As coronavirus ravages Spain, doctors get a grim order on 'futility of care' for the very old and very sick

Melissa Rossi

BARCELONA — On Thursday, a gray and gloomy day in Barcelona — normally sunny and festive this time of year — residents awoke to unsettling news. According to regional newspaper LaVanguardia and other sources, a document circulated by the health department of Catalonia — the northeast region of Spain that has Barcelona as its capital — recommends that emergency teams and health care workers stop using ventilators for patients older than 80, and further recommends that extremely ill victims of COVID-19 be allowed to die at home rather than being taken to the hospital.

Alfons López Tena, a former member of the Catalan Parliament, explained it this way in a tweet: “Catalonia’s govt decides to let die coronavirus patients who have ‘less years to live’, [and recommends] no ‘admissions in hospital of patients with little benefit’. Elders and those with preexisting conditions will be given morphine to avoid ‘futility of health care.’”

End-of-life euthanasia is sanctioned in some countries in Europe but is illegal in Spain, a Catholic country.

It was the ethical call that many health workers had presumed they might face in Catalonia, which has nearly 24,000 cases of COVID-19 and where admissions to intensive care units have tripled in the past few weeks. But the recommendation outraged many elderly residents, according to an online publication for retirees, 65Ymás, and also the Medical Union of Catalonia, whose spokesman, Dr. Álex Ramos, described himself as "absolutely shocked" by the regional government’s recommendations. “It seems to us that age is not a sufficient criterion to deny assistance, if other measures have not been previously tried to avoid saturation of hospitals, such as asking for help from other [hospitals or the government].”

Aid workers from the Spanish NGO Open Arms carry out coronavirus detection tests on the elderly at a nursing home in Barcelona, Spain on April 1, 2020. (Santi Palacios/AP)
Aid workers from the Spanish NGO Open Arms carry out coronavirus detection tests at a nursing home in Barcelona on April 1. (Santi Palacios/AP)

Other headlines spilled more upsetting news: Spain had broken its record for deaths — with more than 950 overnight, bringing the total number of known deaths in this country to over 10,000, a fifth of the world’s known fatalities. (The real figure is probably higher than 10,000, since likely victims who weren’t tested for the virus before they died aren’t being counted.)

All of this is less than two weeks before Easter, normally a joyous time in Spain when tourists descend, town squares are taken over by festivals of giant costumed figures, streets are carpeted with flowers and filled with religious processions, and plazas and terraces are packed with partiers. This year, an uneasy calm instead hovers over this country, which only last year topped Bloomberg’s Healthiest Countries in the World List, based in part on longevity. As of Thursday, Spain had the third-most cases in the world, more than 112,000, not far behind Italy — which was No. 2 on the healthiest countries list. Spain’s government announced a more far-reaching shutdown the next day, demanding all workers, except those in essential industries, stay at home. Across the nation, airports and cruise ports are shut down, hotels and restaurants are shuttered, beaches and parks are empty, convention centers have been converted to makeshift hospitals and ice rinks serve as morgues, and even land borders are largely closed off, making for an eerie quiet.

A COVID-19 patient undergoes treatment in one of the intensive care units (ICU) of the Germans Trias i Pujol hospital in Badalona, Barcelona province, Spain, Wednesday, April 1, 2020. (Felipe Dana/AP)
A COVID-19 patient undergoes treatment at a hospital in Badalona, Spain, on April 1. (Felipe Dana/AP)

The national armed forces have been sent out to construct makeshift hospitals and homeless shelters, a somewhat fraught development in a country with 17 autonomous territories, such as Catalonia, where regional loyalties sometimes outweigh national identity. Sent out to disinfect hot spots, the army made several horrifying discoveries of abandoned nursing homes where COVID-19 patients had been left to die in their beds. (The Defense Ministry has not given details about how many nursing homes were affected or where.) Through the week, the U.S. Embassy warned Americans that flights from Spain to the U.S. had halted, and that they should figure out how to return home by way of another country or prepare “to remain in Spain for an indefinite period.”

But residents, most of whom, to judge by newspaper reader surveys, support the government’s belated efforts to control the virus, came across better news if they managed to keep reading.

Spain’s health officials — including the Ministry of Health’s lead medical expert, Fernando Simón, who announced this week he had tested positive for the coronavirus — believe that the rate of new infections has peaked: Even though 8,100 new cases were reported from the day before, it marked a decrease in the actual rate of new infections. “The data offers a window of hope,” said Salvador Illa, a career politician with no medical experience who took over the Ministry of Health in January.

Workers move a coffin with the body of a victim of coronavirus as others coffins are stored waiting for burial or cremation at the Collserola morgue in Barcelona, Spain, Thursday, April 2, 2020. (Emilio Morenatti/AP)
Workers move a coffin with the body of a coronavirus victim at the Collserola morgue in Barcelona on April 2. (Emilio Morenatti/AP)

In a crisis marked by shortages of medical equipment and botched purchases — including more than 50,000 tests, purchased by the Health Ministry from an unregistered Chinese company, that didn’t work — new supplies, some of them donations, have arrived from Turkey, Japan, China, even Luxembourg, to the relief of struggling health workers, more than 15 percent of whom are testing positive and who have been forced to reuse masks and make gowns from trash bags. But even some of the new supplies are dubious — including a million tests ordered from China that show positives only after five days of infection, and basic protective gear appears to be slow in arriving to health workers. When his long-awaited order of masks arrived from China, one American expat who asked not to be named gave half of them to his neighbor, a doctor, whose supply was depleted. “It’s just a mess,” he said.

While most admit there’s no use in finger-pointing now, even some health professionals have been aghast at the government’s tardiness and lack of thoroughness in implementing measures — among them Catalan epidemiologist Oriol Mitjà, who has been testing drug therapies against COVID-19 but hasn’t released any results yet.

A lone pedestrian walks near to the corner between Major, left, and Jakarta street of the old city, in Pamplona, northern Spain on March 25, 2020. (Alvaro Barrientos/AP)
A lone pedestrian walks near to the corner between Major, left, and Jakarta street of the old city, in Pamplona, northern Spain on March 25, 2020. (Alvaro Barrientos/AP)

When the lockdown began three weeks ago, workers who were unable to work from home were allowed to continue commuting, pushing onto crowded buses and subway trains, causing Mitjà to tweet demands for a total shutdown — and to suggest that the heads of the Health Ministry be replaced.

When his advice apparently went unheeded, he and some 60 other disease experts and researchers wrote a letter, “Experts’ Request to the Spanish Government: move Spain toward complete lockdown,” which was published in the Lancet on March 27. Spain’s government announced a more far-reaching shutdown the next day, demanding that all workers, except those in essential industries, stay at home, and requiring that those going out carry papers stating their reasons.

And even though the Spanish government is passing bills to ease economic woes, including banning evictions or utility cutoffs for six months, many small-business owners and freelancers are worried — all the more with Thursday’s announcement that 900,000 jobs had already been lost in Spain, a country of 47 million, due to the coronavirus.

A member of the Emergency Military Unit waits for a bus in which patients infected with the COVID-19 are being transferred from the Gregorio Maranon hospital to a temporary hospital set up at the IFEMA conference centre, during the coronavirus disease (COVID-19) outbreak in Madrid, Spain April 1, 2020. (Susana Vera/Reuters)
A member of the Emergency Military Unit waits for a bus in which COVID-19 patients were being transferred to another hospital in Madrid on April 1. (Susana Vera/Reuters)

“I’m going crazy,” says Vicky Veiga, who runs Glow Yoga in Barcelona. Business was booming until the shutdown began on March 14, forcing her to close her studio. With her landlord unwilling to give a discount — “They said I should have had savings for moments like these” — she’s now holding her classes online.

Yet in Spain, food remains on the shelves, the mood is tranquil and there’s reason for guarded optimism, as Health Minister Illa pointed out: More than 26,000 Spaniards known to have been infected by the disease have recovered.

Among those who pulled through is Barcelona publicist Nil Monró, 22 — one of Spain’s first known cases — who assumed he was safe from the disease until Feb. 25, when he went into the hospital, where he remained for 24 days. His case illustrates how the virus barreled into Spain, where authorities were not prepared and were not yet issuing any warnings about COVID-19.

Monró had no idea he would be encountering a perfect storm for the coronavirus when he traveled to Italy in the third week of February. Always bustling, Milan was particularly hopping that week: Milan Fashion Week, which attracts thousands from all over the world, kicked off on the 18th of the month, and on Feb. 19, Milan’s San Siro Stadium was site of a soccer game between Valencia and local team Atalanta. By some estimates, a third of the population from the nearby town of Bergamo packed into the 50,000-seat stadium — and several thousand fans arrived from Spain to cheer for Valencia.

At the time, Monró recalls, few worried about COVID-19 in Spain; even in Italy, the virus seemed confined to the small town of Codogno — 40 miles from Milan. But that soccer match has now been dubbed “Game Zero,” likened to a biological bomb, and those who attended Milan Fashion Week, or any of the bars and restaurants where the sports fans gathered, were likely exposed to the virus as well.

Nil Monró from a YouTube video he posted from his hospital room on March 7, 2020.
Nil Monró from a YouTube video he posted from his hospital room on March 7. (YouTube)

When Monró arrived for the fashion event, it was business as usual: “Everything was normal,” he says, with plenty of “kisses and handshakes in the events.” He wasn’t worried until, by the third day, the mood changed dramatically — when the first locally contracted cases appeared in Italy. Some designers canceled their shows, and “people started to wear masks and to not use the Metro.” All the pharmacies sold out of masks, and Asian restaurants closed, he recalls. Yet even after the government shut down museums and halted soccer matches in the north, many people were still socializing and walking the crowded streets.

A few days later, back in Barcelona, he was sick — with headache, fever, congestion. He suspected the coronavirus but was still shocked when he got his diagnosis at the hospital. Monró, widely followed on Instagram, became the first Spaniard to talk openly about the disease, alerting his fellow citizens it had arrived in their country, and that even the young and healthy were vulnerable. Within days, dozens of others who’d visited Italy that week started showing symptoms, and soon after, locally transmitted cases began appearing by the dozens, then the hundreds. But it wasn’t until mid-March that the government banned large gatherings, encouraged social distancing and announced a lockdown.

Even then, many Spaniards continued traveling — often driving back and forth to their summer homes — among them former Prime Minister José María Aznar, who went with his family from Madrid to Málaga. Last week, current Prime Minister Pedro Sánchez —who’s feeling the heat not only from regional governments but from Germany, where the Konrad Adenauer Foundation just released a scathing report on his crisis-management skills — implored Spaniards, yet again, to stay at home. With police stopping people on the street and demanding they prove a reason for being outside, fining and even arresting violators, this week, finally, the lockdown appears to be working.

On Friday, Spaniards awoke to more disturbing news: more than 900 had died overnight, and the number of known COVID-19 victims in Spain shot to above 117,000, more than in Italy, landing it in the No. 2 spot on the world’s known-cases list, after the U.S. At least that day the sun was out.

A woman wearing protective gloves grabs the iron bars of her window, amid the coronavirus disease (COVID-19) outbreak in Ronda, southern Spain, April 2, 2020. (Jon Nazca/Reuters)
A woman grabs the iron bars of her window amid the coronavirus outbreak in Ronda, Spain, on April 2. (Jon Nazca/Reuters)


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