In response to the covid-19 pandemic planned outpatient appointments, diagnostics, treatments, and surgical procedures were deferred or cancelled for millions of patients.¹ This was done to free up capacity to deal with an anticipated surge of critically ill patients as a result of covid-19. Waiting times for non-covid related consultations and operations are now at a high level. As preparations are made for a second covid wave, thoughts turn to how we can maintain activity for the economy, social interaction, and our healthcare systems.²

In hospitals and community settings elective care pathways have been opened; turning “red” covid-19 pathways into “green” covid-free pathways and now, planning pathways to treat patients in line with their risk of contracting covid-19, their risk of suffering severe illness and also the risk that they might pass the disease on to other patients or staff. Elective treatments that had been put on hold, have resumed. Restarting these services is complex requiring considerable planning, prioritisation, deconflicting competing services and needs, and active risk management. What has become clear is that we are learning as we go. As we restore a level of normal working to our urgent elective pathways, it is worth pausing to ask, “what would the prudent patient wish to know about their treatment?”

We are not in the same healthcare environment that existed before covid-19. We still do not fully understand how the disease originated, why it affects some more severely than others, how we may protect the most vulnerable from it, and if, or how, it may resurface. Dealing with this level of uncertainty is uncomfortable and something that traditionally risk averse clinicians may not naturally embrace. Primum non nocere still resonates as a core ethical value for the profession. Yet for some, the risk of proceeding with treatments will be acceptable, even in the context of covid-19. We must try to offer some form of normal care for our patients, many of whom have time sensitive conditions that cannot wait without causing them what may be irreparable harm.

We know that covid-19 is highly infectious and the risk relates to both hospital and community spread. Older patients, people who are immunocompromised and patients from ethnic minority groups seem to be at higher risk of severe disease.³ Patients with cancers, coronary artery disease, and cerebrovascular disease are obviously at high risk of coming to harm as a result of delays in elective treatments. Those who would normally benefit from screening programmes or who suffer from less serious, but limiting conditions like painful arthritis may equally feel that their health is unacceptably and negatively impacted. How do we rationalise and balance these priorities and risks? What do we tell our patients about the risks of hospital acquired infection, post-operative covid pneumonia or mortality? 

The pandemic highlights a core element of informed consent; there is always a balance of risk and with this, a degree of uncertainty. This is not new. The consent process provides the patient with enough information to assess the material risks and alternative treatments available, before making an informed decision with the advice of their doctor. The covid-effect is to increase this level of uncertainty and to make this risk assessment more difficult. 

The Bolam principle would support a decision-making framework that is paternalistic, informed and managed by healthcare professionals. We have moved beyond this and pausing to think what patients would wish to know about their treatment should cause us to reflect on the central importance of the consent process and the need to revisit this for elective procedures carried out at this time and in this environment.⁴

While we do everything that we can to make sure that our patient pathways are as safe as they can be, we cannot eliminate risk. What is important is that we do not shy away from speaking to our patients about this, we ask them what they want and hear their point of view, we continue to advise them, act in their best interests and address their needs, we are able to tell them when we just do not know, and that we continue to learn.

James A. Morris is Junior Clinical Fellow at Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, UK.

Oliver T. Clough is Junior Clinical Fellow at Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, UK.

Raymond E Anakwe is Consultant at Department of Trauma and Orthopaedic Surgery, Imperial College Healthcare NHS Trust, UK. 

 

1. Søreide K, Hallet J, Matthews JB et al.; Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services. Br J Surg. 2020 Apr 30. doi: 10.1002/bjs.11670.
2. Horton R. CoHERE-a call for a post pandemic health strategy. Lancet. 2020 Apr 18;395(10232):1242.
3. Colaneri M, Sacchi P, Zuccaro V et al. Clinical characteristics of coronavirus disease (COVID-19) early findings from a teaching hospital in Pavia, North Italy, 21 to 28 February 2020. Euro Surveill. 2020 Apr;25(16). doi: 10.2807/1560-7917.ES.2020.25.16.2000460.
4. Harrison N, Hewitt H, Pandya P, Reisel D. How Montgomery is reconfiguring consent in the UK. Lancet. 2018 Jul 14;392(10142):102-104.