Yesterday, deaths related to Covid-19 reached a record high with the Deputy Chief Medical Officer for England saying that cases are yet to peak. Predictions vary but Dr Jenny Harries said the peak could come over Easter and cases should begin to fall only if the public follows social-distancing measures.
As pressures mount in an overstretched NHS, no one is under any illusion that difficult decisions will need to be made by doctors coping with a surge of patients in the coming weeks.
The British Medical Association (BMA), however, has stated that if demand on health services outstrips the ability of the NHS to deliver services to pre-pandemic standards, triage decisions must not be solely based on age.
It added that triage requires identification of clinically relevant facts about individual patients and their likelihood of benefiting from available resources. Younger patients will not automatically be prioritised over older ones.
BMA and ethical guidance
The British Medical Association recently produced ethical guidance for doctors if restrictions in the availability of mechanical ventilation become severe.
It said that doctors would be obliged to implement decision-making policies which mean some patients may be denied intensive forms of treatment that they would have received outside a pandemic. Health professionals may also be obliged to withdraw treatment from some patients to enable treatment of other patients with a higher survival probability.
During the peak of the pandemic, doctors are likely to be required to assess a person’s eligibility for treatment based on a ‘capacity to benefit quickly’ basis. As such, some of the most unwell patients may be denied access to treatment such as intensive care or artificial ventilation.
A simple ‘cut-off’ policy with regard to age or disability would be unlawful as it would constitute direct discrimination. A healthy 75-year-old cannot lawfully be denied access to treatment on the basis of age. However, older patients with severe respiratory failure secondary to Covid-19 may have a very high chance of dying despite intensive care, and consequently have a lower priority for admission to intensive care.
Why are older patients more at risk of Covid-19?
The World Health Organisation said that although all age groups are at risk of contracting Covid-19, older people face significant risk of developing severe illness if they contract the disease due to physiological changes that come with ageing.
According to the National Office of Statistics, of 647 deaths which were registered before 27 March more than two thirds (69%) occurred among those aged 75 and over.
President of the British Geriatrics Society, Professor Tahir Masud, said the risk is higher because many older people are living with frailty, which depletes their reserves and makes them less resilient. Many also have other long-term and complex health conditions.
He said: "It is likely that some older people will die of this disease over the coming months, or will die with this disease but from underlying health conditions. It is important for all healthcare professionals to remember that death is a natural part of life and for them to be supported to have responsible and sensitive conversations with their patients and families.
"Conversely, it is important to remember that while older people are the most likely to be seriously affected by Covid-19, many older people who get the virus will recover from it. Treatment for the virus must be determined by clinical need and the best scientific evidence and not by age alone."
Covid-19 and care homes
It is recognised that older people in long-term care facilities have a higher risk of dying from Covid-19 and the risk of transmission of the virus is also especially high at these residences.
There are more than 400,000 people living in care homes in the UK, more than 70% of which are living with some form of dementia. Many of these people also have other underlying health conditions.
Government guidance states that care homes need to continue to make their full capacity available to support the national effort, both in terms of beds and their skilled care staff. They have said that helping to move patients who no longer require acute care into the most appropriate setting will help to save thousands of lives.
It added that residents may also be admitted to a care home from a home setting. Some of these patients may have Covid-19, whether symptomatic or asymptomatic, but said these patients can be safely cared for in a care home if this guidance is followed.
Many care home managers, however, disagree with the guidance with one saying that 'this would be tantamount to importing death into care homes.'
It followed news reports that fifteen residents at Castletroy Residential Home in Luton have died during the coronavirus pandemic. Five of those who have died were confirmed as having Covid-19. The rest were not tested. Another sixteen deaths in a week were also reported in a care home in Glasgow.
The situation prompted the Alzheimer's Association to write to Matt Hancock asking for urgent measures to be implemented in care homes. The charity said that in the last couple of weeks they had received thousands of phone calls and hundreds of emails from worried family members, friends and people living with dementia themselves.
It added that although this group of the population are extremely vulnerable to contracting the virus, they were concerned that measures are not being put in place to protect them and "yet again, social care and those who desperately need it have fallen to the bottom of the pile".
Measures included personal protection equipment (PPE) being readily available to care homes. Also that care home staff and people being discharged from hospital into care homes should be given priority testing for the virus, alongside critical NHS staff.
Advance care planning and DNA-CPR
Another issue raising its head is advance care plans and do not attempt cardiopulmonary resuscitation (DNA-CPR) orders.
The BGS produced guidance that said care homes should work with GPs, community healthcare staff and community geriatricians to review advance care plans as a matter of urgency with care home residents. This should include discussions about how Covid-19 may cause residents to become critically unwell, and a clear decision about whether hospital admission would be considered in this circumstance.
In addition, the Care Quality Commission wrote to adult social care providers and GP practices last week with a statement prepared with the British Medical Association, Care Provider Alliance and Royal College of General Practitioners. The statement sets out their shared position on the importance of advance care planning being based on the needs of the individual.
They said that these advance care plans may result in the consideration and completion of a Do Not Attempt Resuscitation (DNAR) or ReSPECT form. But added that it remained essential that these decisions are made on an individual basis. The GP continues to have a central role in the consideration, completion and signing of DNAR forms for people in community settings.
There were, however, stories in the press of GP surgeries writing to vulnerable patients to suggest that they sign DNAR-CPR orders prompting fears that patients with underlying conditions would be denied supportive treatment.
Age UK and a group of charities advocating for the right of older people confirmed these concerns and said that they had seen shocking examples where blanket decisions seem to be being made about the care and treatment options that will be available to older and vulnerable people, who have felt pressured into signing DNR-CPR forms.
They said: “Alongside this, many of the people affected have experienced fear and anxiety, and feel that their lives and wishes do not matter. This is shameful and unacceptable."
They said that whether or not to sign a DNA-CPR form is an individual’s decision, and they have a right to make that decision without feeling pressurised.
Doctors though have been quick to clarify that a DNA-CPR is not a method to “ration” care but rather to ensure patients are not unknowingly subjected to a futile and inappropriate treatment.
Writing in the Guardian, Dr Rachel Clarke, said: "In the UK, unlike in north America, the decision whether or not to write a DNA-CPR order rests with the clinician, not with the patient or their family. Doctors, not patients, sign the order – contrary to some of the rumours on social media.
"Any patient with capacity can decide from themselves to refuse CPR and request that a doctor completes a DNA-CPR form on their behalf. But no one can insist upon receiving CPR. Like all other medical treatments, CPR will only be administered if a doctor believes it is in the best interests of the patient. And in all cases patients never complete the forms themselves, doctors do.
"We are not giving up on you. At the time of writing, the UK has several thousand spare ITU beds. No one is being denied either an ITU bed or CPR on spurious grounds. Pandemic or no pandemic, we are trying our very best for you."