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Ventilators may be taken from stable patients for healthier ones, BMA says Virus patients more likely to die may have ventilators taken away
(about 7 hours later)
Doctors set out ways care may have to be rationed if NHS becomes overwhelmed BMA doctors set out ways care may have to be rationed as UK braces for sharp rise in deaths
Coronavirus patients with a poor prognosis could be taken off a ventilator even if they are stable or improving to make it available for someone else deemed more likely to survive, under guidelines drawn up by UK doctors. Stable coronavirus patients could be taken off ventilators in favour of saving those more likely to survive, it emerged on Wednesday, as another sharp rise in deaths left the UK braced for the outbreak to reach up to 1,000 deaths a day by the end of the week.
That is one of the ways potentially life-saving care may have to be rationed if the NHS becomes overwhelmed with coronavirus cases, according to a document published by the British Medical Association on Wednesday. In a stark new document issued by the British Medical Association as the death toll rose by 563, doctors set out guidelines to ration care if the NHS becomes overwhelmed with new cases as the outbreak moves towards its peak.
Under the proposals, hospitals may have to impose “severe” limits on who is put on a ventilator, and large numbers of patients could be denied care. The new toll brought the overall total to 2,352, an increase of 31% on Tuesday’s figure. If the total continues to grow in line with increases over the last week, it is on course to go past 1,000 new deaths recorded each day within three to four days.
The doctors’ union suggests older people and those with an underlying illness may not get treatment that could save them, with younger, healthier patients given priority instead. Under the proposals, designed to provide doctors with ethical guidance on how to decide who should get life-saving care when resources are overstretched, hospitals would have to impose severe limits on who is put on a ventilator.
The document outlines how doctors may withhold or withdraw care that could keep someone alive because another patient is deemed more needy and more likely to benefit. Large numbers of patients could be denied care, with those facing a poor prognosis losing the potentially life-saving equipment even if their condition is improving.
The proposals are likely to prompt a vigorous debate about some patients not being given a chance to stay alive once their lungs collapse as a result of the infection. The BMA suggested that younger, healthier people could be given priority over older people and those with an underlying illness may not get treatment that could save them, with younger, healthier patients given priority instead.
The document explains that the guidance has been drawn up because when the outbreak peaks “it is possible that serious health needs may outstrip availability and difficult decisions will be required about how to distribute scare lifesaving resources”. The document explained that the guidance has been drawn up because when the outbreak peaks “it is possible that serious health needs may outstrip availability and difficult decisions will be required about how to distribute scare lifesaving resources”.
The limit on the availability of healthcare and the scale of the outbreak may mean that “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”, it says. The BMA published its proposals amid concern over limits to NHS resources, with officials admitting on Wednesday that only 30 of the 30,000 new ventilators needed as the outbreak escalates will be available by next week.
“Health professionals may be obliged to withdraw treatment from some patients to enable treatment of other patients with a higher survival probability. This may involve withdrawing treatment from an individual who is stable or even improving but whose objective assessment includes a worse prognosis than another patient who requires the same resource.” The proposals came out as:
The paper is intended to give the UK’s 240,000 doctors ethical guidance on how to manage the difficult decisions the pandemic could throw up about which patients should or should not receive treatment at a time when the NHS has had to introduce service rationing. • A retired hospital medical director, Alfa Saadu, became the latest doctor to die of the virus after volunteering at a Hertfordshire hospital at the age of 68.
It says the NHS’s limited supply of intensive care beds will inevitably mean that doctors will have to refuse access to some people, especially those with one or more underlying health conditions and those who are older, though it does not specify an age threshold. • New applications for universal credit approached 1m within two weeks, a rise of more than 500% that dwarves the increases seen during the financial crisis.
• The Ministry of Defence called up 3,000 military reservists to provide medical and logistical support to the NHS.
• Italy extended its lockdown to 13 April but recorded its lowest death toll in more than a week, sparking hopes that the outbreak there could be reaching a plateau.
• The UN secretary general Antonio, Guterres, described the global pandemic as “the most challenging crisis we have faced since the second world war”.
The Department of Health and Social Care said as of 9am on 1 April, a total of 152,979 people had been tested, of whom 29,474 were diagnosed as positive – an increase of 4,324 on the previous day.
London continues to report the highest number of deaths proportionally, accounting for more than a third of England’s total. NHS trusts in the capital have now registered 728 deaths from coronavirus.
But the figures do not provide a precise picture of the deaths within 24 hours, as a number of deaths announced in Wednesday’s figures occurred earlier in March.
The BMA paper, which is intended to help the UK’s 240,000 doctors manage the difficult decisions the pandemic could throw up, explores a range of circumstances that could pose them with severe ethical dilemmas. It also suggests that patients who work in vital services and industries including the NHS, utilities and telecoms may be deemed a priority for an ICU bed.
In another suggestion that could prove controversial, the document said that ICU patients who do not improve or worsen after admission may have their treatment withdrawn under a new “capacity to benefit quickly” approach.
The document said the NHS’s limited supply of intensive care beds will inevitably mean that doctors will have to refuse access to some people, especially those with one or more underlying health conditions and those who are older, though it does not specify an age threshold.
It does not list the illnesses but they are likely to include heart problems, kidney disease, diabetes or a pre-existing lung condition such as COPD. One in four Britons have at least one such chronic illness.It does not list the illnesses but they are likely to include heart problems, kidney disease, diabetes or a pre-existing lung condition such as COPD. One in four Britons have at least one such chronic illness.
“To maximise 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 or extracorporeal membrane oxygenation,” it says. “To maximise 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 or extracorporeal membrane oxygenation,” it said.
“Relevant factors predicting survival include severity of acute illness, presence and severity of comorbidity and, where clinically relevant, patient age. Those patients whose probability of dying, or requiring a prolonged duration of intensive support, exceeds a threshold level would not be considered for intensive treatment, though of course they should still receive other forms of medical care.” “Relevant factors predicting survival include severity of acute illness, presence and severity of co-morbidity and, where clinically relevant, patient age. Those patients whose probability of dying, or requiring a prolonged duration of intensive support, exceeds a threshold level would not be considered for intensive treatment, though of course they should still receive other forms of medical care.”
Hospitals across the UK have been increasing their supply of ICU beds in recent weeks to give them as much capacity as possible to deal with an expected “tsunami” of Covid-19 patients. They have set up overspill ICUs in operating theatres and wards usually used for other patients. However, the NHS still does not have the number of ventilators it needs and is having to deploy doctors and nurses who usually treat other types of patients to boost their intensive care workforce. Rationing could become even tighter as the pandemic progresses, the document stated. “Depending upon the nature of the pandemic, there may be a need during its progress to shift from one level of service rationing to a more or less severe one,” it said.
In other suggestions that may prove controversial, the BMA’s guidance says: The BMA guidelines for doctors came as Public Health England finalises an updated document setting out what protective kit should be worn in different medical settings, which it hopes will dispel the confusion, alarm and fear among frontline NHS staff.
Patients in ICU who do not improve or worsen after admission may have their treatment withdrawn under a new “capacity to benefit quickly” approach, and their place may be given to another patient thought likely to do better. Sources involved said that the document, due out on Thursday, represents a partial revision of guidance which led to PHE facing a barrage of criticism from groups representing doctors, murses, midwives and other NHS staff.
People working in vital services and industries such as the NHS, emergency services, utilities and telecoms may be deemed a priority for an ICU bed. They accused PHE of downgrading advice issued by the World Health Organization about which situations need full PPE – double gloves, surgical gown, FFP3 extractor mask and a visor or goggles – and which others need just a surgical mask, apron and single pair of gloves.
Patients with poor underlying health, such as a history of severe respiratory failure, are unlikely to go on to a ventilator or into ICU. Sources said that PHE’s revised, final guidance, developed after discussions with about 1,000 doctors and medical groups, will increase the number of settings in hospitals where full PPE should be worn because of the risk of contracting the coronavirus and also the type of dealings with patients when both GPs and ambulance crews should wear either full PPE or the more limited form.
Rationing could become even tighter as the pandemic progresses, the document states. “Depending upon the nature of the pandemic, there may be a need during its progress to shift from one level of service rationing to a more or less severe one,”, it says.