By Francois-Xavier Goudot and Sandrine Bretonnière.
It is still too early to predict how long and how many phases we are going to experience with the Covid-19 pandemic. In the wake of 2020, the rapid and massive worldwide dissemination of the virus induced physicians, ethicists and public health authorities – each at their national level – to focus on triage and its ethical stakes : when resources became scarce (which seemed unavoidable), who would be admitted in the ICU? Should basic guidelines be revised? Using what criteria?
As we face a resurgence of Covid-19 cases in the fall of 2020, the public health debate in France again focuses on ICU beds, of potential triage but also on the allocation of resources between Covid+ and Covid- patients: to what extent should surgeries, chemotherapies and other medical acts be (again) rescheduled? The ethical issues of justice and equitable access to healthcare resources challenge and inform public policy and decisions (curfew, lockdown, etc.).
The Covid-19 pandemic is not only about triage and access to the ICU, however; other, less obvious, ethical issues are at stake. Futility is one of them, particularly in non-ICU Covid+ wards. It was not discussed during the first phase of the Covid-19 crisis. As the pandemic gains new momentum, it is key to address it. Based on clinical observations in a French hospital, we will argue here that futile treatment was and remains a high risk for those patients who are cared for in non-ICU beds.
Mr P. is 92 years old. He resides in his flat, with the help of two persons to support him in his daily activities. He is treated for diabetes and hypertension. He contracts Covid-19; he is admitted in the hospital a week later for dyspnea. He is cognitively impaired as a result of the SARS-CoV-2 infection. He has no living will and no proxy. His medical situation rapidly deteriorates. He soon needs oxygen supply with high flow nasal canula. He resists the oxygen treatment; the medical team decides to tie him up to his bed and to sedate him with low doses of benzodiazepine and morphine, to be able to treat him. This regimen is maintained for 12 days, at which point he dies.
This situation occurred in April 2020 in a non-ICU Covid+ ward in a French hospital. At the time, physicians found it difficult to identify the limits of medicine, in its – and their – capacity to save patients in this emergency period fraught with uncertainty and extreme social pressure to combat the pandemic.
What has changed since then? Physicians comprehend the disease better, treatment regimen have been protocolized (corticosteroids, thromboembolic prophylaxis, high flow nasal cannula oxygenotherapy), positively impacting mortality. But the bottom line remains the same: no curative treatment is available, the evolution of the disease is unpredictable. As the number of patients increases again, the risk of futility in Covid+ wards resurfaces. This risk of administering futile treatment was and still is grounded in two factors: intensity and duration of treatment.
How can we deal with this risk? We suggest that a systematic iterative process be put in place on Covid+ wards to evaluate on a regular and frequent basis the benefit or lack thereof of treatment regimens, as is done on ICU wards. In other words, the principle of non-maleficence must be underscored and be made operational to counteract the risk of futile treatment and of suffering of patients. This means asking the following questions:
For each patient, how much oxygen, using which device, should be delivered ? What does this patient actually want? What does her/his proxy have to say about the situation?
How long should this treatment regimen be maintained? This is the hard question because there is no objective medical data to answer it. However, physicians can rely on the patient’s wishes or what her/his proxy indicates as well as on the general clinical state of the patient. As in the ICU, the question of withdrawing or withholding treatment must be asked and discussed.
Pandemics are not an ethics-free parenthesis in modern medicine. The recurrent debates on triage remind all stakeholders of the key role of ethics. But these deliberations should not be limited to those topics. The medical community needs to remain aware of the basic ethical framework and the essential critical thinking that guide its medical practice. It is as crucial today as it was yesterday and will be tomorrow that physicians retain the acute awareness that their role is also to recognize that a treatment may be futile for a particular patient at a given point in time. When that is the case, the treatment must be stopped and the patient appropriately cared for, until death if need be. The specific situation brought upon the medical community by Covid-19 stresses that the performativity of an iterative ethical reasoning in non-ICU wards can be a relevant antidote to futility.
Authors: Francois-Xavier Goudot* and Sandrine Bretonnière**
*Cardiology Department, Hôpitaux Universitaires Paris Seine Saint-Denis, Assistance Publique des Hôpitaux de Paris (APHP), Paris France.
**Centre national des soins palliatifs et de la fin de vie, Paris France.
Competing interests: None declared