Patients crammed into hospital corridors, on trolleys or just slumped against walls. The oldest – and sickest – left gasping for air, deserted. Doctors need to decide who should receive treatment and an opportunity to live, and who should be deprived of help.
Reports of the situation in some Italian and Spanish hospitals read like something from a horror movie. Many commentators have compared the chronic lack of essential equipment – and the rising death rate – to war or an apocalypse.
And the older generation is said to suffer the most. In what seem to be the most cruel of choices, heads of health in Turin have reportedly ordered that vital equipment such as ventilators be reserved for young, fit patients with a higher chance of survival.
End-to-end care: Medical personnel will continue to provide treatment based on clinical need, not of an individual’s age, NHS specialist in intensive care writes. Ron Daniels
The message is that people over 80 only have a few years to live anyway, so they are somehow less important. Above all, it makes it uncomfortable to read, a doctor in intensive care who is confronted with such life and death decisions on a daily basis.
But in recent weeks, a disturbing rumor has spread across social media. Reports, even published by some newspapers, have suggested that millions of people can be banned from intensive care units here simply because they are considered too old or sick.
After caring for the most seriously ill Covid-19 patients in hospitals in the West Midlands for the past two months, I can tell you that this could not be less true. These pernicious falsehoods are not only insulting, they are also harmful to patients.
In recent weeks, I have heard that many elderly patients refused to seek essential medical attention for fear of being left alone in a hospital corridor. Some even believe that they are safer at home, without doctors “playing God”.
But in fact, the UK has an excellent track record in triage – prioritizing who gets treatment based on clinical needs. That is not going to change, even in the grip of a pandemic.
I’d be lying if I said that at some point we might not have to prioritize, especially with vital fans in such a small supply. The cold, harsh truth is that doctors will be forced to make difficult decisions they never thought they would face.
People applaud in front of a big screen in Piccadilly Circus during the Clap for Our Carers campaign in support of the NHS, while the spread of the corona virus continues (file photo)
But these decisions are far from as simplistic as some would have you believe.
Besides being an advisor for intensive care with more than two decades of experience, I am also the founder of the charity The Sepsis Trust. Sepsis is an acute, potentially deadly response to an infection, killing more than 40,000 British every year. It can send a perfectly healthy patient into the downward spiral at a terrifying speed.
It is not uncommon for sepsis patients to require intensive care and life support. But whether a patient is admitted to an intensive care unit – and given life-saving equipment like ventilation – is based on a complicated decision-making process, not just his age.
First, we take every patient’s vital signs – everything from heart rate and blood pressure – because they tell us how sick a person is.
If their scores are far from normal, they are considered a good candidate for intensive care. But if patients do get through, many never fully recover. So when we make a decision to put a patient on a ventilator, we always consider their quality of life afterwards.
Using a ventilator to treat a patient doesn’t necessarily give them the best chance. As with any medical treatment, there are risks involved. The device mechanically pushes air and oxygen in and out of the lungs.
An ambulance parked in front of St Thomas’ Hospital in London, UK, on March 26 (file photo)
Attaching it is risky for the patient, as it sometimes involves a procedure to insert a tube down their throat and into their windpipe. The risk of potentially fatal secondary infections, such as sepsis, is increasing – astonishingly so for those older or with chronic conditions.
Once a patient has come off a ventilator, it can take nearly a month for the lungs to breathe without additional oxygen, which means longer hospitalization. And if a coronavirus patient has been breathing through a ventilator for weeks, it is unlikely to regain full lung capacity.
If a patient is severely physically incapacitated for work, we don’t simply consider him not worth helping – the team talks to the patient’s family doctor and family members to come to a joint decision about what can be realistically achieved.
According to studies, only a fifth of 80-year-olds live longer than a year after admission to intensive care, the trauma of aggressive treatment. And only 57 percent of working-age IC patients are good enough to return to work one year after discharge.
As a result of all this, doctors are working hand in hand with a team of experts called critical care outreach teams. These are usually composed of senior nurses who have received advanced training and their job is not only to provide care in the wards, but also to decide whether the benefit of treatment in intensive care, including ventilation, will be greater than the risks.
When a patient is severely physically incapacitated for work, we don’t simply consider him not worth helping – the team talks to the patient’s family doctor and family members to come to a joint decision about what can be realistically achieved.
A worker presses pieces for a fan in Barcelona, Spain on March 23 (file photo)
If there is a reasonable chance of giving them a good quality of life again, they are probably a good candidate.
A healthy 75-year-old without serious underlying conditions is treated just as well as someone in their thirties.
If there is ever a situation where we think the risks outweigh the benefits, we need to call on another expert body in the hospital called an ethics committee to make the final decision. This could be a group of senior colleagues from specialties like intensive care or respiratory medicine who come together to discuss whether an ICU referral is really the best option.
And for some patients – like those with terminal cancer – it just won’t be. Many prefer to live surrounded by loved ones at home for their last weeks or months rather than undergoing aggressive, risky treatment.
Deciding against intensive care treatment for these patients is neither cruel nor heartless. It is the opposite – it gives them an opportunity to die with dignity. And that will remain our goal, despite this frightening pandemic.