Covid-19 - rationing of medical care

It is starting to look like there may be a covert policy of cull by virus for the non/ less productive members of society.

Did you catch the bit that if resources are short, as they are/will be, that treatment options are to be decided not just by chances of survival but by that persons 'usefulness' e.g. are they a key worker or not?
 
Wonko said:
It is starting to look like there is a covert policy of cull by virus for thenon/ less productive members of society.

Did you catch the bit that if resources are short, as they are/will be, that treatment options are to be decided not just by chances of survival but by that persons 'usefulness' e.g. are they a key worker or not?
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Are you being serious (about the key workers - your second paragraph)? If so, no I didn’t hear about it - when did they say that? I heard that it’s decided on how “frail” you are (under that system I think I worked out many of those with severe ME like me may well not score well enough to get help :( )
 
Yes, it's just been on Newsnight.

ETA - https://www.bbc.co.uk/iplayer/episode/m000gx71/newsnight-02042020
that segment starts around 35 minutes in

That part is a perfectly logical thing to do, give preference to those deemed most useful to society. Not right or ethical, but it is logical.

It is however not how the NHS, or society, likes to think of itself - and it's not how the politicians are portraying things, it's more or less in direct opposition to how they are portraying things.

It's like something out of a dark film.

I find the whole isolating and leaving to die the people in homes things much more disturbing.
 
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BurnA said:
It seems UK health secretary Matt Hancock prioritised testing for patients over healthcare workers, saying it could be the difference between treatment to save a patient or not.
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My vote would be healthcare workers should have priority however -

A relative who has serious ongoing health problems was rushed to hospital. The specialist ward this person needs to go on has some very ill people on it, some of whom may well recover, some won't, regardless of corona virus. Before going to the ward my relative was held in isolation pending a covid test. I think this is valid use of the test.

However, this person is very sick, the condition is affecting cognitive function, ability to give informed consent etc. This person may not have long left & will not be allowed any visitors, not even a partner of 30 or so years and it also means the partner cannot ask the staff questions face to face and staff aren't talking to them in the phone. If the partner could be tested as clear or as having had it and allowed access it would make the situation much more bearable.

So my vote would be testing primarily for healthcare workers, the patients coming into hospital to assess risk of infecting other patients and where patients are extremely sick & possibly dying a loved one tested and cleared to visit - even if that is just one person.

Mind you there's also the argument for testing healthcare workers families too...
 
Wonko said:
I find the whole isolating and leaving to die the people in homes things much more disturbing.
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This situation is so desperately sad - the chronic neglect of the social care system, underfunding of the NHS, and the dithering of the UK govt when we had months to prepare combined with making decisions like following herd immunity and no testing and stopping contact tracing, and asking Dyson to make ventilators (30 next week), when there were existing companies willing to make thousands, weeks ago..the whole situation is so desperate and unbelievable.

I find it very hard to understand how there’s not a real public outcry over this, and now..this care home situation and choosing “key workers”.
 
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Wonko said:
It is starting to look like there may be a covert policy of cull by virus for the non/ less productive members of society.

Did you catch the bit that if resources are short, as they are/will be, that treatment options are to be decided not just by chances of survival but by that persons 'usefulness' e.g. are they a key worker or not?
Click to expand...

lunarainbows said:
Are you being serious (about the key workers - your second paragraph)? If so, no I didn’t hear about it - when did they say that?
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Yes it was on Newsnight but the idea has come from a new document issued by the British Medical Association which sets out guidelines on how to ration care if the NHS is overwhelmed. This is the section relating to prioritising key workers:

Maintaining essential services

Although we are not there yet, it is possible we may reach a stage where decisions about beneficial distribution of resources can no longer be restricted to medical utility alone. Given the potential for widespread social and economic disruption, decisions about which groups will have first call on scarce resources may also need to take account of the need to maintain essential services, in a situation where the workforce providing those services is severely depleted. This may mean giving some priority to those who are responsible for delivering those services and who have a good chance of recovery, in order to get them back into the workforce. In addition to delivering maximum clinical benefit, priorities during a severe pandemic may include:

– limiting social disruption
– ensuring maintenance of healthcare systems
– ensuring integrity of social infrastructure
– limiting economic losses.

In addition to those individuals involved in tackling the immediate health and social care aspects of the pandemic, and particularly those with scarce and irreplaceable skills, many public and private actors are necessary to ensure that essential services are maintained. This could include personnel in the emergency services, security, essential products and services, the maintenance of critical infrastructure such as transportation, utilities such as electricity, water and sewage systems, telecommunications and sanitation. Priority will also need to be given to the continued function of governance structures. Key individuals who are involved in the production of countermeasures, including vaccines, anti-virals and other essential health products may also form part of this prioritised group. In our view it will be for Government to define the categories of essential workers and the tests to be applied. This is not a responsibility that should lie with doctors.

Giving priority to those working in essential services in this way would move beyond our usual system of resource allocation and decision-makers could face criticism for discriminating between individuals on the basis of social, rather than solely medical, factors. Should such an eventuality arise, procedures for decision-making must be transparent, reasonable and based on defensible moral principles and great care must be taken in clearly communicating the rationale for this approach and the critical importance for all of maintaining these vital services.
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(My bolding)

https://www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf

lunarainbows said:
I find it very hard to understand how there’s not a real public outcry over this, no ones been able to hold the Govt to account or force them do anything while they keep spinning the situation, and now..this care home situation and choosing “key workers”.
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The BMA document was only released 2 days ago and has only just started to get media coverage. I’m sure there will be a huge public outcry about this once people learn the details of what’s being planned.
 
When I was still working I used to go into a lot of residential facilities for the elderly. Discussion around resuscitation took place when the person moved in, and was reviewed regularly. Staff working in these homes are very used to people dying - the residents usually have multiple health issues and often they don’t want to go to hospital. Of course, they aren’t familiar with coping with Covid-19, but they will certainly be familiar with managing pneumonia. So I don’t think that twitter comment from Lewis Goodall is accurate.

I do think that the staff working in these facilities should be prioritised for testing.
 
Daisybell said:
When I was still working I used to go into a lot of residential facilities for the elderly. Discussion around resuscitation took place when the person moved in, and was reviewed regularly. Staff working in these homes are very used to people dying - the residents usually have multiple health issues and often they don’t want to go to hospital. Of course, they aren’t familiar with coping with Covid-19, but they will certainly be familiar with managing pneumonia. So I don’t think that twitter comment from Lewis Goodall is accurate.

I do think that the staff working in these facilities should be prioritised for testing.
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They may be trained in helping with some end of life care, but looking after patients without PPE during a pandemic that can sweep through the population of the care home and can cross-infect between staff and patients and vice versa, this seems to be very different. In other countries even mild patients were put into centralised quarantine and looked after and lives attempted to be saved by making sure they didn’t infect others. Yet here elderly people who have the absolute highest chance of dying, are being given DNR orders “en masse”.
 
If it's on a piece of paper, or a screen, with a flowchart, then it is automatically seen as ethical - because someone 'higher up' has deemed it so, and they couldn't possibly be wrong.

It's the whole following orders thing where someone else has all the responsibility - and that's always worked so well in the past.

As I understand it normal triage involves finding who is in most need and treating them first.

Current thinking seem to suggest that this should be turned on it's head, that the most bang for resource is achieved by treating the least ill first, as that will require less resources, meaning more people could potentially be successfully treated.

Both approaches have their merits where resources are constrained, but the later is not how, or why, the NHS is there, at least according to the NHS.
 
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The British paper says that decisions have to be made transparent - how transparent and well thought through can they be in an overwhelmed hospital? Or do they just need the patients' job title?

I get the logic behind it but it gives me cold shivers.

The German guidlines say they will make decisions based on medical data (comorbidities etc., not only age) and on what the patient wants. Not sure how they plan to ask them though.
 
Wonko said:
It is starting to look like there may be a covert policy of cull by virus for the non/ less productive members of society.

Did you catch the bit that if resources are short, as they are/will be, that treatment options are to be decided not just by chances of survival but by that persons 'usefulness' e.g. are they a key worker or not?
Click to expand...

Yes, I noticed that the category of usefulness* was attracting comment.

On Newsnight (BBC2) last night there was an interview with a Doctor and my take was that these decisions are already being taken --- in some hospitals --- presumably other hospitals are not far behind.

Those who have received shielding letters are worried.

*"limiting economic losses" -https://www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf
 
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lunarainbows said:
Are you being serious (about the key workers - your second paragraph)? If so, no I didn’t hear about it - when did they say that? I heard that it’s decided on how “frail” you are (under that system I think I worked out many of those with severe ME like me may well not score well enough to get help :( )
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New guidance was issued yesterday; you can access the PDF here*. The new controversial phase is "limiting economic losses"

*https://www.bma.org.uk/advice-and-support/covid-19/ethics/covid-19-ethical-issues
 
Leila said:
This article discusses different ethical/philisophical approaches on who to treat:

The grim ethical dilemma of rationing medical care, explained
How hospitals decide which Covid-19 patients to prioritize when resources are scarce.

"There are three theories of how to make ethical triage decisions, according to David Magnus, director of the Stanford Center for Biomedical Ethics: egalitarianism, utilitarianism, and prioritarianism."
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Leila, thank you for posting this. It gives me cold shivers too.

“Each theory has its own moral logic. Egalitarianism seeks to treat patients equally; using a lottery system to select vaccine recipients is one example. Utilitarianism aims to maximize total benefit, generally measured by the remaining life years — or expected remaining high-quality years — that decisions will save. If a 20-year-old and an 80-year-old both required a ventilator, treating the 20-year-old would likely maximize life years. In a choice between two people of the same age, the quality of life that each could expect upon recovery would become relevant. Prioritarianism, or the “rule of rescue,” treats the sickest people first; emergency rooms operate on this principle, for example, choosing to treat the gunshot wound victim before the person with a broken leg.

Though each of these appeals to certain moral intuitions, they all have serious problems. To treat patients equally, for example, is also to treat them indiscriminately — because egalitarianism does not distinguish between the age of patients or the severity of their conditions, it can easily seem like an arbitrary or wasteful use of resources.

In the United Kingdom, quality-adjusted life year, or QALY, scores are a crucial factor in health care decision-making and are calculated by multiplying years of life by quality of life. If a given medical treatment would allow a patient one year with full quality of life, the patient would have a quality score of 1. If the same treatment would produce a year of life with only half of the normal quality of life, they would have a quality score of 0.5.”

I don’t know if this is the right place to start this (ethics/morality) discussion. But reading this, I have a lot of questions going round in my head. I have feeling I wouldn’t be saved. I’m not “useful” to anyone. I don’t perform a “key service”. My “quality of life” is probably 1/10th if not less of a “healthy” persons life. But how can a doctor, or anyone, decide that even if I were only to live less than a healthy person, and even if it’s spent just listening to audiobooks and unable to dress myself, that I’m not worth saving compared to someone who can dress themselves? I may be infact happier than many people who have perfectly healthy and free lives. Do they for example take that into account?

Even if I’m not a “key worker”, or giving any economic advantage, do they take into account my partner and my mum, for both of whom I am such a big (or even the only) part of their lives as they don’t have many other people in their lives.. the sheer attachment we have for each other.. do they take that into account?

Why does the amount of years left to live, as well as how “physically healthy” they will be in those lives, determine whether someone should be saved or not? Is that what measures “life”? How can someone else, make that decision for us?
 
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Leila said:
The German guidlines say they will make decisions based on medical data (comorbidities etc., not only age) and on what the patient wants. Not sure how they plan to ask them though.
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If the will is already documented (which often is, for the case of complications), or if they can speak.

Last week in Dutch TV there was a report, interviewing older people about this issue. It was thought that the next week will be going to be "heel spannend" (maybe "very exiting" would be a translation). I saw only the last two answeres. One said that he would like to have done everything possible, two others (both apparently in rather very good shape) said that they had a nice life, and it would be ok to have come to an end if the situation were as it were.
 
lunarainbows said:
Leila, thank you for posting this. It gives me cold shivers too.

“Each theory has its own moral logic. Egalitarianism seeks to treat patients equally; using a lottery system to select vaccine recipients is one example. Utilitarianism aims to maximize total benefit, generally measured by the remaining life years — or expected remaining high-quality years — that decisions will save. If a 20-year-old and an 80-year-old both required a ventilator, treating the 20-year-old would likely maximize life years. In a choice between two people of the same age, the quality of life that each could expect upon recovery would become relevant. Prioritarianism, or the “rule of rescue,” treats the sickest people first; emergency rooms operate on this principle, for example, choosing to treat the gunshot wound victim before the person with a broken leg.

Though each of these appeals to certain moral intuitions, they all have serious problems. To treat patients equally, for example, is also to treat them indiscriminately — because egalitarianism does not distinguish between the age of patients or the severity of their conditions, it can easily seem like an arbitrary or wasteful use of resources.

In the United Kingdom, quality-adjusted life year, or QALY, scores are a crucial factor in health care decision-making and are calculated by multiplying years of life by quality of life. If a given medical treatment would allow a patient one year with full quality of life, the patient would have a quality score of 1. If the same treatment would produce a year of life with only half of the normal quality of life, they would have a quality score of 0.5.”

I don’t know if this is the right place to start this (ethics/morality) discussion. But reading this, I have a lot of questions going round in my head. I have feeling I wouldn’t be saved. I’m not “useful” to anyone. I don’t perform a “key service”. My “quality of life” is probably 1/10th if not less of a “healthy” persons life. But how can a doctor, or anyone, decide that even if I were only to live less than a healthy person, and even if it’s spent just listening to audiobooks and unable to dress myself, that I’m not worth saving compared to someone who can dress themselves? I may be infact happier than many people who have perfectly healthy and free lives. Do they for example take that into account?

Even if I’m not a “key worker”, or giving any economic advantage, do they take into account my partner and my mum, for both of whom I am such a big (or even the only) part of their lives as they don’t have many other people in their lives.. the sheer attachment we have for each other.. do they take that into account?

Why does the amount of years left to live, as well as how “physically healthy” they will be in those lives, determine whether someone should be saved or not? Is that what measures “life”? How can someone else, make that decision for us?
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This is a core ethical dilemma, who decides for you when you can't and who determines what "quality of life" means?

That dilemma came up with the advanced medicine and intensive care and societies haven't caught up with sufficient solutions, I think.

For myself, I have decided yrs ago that I don't want to be in intensive care when it includes being intubated or being tube fed. But this is MY decision and in an ideal situation that should be the only thing that counts. Not my title as a "societal useless person", that is sickening.
 
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