The arrival of covid-19 in low and middle-income countries should promote training in palliative care 

Chances of a healthy recovery from covid-19 are not bright for the elderly who need hospital care. In a series of 5700 patients with covid-19 treated in New York hospitals, there were 320 who were treated with mechanical ventilation and either were discharged or died. Mortality among the 140 under 65 was 76.4% and 97.2% among the 180 aged over 65.

The older the people are and the more the associated medical problems they have, the smaller their chances of survival. Yet the world does not seem to be discussing how the suffering of these people is to be alleviated. Instead, even in low and middle income countries we are talking about how we can put each one of them on an expensive artificial ventilator. We wonder if we can create inexpensive ventilators. We ask if we can slow the spread of the disease so that the healthcare system will be able to provide ventilators for every person with covid-19 and difficulty breathing.

But whether it is a pandemic or the death that comes to all human beings from a variety of causes, including cancers and the frailty of old age, all dying people need not be and should not be subjected to aggressive life support systems, including artificial ventilation of the lungs.

Currently there is a paradox in low-middle income countries like India: facilities like artificial ventilation of the lungs are made available to some, while even basic pain relief fails to reach the vast majority. If people are brave enough to think about it and have the agency to take the decision many may opt for withdrawal of life support systems and to receive compassionate care and a compassionate death. Covid-19 should prompt us to rethink human mortality and plan rational action by healthcare systems.

Rational action means the health system accepting that death is not an enemy to be conquered at all costs. It is pointless to stretch out the dying process into days, weeks, or months. As most intensive care units in low and middle income countries do not permit a family member to stay with the patient, only the intensive care staff come to realise (if they find time to stop and think) that every moment of those days or weeks is agonising for the patient physically and emotionally. Physically because the person is troubled by numerous sources of pain and suffering, including the presence of a large tube in one of the most sensitive parts of the body, the airway, and the added discomfort of a suction catheter being pushed regularly deep inside the breathing passage to suck out mucus. At the end of life a person should be at peace and offered as much of dignity and comfort as possible, but the opposite happens in intensive care units. 

Even with covid-19 threatening every life this death-denying behavior does not seem to change. 

We must prevent covid-19 in as many people as possible, and we must take preventive action for the future. But we must also accept the reality that some of those who contract the disease, particularly older people with comorbidities, will die. When doctors are reasonably certain that aggressive life support measures are likely to be futile, we should refrain from initiating them and instead offer palliative care—compassionate care aimed at physical, social, and mental wellbeing. Such wellbeing, not simply survival, should be the aim of the healthcare.

A document from the Indian Council of Medical Research clarifies the doctor’s duty of care: “It is to mitigate suffering. It is to cure sometimes, relieve often, and to comfort always. There exists no exception to this rule.  Unfortunately, in India and many other countries healthcare has evolved into the healthcare industry, which is aimed more at profit than health. With this evolution aggressive treatment at the end of life becomes normal for those who can afford it.

Much of the world is faced with a surge of people with advanced covid-19. Many dying patients, including frail elderly patients with comorbidity, will be connected to an artificial ventilator in an intensive care unit. This happens despite poor survival rates in the frail elderly, and one consequence is likely to be that young people who may well survive after treatment on a ventilator will be denied the treatment. To give priority to the young with a high chance of healthy survival is not ageism but good healthcare.

We propose the following sequence of actions:

  1. As has already happened in some countries, a group of health workers are assigned to triage patients. They are not from the treating team. They evaluate patients regarding possible chance of success of the treatment. 
  2. Those who have good chances of healthy survival are offered aggressive life support measures. 
  3. Those with a low chance of healthy survival are offered palliative care. This means a counselor providing unbiased information to the patients and their families. We must be compassionate and honest in conveying to the patients that we care for their welfare and that the best course of action is to aim for comfort and dignity, not survival. The counselor must assure patients and their families that all that is medically necessary and appropriate will be provided for them within the capacity of the system. 

Unfortunately, most doctors and nurses in low and middle income countries have not had training or even exposure to palliative care. The arrival of covid-19 with many elderly people dying means that such training is urgently needed. The training should cover control of symptoms like pain, breathlessness, delirium and agitation, and end of life care. It must also include basic principles of communication and of communicating bad news, neither of which are taught to most nursing and medical students in low and middle income countries. The basics can be taught online. 

Another problem is that opioid medicines like morphine, which are needed in palliative care, are often not available in low and middle income countries—not because of cost, but because of regulatory barriers. It makes no sense to do everything possible to procure ventilators, but to neglect providing training in palliative care and access to opioids. We hope that the tragedy of the covid-19 pandemic will urgently promote training in palliative care and access to opioids for end of life care, bringing continuing benefit when the pandemic is over, but death continues.

M R Rajagopal (age 72) is an anaesthetist, intensive care doctor, palliative care physician, founder chairman of Pallium India, a palliative care non-governmental organisation based in Kerala, and a member of the Lancet Commission on the Value of Death.

Richard Smith (age 68) is a former editor of the BMJ and chair of the Lancet Commission on the Value of Death.

Competing interests: None declared