a need for intensive care exceeding the available resources.[23] Although, as of the middle of November 2020, it is not known whether they have ever been applied, a summary of the main principles is called for.

Thus, before applying the principles for prioritisation laid down in the document, the first step should be to “exhaust all possibilities to increase the relevant intensive care resources concerned.”[24] This is a wise priority before triage becomes necessary, but it might indeed be a considerable challenge when you are faced with a sudden medical emergency.

In the section “Prioritising access to intensive care according to need and patient benefit”, it is then stated that in “extraordinary circumstances with limited resources the indication for intensive care needs to be tightened”; in such situations the intensive care resources “must ... be reserved for patients where the intensive care has a great probability to contribute to continued survival”. This also implies “a greater constraint with regard to the beginning or continuation of intensive care than in the normal case”.[25]

However, it is also made clear that, in line with the human value principle, “prioritisation may not occur on the basis of the patient’s chronological age as such”, although it is permissible to consider the patient’s biological age, meaning the possible “patient benefit” given the patient’s biological state. A fragile younger person may, in other words, be given lower priority than an older person having “greater capacity to manage and continue living after intensive care.”[26] Finally, prioritisation may not be made on the basis of the patient’s social situation or status, possible disability or if the patient has herself contributed to create her condition.[27] With regard to the application of these principles in connection with “an extraordinary resource situation”, it is also made clear, however, that a patient’s “biological age and its impact on the patient benefit in terms of continued survival will be central”.[28] Patients who are “prioritised down”, shall be offered alternatives, such as, for instance, geriatric or specialised palliative care, advanced medical care at home, or in a retirement home.[29]

The above emergency principles are expressly based on the three principles for prioritisations decided by the parliamentary ethical platform: (1) the human value principle, (2) the needs- and solidarity principle, and (3) the cost-efficiency principle.[30] What is intriguing with this statement is, however, that one important element has been omitted: That these important legal-ethical principles are mentioned in order of precedence, meaning that that cost-efficiency principle is subordinated to the principle of human value and the needs- and solidarity principle. This is made clear in the National principles for prioritisation of routine health care during the covid-19 pandemic, where special emphasis is given to this fundamentally important order of precedence.[31] With some good will, one might infer from the intensive care prioritisation principles that this is the case, but in such fundamentally critical situation as when a person’s life is at stake – also an older person’s life! - it would have been particularly important to expressly stress the subordinated role of the cost-efficiency principle

.

Maybe this lacuna is due to the speed with which in particular the intensive care prioritisation principles were probably drafted and adopted in the beginning of the pandemic in March 2020. As we will now see with regard to Switzerland, drafting rules and regulations in the midst of a medical emergency is not a good idea. It can have serious consequences ...

SWITZERLAND

Basic information: As of 22 May 2020, over 50% of the deaths from Covid-19 had occurred in care homes in Switzerland, with the corresponding death rate amounting to 60% in the canton of Vaud. In an interview on the Swiss radio, Dr. Tosca Bizzozzero, geriatrician and chairperson of the association of doctors in care homes in Vaud, noted that these numbers were “effectively impressive”, but that they were “not really surprising” considering that the virus is particularly deadly for very old people suffering from multimorbidity. With regard to the management of the pandemic in the care homes, Dr. Tosca Bizzozzero believed that “all necessary measures had been taken, and taken in time”, but that “the one thing that might be criticised would be that at one point they did not have sufficient material of protection.” However, somewhat surprisingly, she was not convinced that this lack of material had resulted in a higher death rate. Thus, they did not yet know what other causes than high age and multimorbidity had resulted in deaths, but it was hoped that this would be clarified in due course.[32]

Switzerland is now (mid-November 2020) in the midst of the second more severe wave of the pandemic. It remains to be seen how the persons in the various residencies around the country will fare and whether any lessons have been learnt from the first wave. The good news is for the time being that people aged 60 years and up are so far the least affected group of Covid-19 patients.

The legislation: What needs to be particularly highlighted with regard to Switzerland is the modified guidelines about triage of patients to intensive care, the third updated version of which was adopted on 4 November 2020 by the Swiss Academy of Medical Sciences and the Swiss Society of Intensive Medicine.[33] This new version of the guidelines is a welcome improvement of the earlier update from March 2020, which introduced a dangerous element of age discrimination. We will return to this below, but first some general information on relevant Swiss law.

It is understandable that when health systems are seriously challenged, such as during pandemics, it may exceptionally be necessary to resort to triage in case of resource scarcity. The question is, however, on what criteria this selection should be done. With regard to Switzerland, this problematic choice is regulated in Section 9.3 on “Resource scarcity and triage” of the medical-ethical guidelines and recommendations on Intensive-care interventions from 2013. It reads as follows:

“If available resources are no longer sufficient to optimize the chances of all individuals concerned, decisions on rationing become unavoidable. These must be based on ethical principles, and the criteria applied must be justified and made transparent. In cases of absolute resource scarcity, such as may arise during a pandemic, highest priority is to be accorded to patients whose prognosis is good with, but poor without, ICU treatment.”[34]

Section 9(3) has to be interpreted in the light of Section 2 of the guidelines, which specifies that “[t]he fundamental ethical principles of beneficence, non-maleficence, respect for autonomy and equity serve as a guide for considered and reasoned decision-making.”[35]

It is interesting to note that it is also explained that these “ethical principles are not derived from an external source, but are inherent”, meaning that “the responsibilities of intensive-care medicine cannot be defined without reference to these principles, and sound intensive-care practice has always – more or less consciously - been guided by them.”[36]The principles do not, consequently, appear to be inspired by human rights law, as such, or any other law, but by ethical principles inherent in the activities of the medical professions, to help them serve, to the best of their ability, the health of each individual person.

As explained in the guidelines, the criteria applied must be “objectively justified and transparent.”[37] Further, and here we come to an additional key condition for our particular purposes, “[t]hey are to be applied without discrimination (e.g. on the grounds of age, sex, canton of residence, nationality, religious affiliation, social and insurance status or existing chronic disability), in an equitable procedure”, which is “to be managed by trustworthy and experienced persons, who are legally accountable and who adapt the triage procedure to changing requirements.”[38]

Here we thus learn about the importance of an objectively justified, transparent and non-discriminatory application of triage criteria in an equitable procedure by competent and accountable persons. So far so good. But what actually happened during the Covid-19 pandemic? As we will see, there was for a few months a serious bump on the road...

While the above guidelines were written in 2013, the Swiss Academy of Medical Sciences and the Swiss Society of Intensive Medicine provided, as previously noted, further guidance on the triage for intensive-care treatment under resource scarcity in March 2020. Here it is surprising to see that the question of age appeared as a single criterion to exclude seriously ill patients from intensive care (ICU) when no beds were available. After it had been confirmed that a patient had one of the two “inclusion criteria”, a number of “exclusion criteria” were enumerated, including the fact of being over 85 years of age; it was stated in clear terms that if only “one” of the exclusion criteria was fulfilled, the patient was not to be admitted to the ICU.”[39] This triage on the sole basis of age, thus contradicted both the 2013 explanatory text, according to which discrimination based on age was not allowed, and the Swiss Federal Constitution which prohibits age-based discrimination (Article 8(2)). The March version of the guidelines was actually also in contradiction with itself, since it was stated in Part 2 on “Fundamental ethical principles”, that available resources “are to be allocated without discrimination – i.e. without unjustified unequal treatment on grounds of age...”![40]

Fortunately, reason has prevailed in Switzerland. On 4 November 2020, the third updated version of the guidelines was adopted, and age is no longer per se a reason to exclude a patient from intensive care in case of resource scarcity. In this post I will not dwell on the details of the triage system. However, what is clear is that, whenever age is a factor of the assessment, it is linked either to a Clinical Frailty Scale (CFS) score, or an existing severe comorbidity (liver cirrhosis; chronic kidney disease; heart failure).[41] On the other hand, it is important also to highlight what the guidelines say with regard to age, disability, dementia and frailty in Section 3 entitled “Criteria for ICU triage (admission and continued occupancy) under resource scarcity:

“Age, disability or dementia in themselves are not to be applied as criteria, as this would be to accord less value to older or disabled people, thus infringing the constitutional prohibition on discrimination. These factors are, however, indirectly taken into account under the main criterion ‘short-term prognosis’, since older people more frequently suffer from comorbidity, and the short-term prognosis may also be adversely affected by dementia and certain disabilities. In connection with COVID-19, age, disability and dementia are risk factors for mortality and must be taken into account like all the other independent risk factors identified since March 2020.

Frailty is an important criterion to consider in a situation of resource scarcity. Of the various tools proposed for the evaluation of frailty, the best validated is the Clinical Frailty Scale (...).”[42]

It would appear clear that the March 2020 version of the guidelines was drafted and adopted in a rush at a time of panic in the beginning of a pandemic which not even the medical professions fully understood. It is simple to say but, to the extent possible, emergency laws, regulations and guidelines should not be developed in the midst of a crisis, but in more normal and peaceful times, when we can think about solving problems in a professionally constructive and balanced manner. If our Governments had adequately prepared for a pandemic they had been warned about for years, some of the malfunctioning that we have seen during the present health crisis could most likely have been avoided, and lives could have been spared...

* * *

In this post I have wanted to provide examples from three European countries showing the challenges and dangers in a pandemic for older people, on the one hand, and for medical professionals, on the other hand. I am fully aware that much wonderful work has been done - and is being done - by medical staff at this difficult time. However, it is imperative also to focus on what has gone wrong and what therefore can and must be improved in the future, such as with regard to how we treat our seniors both in normal times and in times of crisis, such as pandemics.

It should be self-evident to ensure that also older persons are treated with the respect for their intrinsic human value at all times. Because, remember: Human Rights – Better Life!

My next post will therefore raise some of the numerous questions with regard to the human rights of our elderly that the Covid-19 pandemic has given rise, and to which I hope that we will have some substantive and constructive answers as soon as

investigations in Spain, Sweden and Switzerland have been finalised and made public.

Anna-Lena Christina

18 November 2020

[1] Information contained in an invitation to join the WHO Social Determinants of Health Webinar No. 2 on “COVID-19, social determinants and violence” on 2 December 2020. [2] “Radiografía del coronavirus en residencias de ancianos: más de 22.000 muertos con COVID-19 o síntomas compatibles”, in https://www.rtve.es/noticias/20201110/radiografia-del-coronavirus-residencias-ancianos-espana/2011609.shtml, consulted on 11 November 2020. [3] Ibid. – On the total number of deaths, see Spanish Ministry of Health: “Actualización no 247. Enfermedad por el coronavirus (COVID-19). 10.11.2020” at https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/Actualizacion_247_COVID-19.pdf. [4] Spanish Ministry of Health: “Actualización no 224. Enfermedad por el coronavirus (COVID-19). 08.10.2020” at https://www.mscbs.gob.es/profesionales/saludPublica/ccayes/alertasActual/nCov/documentos/Actualizacion_224_COVID-19.pdf. [5] See “Radiografía del coronavirus en residencias de ancianos: más de 22.000 muertos con Covid-19 o síntomas compatibles”, inhttps://www.rtve.es/noticias/20201110/radiografia-del-coronavirus-residencias-ancianos-espana/2011609.shtml, consulted on 11 November 2020. [6] Ibid. [7] “Los mayores con seguro privado sí fueron trasladados de residencias a hospitales en Madrid” in https://elpais.com/espana/madrid/2020-06-10/los-mayores-con-seguro-privado-pudieron-ser-trasladados-de-residencias-a-hospitales-en-madrid.html, consulted on 11 November 2020. [8] “Solo 921 mayores de 70 años con coronvirus han ingresado en UCI de Madrid desde el 1 de marzo”, in https://elpais.com/espana/madrid/2020-06-11/solo-921-mayores-de-70-anos-ingresaron-en-ucis-de-madrid-donde-han-muerto-mas-de-13000-durante-la-crisis-del-coronavirus.html, consulted on 16 November 2020. [9] Ibid. [10] “Vamos a denegar la cama a los pacientes que más riesgo de morir tienen”: https://elpais.com/espana/madrid/2020-06-17/vamos-a-denegar-la-cama-a-los-pacientes-que-mas-riesgo-de-morir-tienen.html?autoplay=1, consulted on 11 November 2020; author’s translation from Spanish. [11] “Ayuso, sobre el vídeo del hospital de Madrid: ‘No eran instrucciones sino una sesión entre médicos’” in https://elpais.com/espana/madrid/2020-06-18/ayuso-sobre-el-video-del-hospital-de-madrid-no-eran-instrucciones-sino-una-sesion-entre-medicos.html, consulted on 11 November 2020. [12] See statistics from the Public Health Authority (Folkhälsomyndigheten), consulted on 11 November 2020: https://experience.arcgis.com/experience/09f821667ce64bf7be6f9f87457ed9aa. [13] See statistics from the National Board of Health and Welfare (Socialstyrelsen), updated as of 9 November 2020: https://socialstyrelsen.se/statistik-och-data/statistik/statistik-om-covid-19/statistik-om-covid-19-bland-aldre-efter-boendeform/, consulted on 11 November 2020. [14] Ibid. [15] See document dated 20 August 2020 from the National Board of Health and Welfare at: https://www.socialstyrelsen.se/globalassets/1-globalt/covid-19-statistik/statistik-over-antal-avlidna-i-covid-19/faktablad-statistik-avlidna-sarskilt-boende-hemtjanst-covid19.pdf, consulted on 11 November 2020. [16] For details of the statistics, see ibid. [17] “De valdes bort av vården – fast vårdplatser stod tomma”: https://www.dn.se/sthlm/de-valdes-bort-av-varden/, consulted on 12 November 2020. [18] Ibid. [19] Ibid. [20] Ibid. [21] See Dagens Medicin, “Fältsjukhus – en förberedelse för det värsta”, in https://www.dagensmedicin.se/alla-nyheter/nyheter/faltsjukhus-en-forberedelse-for-det-varsta/. See also Interview with Björn Ericsson, Director of health- and medical care, Region Stockholm, in https://sverigesradio.se/artikel/7488208. Both sites consulted on 12 November 2020. [22] For the Swedish text of the law, see https://www.riksdagen.se/sv/dokument-lagar/dokument/svensk-forfattningssamling/halso--och-sjukvardslag_sfs-2017-30; author’s translation. [23] See “Nationella principer för prioritering inom intensivvård under extraordinära förhållanden”, adopted by the Swedish National Board of Health and Welfare in March 2020, at https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/dokument-webb/ovrigt/nationella-prioriteringar-intensivvarden.pdf, p. 3. [24] Ibid., p. 5. [25] Ibid., 6. [26] Ibid. [27] Ibid. [28] Ibid. [29] Ibid., p. 7. [30] Ibid., p. 8. [31] See “Nationella principer för prioritering av rutinsjukvård under covid-19 pandemin”, at https://www.socialstyrelsen.se/globalassets/sharepoint-dokument/dokument-webb/ovrigt/nationella-principer-for-prioritering-av-rutinsjukvard-covid19.pdf, p. 6. [32] See interview with Dr. Tosca Bizzozzero of 22 May 2020: https://www.rts.ch/play/tv/forum/video/la-moitie-des-deces-suisses-lies-a-la-pandemie-ont-eu-lieu-en-ems-interview-de-tosca-bizzozzero?id=11344288, consulted on 12 November 2020. [33] See document entitled “COVID-19 pandemic: triage for intensive-care treatment under resource scarcity – Guidance on the application of Section 9.3 of the SAMS Guidelines ‘Intensive-care interventions’ (2013)”, at https://www.samw.ch/en/Publications/Medical-ethical-Guidelines.html(3rd, updated version of 4 November 2020). For the Medical-ethical guidelines on Intensive-Care Interventions (2013), see ibid. [34] See p. 35 of the English text of the publication which can be found in different languages at https://www.sams.ch/en/Ethics/Topics-A-to-Z/Intensive-care-medicine.html. [35] Ibid., p. 7. [36] Ibid. [37] Ibid, p. 36. [38] Ibid. [39] This version is still available on Swiss Medical Weekly: https://smw.ch/article/doi/smw.2020.20229, consulted on 13 November 2020. – This triage based on age has also been criticized by Mark-Anthony Schwestermann, see article “Une limite d’âge discriminatoire pour le traitement des patient·e·s atteint·e·s de la COVID-19”, at https://www.humanrights.ch/fr/pfi/droits-humains/agisme/limite-age-discriminatoire-traitement-patients-covid, consulted on 13 November 2020. [40] See Swiss Medical Weekly, https://smw.ch/article/doi/smw.2020.20229 , consulted on 16 November 2020. [41] See link in note 33, pages 7-8 of the Guidelines as updated on 4 November 2020. [42] Ibid., p. 4. For an easily accessible version of the Clinical Frailty Scale, see https://www.nice.org.uk/guidance/ng159/resources/clinical-frailty-scale-pdf-8712262765.