Covid-19 - rationing of medical care

[Leila]

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.

Yes that's why I think making a will is important, also for young people and not only during a pandemic. Still many people don't have one and in a situation where triage is necessary the patient most likely can't articulate anymore. Families can't get included in discussions about end of life care either, at least not at the hospital.

 

[Simbindi]

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

What is being proposed is battlefield triage. My eldest sister was a nurse for nearly 40 years. She joined the navy when she was 18 and specialised in Accident and Emergency from the time she originally finished her nursing qualifications. I recall her explaining her military training to me when I was still a kid and how this differed from the way civilian nursing works (how military nursing works in a war time situation, not normal circumstances).

She spent 15 years working in a Navel hospital until the government in its wisdom, closed them all. She then had to work in an NHS hospital (while still in the Navy) and was horrified by their complete inefficiency, lack of leadership, lack of senior accountability etc. After completing her 20 year military commission, she spent 15 years as a 'civvy' in the NHS, working as a Nurse Practitioner, then Clinical Manager of the Minor Injuries Centre and other specialist services in a large city. 5 years ago she was made compulsory redundant due to the austerity measures cutting back on the number of personnel running these vital NHS services. This is what has happened to a large number of the highly qualified people this country now desperately needs.

Edit: When someones signs up to the military, they know they may be expected to be treated using 'battlefield triage'. However, it's a very different thing for civilians to suddenly face the fact that the NHS may have to start taking such an approach.

 

[JaneL]

The Italians have also come up with guidelines on how to allocate limited health resources:

Now the Italian College of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) has published guidelines for the criteria that doctors and nurses should follow as these already extraordinary circumstances worsen. The document begins by likening the moral choices Italian doctors may face to the forms of wartime triage that are required in the field of “catastrophe medicine.” Instead of providing intensive care to all patients who need it, the authors suggest, it may become necessary to follow “the most widely shared criteria regarding distributive justice and the appropriate allocation of limited health resources.”

The authors, who are medical doctors, then deduce a set of concrete recommendations for how to manage these impossible choices, including this: “It may become necessary to establish an age limit for access to intensive care.”

Those who are too old to have a high likelihood of recovery, or who have too low a number of “life-years” left even if they should survive, would be left to die. This sounds cruel, but the alternative, the document argues, is no better. “In case of a total saturation of resources, maintaining the criterion of ‘first come, first served’ would amount to a decision to exclude late-arriving patients from access to intensive care.”

In addition to age, doctors and nurses are also advised to take a patient’s overall state of health into account: “The presence of comorbidities needs to be carefully evaluated.” This is in part because early studies of the virus seem to suggest that patients with serious preexisting health conditions are significantly more likely to die. But it is also because patients in a worse state of overall health could require a greater share of scarce resources to survive: “What might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”

https://www.theatlantic.com/ideas/archive/2020/03/who-gets-hospital-bed/607807/

http://www.siaarti.it/SiteAssets/News/COVID19 - documenti SIAARTI/SIAARTI - Covid19 - Raccomandazioni di etica clinica.pdf

I wonder how many other countries are going to follow suit on this?

 

[Leila]

The rationing of medical care also includes vaccines (when developed) and promising drugs.

Gilead has announced that they will give away their supply of Remdesivir for free for compassionate use and studies.

"Having a potential treatment in our hands comes with significant responsibility. Providing our existing supplies at no charge is the right thing to do, to facilitate access to patients as quickly as possible and in recognition of the public emergency posed by this pandemic."

It's 1.5 million individual doses that "equate to well over 140,000 treatment courses for patients."

I can't find information though on how exactly they will distribute them (at least not to the highest bidder).

 

[Hip]

The Italians have also come up with guidelines on how to allocate limited health resources:

I think guidelines are important, not just for best allocating the very strained and limited hospital resources, but also to preserve the sanity of doctors. If doctors have to decide who lives and who dies in a time of limited resources, it puts them in a terrible position emotionally. Nobody wants to play God like that. At least if they have guidelines, doctors can to an extent distance themselves from the who-lives-and-who-dies decision process.


It's a horrible reality the medical community have to face.

And SARS-CoV-2 is actually a relatively benign virus, on the scale viral nastiness. It's death rate is less than 1%. But the next one to hit us might have a death rate of 30%. Or more. That would be a real catastrophe.

It's been predicted that as a consequence of globalization, and of our increasing incursion into natural habitats (which puts us into more contact with animals, risking more cross-species transfer of viruses), we are going to be seeing more of these pandemics.

I really think we need to start thinking in terms of viral pandemic insurance policies. We need to pump money into antiviral research.

If, after this pandemic, humanity just falls back into its usual activities, without learning an important lesson and making plans to prevent a repeat of this, then we can consider ourselves to be a particularly stupid species.

DRACO, a universal antiviral drug in development that could have worked against coronavirus, has not been able to get any decent funding for 16 years. That's an example of human shortsightedness.

 

[lunarainbows]

Today on sky news, my mum tells me, was a young woman who had blood cancer who was told by her GP about DNR and that she wouldn’t be allowed a ventilator if she went to hospital.

then I saw this:







If someone tries to tell me I will be denied care because of my conditions, I will not accept it. I have my mum and my partner to think of, and I want a chance to live. No one else should make that decision for me, because of circumstances outside my control.

Also, DNR doesn’t mean do not treat. Yet it seems people are being told they won’t even get a hospital bed or a ventilator.

 

[Invisible Woman]

If someone tries to tell me I will be denied care because of my conditions, I will not accept it. I have my mum and my partner to think of, and I want a chance to live. No one else should make that decision for me, because of circumstances outside my control.

Why should you accept it? A DNR is a very personal decision made by the individual and their families in consultation with a doctor. Not something foisted on individuals.

I know this is a bad time to criticise the medical profession but they can't have it both ways.

Foisting DNRs on people who don't want them at times of great stress and when their in isolation is cruel & is inflicting harm. No cartesian dualism & all that.

One of the main arguments against legalised self euthanasia in this country is because of the risk people who don't want to self euthanise might be forced into it. How is forcing someone to accept an unwanted DNR - meaning you won't get a vent & as @lunarainbows says therefore equates to do not treat any different?

I'm not entirely sure I'm using the correct term - by self euthanise I don't mean suicide - I mean the person has agreed and wants euthanasia

 

[Leila]

Is DNR like a patient's will regarding end of life care?

What I find sad:

So many people with disablilities and chronic illnesses are being denied benefits/financial support/care etc. - because their condition isn't considered to be severe enough.

But in a triage situation it is?

Our triage guidelines using the Clinical Frailty Scale are questionable, too. But aside from disability activists, no one is discussing them.

 

[Invisible Woman]

Is DNR like a patient's will regarding end of life care?

As far as I know DNR simply stands for Do Not Resuscitate on a patient's records. So, in theory, their treatment continues but if the patient deteriorates they wouldn't be placed on a ventilator, have any attempt made to restart their heart. That kind of thing.

A living will is broader I think. More detailed about treatment decisions to be made if a person is no longer capable of making those decisions for themselves. It could include, but not be limited to a DNR.

 

[lunarainbows]

Trigger Warning: may be upsetting for people with ME, especially severe ME, older people, or if you know people with other conditions. About death and if you are entitled to ICU care.

Financial Times article:
NHS ‘score’ tool to decide which patients receive critical care

https://www.ft.com/content/d738b2c6-000a-421b-9dbd-f85e6b333684

I have worked out that according to this, I score an “8”. Which means I am just at the threshold for receiving ICU care, and shouldn’t be denied ICU care, according to this graph. This is in part due to my age, as I am under 50, so score a 0 on that part.

0 (for age) + 7 (frailty) + 2 (2 pre existing conditions in the list) - 1(being female).

 

[Arnie Pye]

@lunarainbows

I've noticed that you use the abbreviation/acronym "TW" quite often. What does it mean?

 

[lunarainbows]

@lunarainbows

I've noticed that you use the abbreviation/acronym "TW" quite often. What does it mean?

Trigger Warning,

https://www.oxfordsu.org/resourcehub/guidetotriggerwarnings/

At the moment with coronavirus I often feel like I need to put trigger warnings in front of many posts. I’m not sure if I should. But I’m trying to do it with posts in this topic/thread in particular, as I feel they are particularly upsetting and difficult topics.

I have diagnosed with both eating disorder and PTSD in the past, I have OCD & Anxiety, so I understand why it can be helpful. So if someone doesn’t want to read something - they can skip over it as soon as they see the TW. TW’s also help prepare people for certain difficult topics : I find this helpful as well.

 

[Simbindi]

Is there any evidence that 'frailty' is comparable to the functional restrictions that result from M.E.? I would have thought that the warning this scoring system gives that 'special consideration should be given' would apply to PWME:

There may be situations arising that are outside the scope of the framework that require special consideration, thus clinical discretion will continue to apply. Frailty scoring is used as a proxy for physiological frailty which leads to reduced chances of recovery in ICU, therefore where conditions pre-exist impact on physical activity but are stable and inappropriately affect the score, then that situation requires special consideration.

 

[lunarainbows]

Is there any evidence that 'fraility' is comparable to the functional restrictions that result from M.E.? I would have thought that the warning this scoring system gives that 'special consideration should be given' would apply to PWME:

I did see that. I would hope you are right, but when I last saw an anaesthetist (for that surgery that got cancelled), he told me that I was considered very frail, and he knew what conditions I had.

 

[Barry]

I did see that. I would hope you are right, but when I last saw an anaesthetist (for that surgery that got cancelled), he told me that I was considered very frail, and he knew what conditions I had.

Yes, but in this context is 'frailty' necessarily synonymous with low probability of a favourable response to ICU treatment? It seems the word 'frailty' is rather imprecise in this medical context.

 

[Sly Saint]

Financial Times article:
NHS ‘score’ tool to decide which patients receive critical care

The NHS chart that will decide whether you receive ventilation if you need it

Points-based system means even relatively young people with moderate health issues – or almost anyone with significant physical or mental disability – can be ruled out of life-saving intervention
An chart first published by the Financial Times reveals the decision-making system that the government’s failure to plan ahead and build up the availability of ventilators and a decade of cuts and fragmentation have forced on the NHS in its treatment of coronavirus patients – and how shockingly easy it is to end up with a ‘score’ that may deprive someone of intensive medical intervention if they become seriously ill.

The NHS ‘Decision Support Tool’ allocates points to each patient based on their age, condition and ‘co-morbidities’ – other existing medical conditions – and unlike in most sports, the people with the most points lose.

The chart also reveals the chilling reality that patients with physical or mental disability – even if not otherwise life-limiting – are almost certain to fall foul of the system and miss out on ventilation.

And even not taking regular exercise will put you almost halfway there:

https://skwawkbox.org/2020/04/13/th...ether-you-receive-ventilation-if-you-need-it/

eta: note Clinical Frailty Scale (CFS)

 

[Leila]

This article discusses triage approaches in different countries

The heart-wrenching choice of who lives and dies

"All across the world, hospitals and health authorities are issuing similar guidelines to help their medical staff make the difficult decisions they are now facing. They are being put in place to try to save people. But they not only affect the physical health of people who are likely to lose out, but also increase their anxiety about what would happen if they do fall ill."

 

[Anna H]

Post moved from biology of Covid thread.

Not sure this is the right thread.. More about lack of treatment.

Article in Dagens Nyheter about elderly with covid-19 living in care homes often receiving palliative care immediately instead of treatment. This is often prescribed by a clinician over the phone, without them even seeing the patient or relatives being informed.

https://www.dn.se/nyheter/sverige/c...tiv-vard-blev-frisk-nar-familjen-satte-stopp/

"Jan, 81, received palliative care - recovered when the family put a stop to it
Several relatives DN talked to are critical of the elderly not being treated against covid-19, but instead being given palliative care immediately - without having to see a doctor.
When the son of Covid Ill Jan, 81, demanded that he get nutrition instead of morphine, he recovered quickly.

It was after a hospital visit at the end of March that Jan Andersson, 81, fell ill in covid-19 at Ärlingshem's elderly home in Märsta north of Stockholm. Without meeting Jan and without informing neither him nor his relatives, doctors - by phone to the nurse at the elderly home - decided to prescribe palliative care with morphine.

- Dad was completely out of it because of morphine. It was only when I contacted the media and all those responsible that Dad was instead put on drip and received his usual medication, such as blood thinning, by injection. Quite quickly he bounced back and today he is recovered"



Another article in Dagens Nyheter on the same subject :
https://www.dn.se/nyheter/sverige/geriatrikprofessor-det-har-ar-aktiv-dodshjalp/

"Geriatrics professor: This is active euthanasia

Geriatrics professor Yngve Gustafson believes that many elderly people are not being treated for covid-19, but instead receive palliative care immediately.

- To routinely give older people with lung infection drugs that inhibits respiration, is active euthanasia, if not worse , he says."


" - Living in a retirement home is not a diagnosis. That in itself can never be a medical basis for deciding whether to live or die. A doctor can prescribe palliative treatment over the phone. It is a offensive, discriminatory and a law violation not to make a medical assessment of what is best for the individual patient.

Gustafson emphasizes that basal treatment with nutrient drip, blood clot prevention, oxygen and treatment of secondary bacterial pneumonia with antibiotics thus helps the elderly. At elderly homes, there is no competence today to provide oxygen or drop at night, he points out."




" A doctor and researcher at Karolinska University Hospital describes to DN that the use of a "palliative cocktail" with sedatives and pain relief is being used, as he sees it, to a large extent on covid patients both in hospitals and elderly residents. He is careful to remain anonymous."

" According to the doctor, the standard mixture contains the drugs morphine, haldol and midazolam, which are also included in the Swedish National Board of Health's recommendations for care at the end of life.

- Many covid-19 patients are treated in this way. This is usually used for patients with terminal cancer who don't have much time left. But when used in patients with oxygen deficiency, it definitely accelerates death for them. Because visitors aren't allowed, relatives often doesn't know anything. Ethical aspects are not discussed, but I think this is illegal, and that some of these patients could have managed if they had been given oxygen therapy instead."