Coronavirus patients with a poor prognosis could be taken off a ventilator even if they are stable or improving to make it available for someone else deemed more likely to survive, under guidelines drawn up by UK doctors.
That is one of the ways potentially life-saving care may have to be rationed if the NHS becomes overwhelmed with coronavirus cases, according to a document published by the British Medical Association on Wednesday.
Under the proposals, hospitals may have to impose “severe” limits on who is put on a ventilator, and large numbers of patients could be denied care.
The doctors ’union suggests older people and those with an underlying illness may not get treatment that could save them, with younger, healthier patients given priority instead.
The document outlines how doctors may withhold or withdraw care that could keep someone alive because another patient is deemed more needy and more likely to benefit.
The proposals are likely to prompt a vigorous debate about some patients not being given a chance to stay alive once their lungs collapse as a result of the infection.
The document explains that the guidance has been drawn up because when the outbreak peaks “it is possible that serious health needs may outstrip availability and difficult decisions will be required about how to distribute scare lifesaving resources ”.
The limit on the availability of healthcare and the scale of the outbreak may mean 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 , It says.
“Health professionals may be obliged to withdraw treatment from some patients to enable treatment of other patients with a higher survival probability. This may involve withdrawing treatment from an individual who is stable or even improving but whose objective assessment includes a worse prognosis than another patient who requires the same resource. ”
The paper is intended to give the UK’s 728, 000 doctors ethical guidance on how to manage the difficult decisions the pandemic could throw up about which patients should or should not receive treatment at a time when the NHS has had to introduce service rationing.
It says the NHS’s limited supply of intensive care beds will inevitably mean that doctors will have to refuse access to some people, especially those with one or more underlying health conditions and those who are older, though it does not specify an age threshold.
It does not list the illnesses but they are likely to include heart problems, kidney disease, diabetes or a pre-existing lung condition such as COPD. One in four Britons have at least one such chronic illness.
“To maximise benefit from admission to intensive care, it will be necessary to adopt a threshold for admission to intensive care or use of scarce intensive treatments such as mechanical ventilation or extracorporeal membrane oxygenation,” it says.
“Relevant factors predicting survival include severity of acute illness, presence and severity of comorbidity and, where clinically relevant, patient age. Those patients whose probability of dying, or requiring a prolonged duration of intensive support, exceeds a threshold level would not be considered for intensive treatment, though of course they should still receive other forms of medical care. ”
Hospitals across the UK have been increasing their supply of ICU beds in recent weeks to give them as much capacity as possible to deal with an expected “tsunami” of Covid – 240 patients. They have set up overspill ICUs in operating theaters and wards usually used for other patients. However, the NHS still does not have the number of ventilators it needs and is having to deploy doctors and nurses who usually treat other types of patients to boost their intensive care workforce.
In other suggestions that may prove controversial, the BMA’s guidance says:
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Patients in ICU who do not improve or worsen after admission may have their treatment withdrawn under a new “capacity to benefit quickly ”approach, and their place may be given to another patient thought likely to do better.
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People working in vital services and industries such as the NHS, emergency services, utilities and telecoms may be deemed a priority for an ICU bed.
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Patients with poor underlying health, such as a history of severe respiratory failure, are unlikely to go on to a ventilator or into ICU.
Rationing could become even tighter as the pandemic progresses, the document states. “Depending upon the nature of the pandemic, there may be a need during its progress to shift from one level of service rationing to a more or less severe one,”, it says.
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