By Anne Slowther and Sarah Mitchell
As the number of cases and number of deaths from COVID-19 continues to rise exponentially much of the health care response, and subsequent bioethics commentary, has focussed on provision of intensive care for critically ill patients who require ventilation. This is understandable given the mismatch between the number of people who will require ventilation and critical care management to survive the disease and the number of ventilators/critical care beds currently available. Ethical frameworks and guidance to ensure fair and consistent decision making around prioritisation of intensive care resources and provide support for clinicians making these decisions are needed urgently. However, the ethical implications of these decisions, and the need for them, ripple out beyond the hospital, into primary care and the wider community.
A General Practitioner (GP) does not make ICU admission decisions. However, if local ICU beds are under extreme pressure and their very sick patient has a very small chance of surviving intensive care, the GP may need to consider whether the patient should be admitted to hospital at all or should remain at home with the very real likelihood that they will not survive. As hospitals reconfigure their resources to focus on intensive care there will be less availability of lower level care provision which will in turn need to be prioritised. There is an ethical imperative to consider the impact of these reconfigurations on clinical decision-making and the provision of care to patients across the wider healthcare system. Decisions cannot be made solely on clinical scoring systems and likelihood of surviving intensive care. Other considerations must be part of a holistic assessment of what is the best treatment option for the individual patient. For example, whether there is adequate family or social care available to support the patient at home at the end of their life, or the fact that if admitted to hospital they may not be able to see their family because of visiting prohibitions. A transparent, ethically justifiable process for decisions about treatment will be required, whether treatment decisions are made in the patient’s home or in the emergency department.
GPs and other members of the primary care team will need to have conversations with many of their patients who are at increased risk of severe disease about potential outcomes and available treatment options in advance. Patients should be able to express their view and contribute to decisions about their own care while they are well enough to do so, to enable the best possible decision to be made should their condition deteriorate. Patients who are aware that they have a life limiting condition may already have had advance care planning conversations, but many people in high-risk groups for COVID-19 may not have considered the possibility of future treatments limitation decisions. These conversations with patients can be challenging, require great sensitivity, and would normally be done face to face. How do primary care clinicians hold compassionate and empathetic conversations about treatment limitation with patients and families when remote consultations are the norm and families may be self-isolating?
Many people will die as a result of COVID-19, including those for whom intensive care treatment is unsuccessful, those for whom intensive care treatment is not initiated because they are very unlikely to benefit from it, and those patients where a decision is made that end of life care at home is the most appropriate treatment. Palliative and end of life care resources including drugs, drug delivery systems such as syringe drivers and trained staff to provide care in the community are also limited and there is likely to be a similar demand/supply mismatch as that seen for ventilators and ICU resources. Much of the demand for these services will fall to Primary Care as patients are either not admitted or are discharged home from hospital for palliative care. GPs and community healthcare teams will face difficult decisions around allocating scarce resources, protecting their staff who are providing home care, and supporting families to provide care when professional care is less available.
While maximising benefit by saving lives, or life years, is understandably seen as a priority in a pandemic that threatens hundreds of thousands lives, other benefits such as a dignified and peaceful death should not be discounted and other ethical principles, such as fairness and respect for persons, should be included in decision-making processes. A challenge for all healthcare professionals, but perhaps particularly those providing primary care, will be upholding a duty to care for each individual patient in the context of overwhelming need for limited healthcare resources.
Authors: Anne Slowther1, Sara Mitchell2
1 Professor of clinical ethics Warwick Medical School, clinical ethicist University Hospital Coventry and Warwickshire, UK
2 GP White House Surgery, Sheffield, Yorkshire Cancer Research Connects Fellow, University of Sheffield, Macmillan GP and Clinical Lead for Children and Young People, Sheffield CCG, UK
Competing interests: none