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The Covid-19 pandemic may have made doctors less willing to resuscitate very sick and/or frail patients, according to new research published in the Journal of Medical Ethics.
However, views on euthanasia and physician assisted dying have remained similar, with around a third of respondents still strongly opposed to these policies.
One review found that DNACPR decisions were inappropriately applied to over 500 people
At the beginning of the pandemic, the Department of Health and Social Care raised concerns that ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) decisions were being applied to groups of people, instead of considering the needs of each person and their individual circumstances.
There were particular concerns that this was affecting people with a learning disability and older people.
As a result, the Care Quality Commission (CQC) conducted a rapid review of how DNACPR decisions were being made during the pandemic. Shockingly, they discovered that DNACPR decisions were inappropriately applied to over 500 people, without their consent or prior knowledge.
In light of this research, the study authors wanted to find out if the pandemic has changed the way in which doctors make end of life decisions, specifically in respect of DNACPR orders and treatment escalation to intensive care.
They also wanted to know whether the pandemic had changed doctors’ views on euthanasia and physician assisted suicide.
Half the respondents were more likely not to attempt to resuscitate a patient
In total, 231 responses were received between May an August 2021: 146 (63%) from senior junior doctors (SHOs); 42 (18%) from hospital specialty trainees or equivalent; 24 (10.5%) from consultants or GPs; 15 (6.5%) from foundation year 1 junior doctors; and four others (2%).
The results showed that half the respondents were more likely not to attempt to restart a patient’s heart when it stops. The most frequently cited contributory factors were: ‘likely futility of CPR’ (91%); co-existing conditions (89%); and patient wishes (80.5%). Advance care plans and ‘quality of life’ after resuscitation also received large vote-share.
The number of respondents who stated that ‘patient age’ was a major factor informing their decision increased from 50.5% pre-pandemic to around 60%, and the proportion who cited a patient’s frailty rose by 15% from 58% pre-pandemic to 73%.
But the biggest change in vote-share was ‘resource limitation’, which increased by 20%, from 2.5% to 22.5%.
Views on euthanasia and physician assisted suicide remained at similar levels
When asked whether the thresholds for escalating patients to intensive care or providing palliative care had changed, the largest vote-share was the ‘same or unsure’: 46% (weighted) for referral; 64.5% (weighted) for palliative care.
But a substantial minority said that now they had a higher threshold for referral to intensive care (22.5% weighted) and a lower threshold for palliation (18.5% weighted).
When it came to the legalisation of euthanasia and physician assisted suicide, the responses showed that the pandemic has led to marginal, but not statistically significant, changes of opinion:
In total, 48% were strongly or somewhat opposed to the legalisation of euthanasia before the pandemic compared to 40% during the pandemic; 20% were neutral or unsure pre-pandemic compared to 18% during the pandemic; and around a third were somewhat or strongly in favour pre-pandemic compared to 35% during the pandemic.
Similarly, before the pandemic, 51% said they had strongly or somewhat opposed the legalisation of physician assisted suicide, 24% had been neutral or unsure, and 25% had been somewhat or strongly in favour. These proportions changed to 52%, 22%, and 26%, respectively during the pandemic.
Resource limitation continued to factor into clinical decision making even when hospital cases lowered
From these results, the researchers concluded that “for a significant proportion of clinicians, resource limitation continued to factor into clinical decision making even when pressures on NHS resources had returned to near-normal levels.”
They add that more research will now need to be done to determine whether these changes will stay the same, evolve even further or revert back to pre-pandemic practices.