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Coronavirus: Ventilators may be taken away from elderly patients and given to those more likely to survive

Relevant factors predicting survival include the severity of acute illness, presence, and severity of underlying medical conditions
UPDATED APR 2, 2020
(Getty Images)
(Getty Images)

Amid the ongoing coronavirus pandemic, one thing has become clear: resources are scarce, they are becoming increasingly restricted and choices of available care are limited. Recent guidelines from the British Medical Association (BMA) on ethical issues arising during the COVID-19 pandemic highlight this grim reality where doctors may be forced to make hard choices.

Health professionals may be obliged to withdraw treatment from some patients to enable the treatment of other patients with a higher survival probability, says the document issued by BMA. This may involve withdrawing treatment from an individual who is stable or even improving but whose “objective assessment” indicates a worse outcome than another patient who requires the same resource.

“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,” says the document titled ‘COVID-19 - ethical issues. A guidance.’

The experts argue that as seen in China, Italy, and Spain, deaths frequently follow hospitalization and critical care interventions. In Wuhan, 5% of those infected were admitted to ICU, and 2.5% required mechanical ventilation. It is possible therefore that restrictions in the availability of mechanical ventilation may become severe, says the document. 

The guidance explains that to maximize 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. Relevant factors predicting survival include the severity of acute illness, presence and severity of underlying medical conditions and, where clinically relevant, patient age.

Those patients whose probability of dying, or of requiring a prolonged duration of intensive support, “exceeds a threshold level” would not be considered for intensive treatment, though they should still receive other forms of medical care. 

“Although not everyone will become ill at once, the initial wave of illness can be extremely rapid, over a few days to a few weeks. In these circumstances, if demand outstrips the ability to deliver to existing standards, more strictly utilitarian considerations will have to be applied, and decisions about how to meet the individual need will give way to decisions about how to maximize overall benefit. We know that health professionals would find decision-making in these circumstances ethically challenging,” say experts.

National Health Service staff wait in their cars to take a coronavirus test at a drive through centre in north London (AP Photo/Frank Augstein)

While the Association does not mention any age cut-off, it says that older patients with severe respiratory failure may have a very high chance of dying despite intensive care, and consequently have a lower priority for admission to intensive care. 

“As such, some of the most unwell patients may be denied access to treatment such as intensive care or artificial ventilation. This will inevitably be indirectly discriminatory against both the elderly and those with long-term health conditions, with the latter being denied access to life-saving treatment as a result of their pre-existing health problems. A simple ‘cut-off’ policy with regard to age or disability would be unlawful as it would constitute direct discrimination. A healthy 75-year-old cannot lawfully be denied access to treatment on the basis of age,” says BMA.

The guidance says that the presence of underlying health conditions may exclude individuals from eligibility. In these circumstances, it may be necessary to discontinue treatment that has already been started, as there are patients in need whose outcomes are likely to be more favorable. 

Doctors get instructions on a ventilator at the University Hospital Eppendorf in Hamburg Germany 
(Axel Heimken/Pool Photo via AP)

Further explaining, the BMA says that if services are overwhelmed during this pandemic, health providers will put in place — or expand — systems of triage. Triage is a form of rationing or allocation of scarce resources under critical or emergency circumstances where decisions about who should receive treatment must be made immediately because more individuals have life-threatening conditions than can be treated at once.

“Triage sorts or grades persons according to their needs and the probable outcomes of intervention. It can also involve identifying those who are so ill or badly injured that even with aggressive treatment they are unlikely to survive and should, therefore, receive a lower priority for acute emergency interventions while nonetheless receiving the best available symptomatic relief,” it says.

The guidance warns it is possible one could reach a point where the decisions made in triage will determine whether potentially large numbers of individuals will receive life-saving treatment or not.

“In the setting of overwhelming demand, if patients’ prognosis worsens after admission to intensive care — sufficiently that, if it had been the case prior to admission, the treatment would not have been commenced — it should be withdrawn and the same facility offered to another patient reasonably believed to have the capacity to benefit quickly, says BMA.

The BMA, however, emphasizes that where a decision is made to withhold or withdraw some forms of treatment from patients on the grounds of resource allocation, it is crucial that those patients still receive “compassionate and dedicated medical care and attention,” as far as possible in the circumstances. This should include appropriate symptom management and, where patients are dying, the best available end-of-life care.

“If it becomes necessary to make these decisions, they are likely to have a significant emotional impact on health workers, both in the short term and, in some cases, more enduringly,” say health experts.

According to the John Hopkins tracker, so far, 939,436 cases have been reported globally, and over 47,270 have died in the pandemic. In the UK, 29,865 cases have been reported and over 2,352 have died.

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