This article is from the source 'nytimes' and was first published or seen on . It last changed over 40 days ago and won't be checked again for changes.

You can find the current article at its original source at https://www.nytimes.com/2020/04/03/world/europe/britain-coronavirus-triage.html

The article has changed 32 times. There is an RSS feed of changes available.

Version 17 Version 18
U.K. Backs Off Medical Rationing Plan as Coronavirus Rages U.K. Backs Off Medical Rationing Plan as Coronavirus Rages
(about 16 hours later)
LONDON — Denying lifesaving care to conserve public resources is nothing new for Britain’s National Health Service.LONDON — Denying lifesaving care to conserve public resources is nothing new for Britain’s National Health Service.
In expensive treatments for cancer and other diseases, the health service officially limits what it will spend to postpone a death: 30,000 pounds, or about $37,000, for each year of full “quality” life provided to a patient.In expensive treatments for cancer and other diseases, the health service officially limits what it will spend to postpone a death: 30,000 pounds, or about $37,000, for each year of full “quality” life provided to a patient.
In the case of a pandemic, the public guidance from health officials for more than a decade has been that doctors should prepare to withhold scarce resources from the weakest patients in order to save more of the strong, especially with the use of life-sustaining ventilators.In the case of a pandemic, the public guidance from health officials for more than a decade has been that doctors should prepare to withhold scarce resources from the weakest patients in order to save more of the strong, especially with the use of life-sustaining ventilators.
Yet now that a pandemic has finally arrived, the health authorities this week balked at spelling out exactly how to make those agonizing choices, evidently for fear of a public uproar.Yet now that a pandemic has finally arrived, the health authorities this week balked at spelling out exactly how to make those agonizing choices, evidently for fear of a public uproar.
Barraged with criticism from all sides for its sluggish response to the threat, the government of Prime Minister Boris Johnson has elected to avoid the political pain of disclosing its already-drafted criteria for deciding which patients should be allowed to die of the disease — even those with some chance of survival.Barraged with criticism from all sides for its sluggish response to the threat, the government of Prime Minister Boris Johnson has elected to avoid the political pain of disclosing its already-drafted criteria for deciding which patients should be allowed to die of the disease — even those with some chance of survival.
[Analysis: Coronavirus puts to the fore an improbable U.K. leader: Dominic Raab.][Analysis: Coronavirus puts to the fore an improbable U.K. leader: Dominic Raab.]
The absence of official guidance could effectively force front-line doctors to improvise their own criteria, lawyers and ethicists say, potentially consigning poor, aging or disabled patients to the back of the line.The absence of official guidance could effectively force front-line doctors to improvise their own criteria, lawyers and ethicists say, potentially consigning poor, aging or disabled patients to the back of the line.
Doctors in Northern Italy have already reported withholding life-extending support from patients in order to devote scarce ventilators to those with better odds. Now other European governments and many American states are scrambling to craft similar triage policies in case their hospitals become overwhelmed.Doctors in Northern Italy have already reported withholding life-extending support from patients in order to devote scarce ventilators to those with better odds. Now other European governments and many American states are scrambling to craft similar triage policies in case their hospitals become overwhelmed.
Yet the British government has far more experience and expertise than American states in rationing treatments for medical problems, making its failure to spell out a policy especially striking.Yet the British government has far more experience and expertise than American states in rationing treatments for medical problems, making its failure to spell out a policy especially striking.
“In the U.K., these are decisions by public bodies for which they are publicly accountable,” said David Lock, a lawyer who is advising the British Medical Association on legal and ethical issues. “Therefore, there is an urgent need for a clear framework for doctors to make these decisions on behalf of the public bodies that employ them.”“In the U.K., these are decisions by public bodies for which they are publicly accountable,” said David Lock, a lawyer who is advising the British Medical Association on legal and ethical issues. “Therefore, there is an urgent need for a clear framework for doctors to make these decisions on behalf of the public bodies that employ them.”
Without more careful guidelines, “really terrible decisions could be made,” said Peter Todd, a lawyer who has represented autistic patients who were denied medical treatment by the National Health Service.Without more careful guidelines, “really terrible decisions could be made,” said Peter Todd, a lawyer who has represented autistic patients who were denied medical treatment by the National Health Service.
Senior health officials took initial steps last week to develop such a triage policy, quietly commissioning a small committee of doctors and other experts to help set a specific protocol for access to ventilators, three people familiar with the effort said. The office of the chief medical officer had been expected to issue the guidelines by the end of last week.Senior health officials took initial steps last week to develop such a triage policy, quietly commissioning a small committee of doctors and other experts to help set a specific protocol for access to ventilators, three people familiar with the effort said. The office of the chief medical officer had been expected to issue the guidelines by the end of last week.
After considering whether special panels in each hospital should make such decisions, the committee leaned toward setting a numerical formula ranking chances of survival, much like the calculations British doctors currently use to rank patients seeking liver transplants. Proponents argued that a numerical ranking could lift burdens from front-line doctors while reducing inconsistencies from one hospital to the next.After considering whether special panels in each hospital should make such decisions, the committee leaned toward setting a numerical formula ranking chances of survival, much like the calculations British doctors currently use to rank patients seeking liver transplants. Proponents argued that a numerical ranking could lift burdens from front-line doctors while reducing inconsistencies from one hospital to the next.
On Monday, however, for fear of sowing panic, health officials reversed themselves and decided to put off disclosing the effort at all, people familiar with the project say. Officials argued that the recently imposed policy of strict social distancing might slow the rate of infections enough to avoid the need for such triage.On Monday, however, for fear of sowing panic, health officials reversed themselves and decided to put off disclosing the effort at all, people familiar with the project say. Officials argued that the recently imposed policy of strict social distancing might slow the rate of infections enough to avoid the need for such triage.
Asked about the decisions first to draft and then pull back the triage criteria, representatives of the Department of Heath and Social Care sent an emailed statement: “As the public would expect, we do lots of work to prepare for a number of different scenarios so we are as prepared as possible.”Asked about the decisions first to draft and then pull back the triage criteria, representatives of the Department of Heath and Social Care sent an emailed statement: “As the public would expect, we do lots of work to prepare for a number of different scenarios so we are as prepared as possible.”
Despite official hopes of averting the darkest scenarios, though, doctors say the strains on the British health care system continue to build. Desperate efforts to produce more ventilators have so far failed to significantly expand the number available — currently fewer than 10,000 — and the numbers of those infected continue to climb.Despite official hopes of averting the darkest scenarios, though, doctors say the strains on the British health care system continue to build. Desperate efforts to produce more ventilators have so far failed to significantly expand the number available — currently fewer than 10,000 — and the numbers of those infected continue to climb.
British health officials said Friday that the number of hospital deaths in the previous 24 hours had reached a new high of 684, bringing the total to 3,605. The full extent of infection remained impossible to quantify, in part because testing materials were in such short supply.British health officials said Friday that the number of hospital deaths in the previous 24 hours had reached a new high of 684, bringing the total to 3,605. The full extent of infection remained impossible to quantify, in part because testing materials were in such short supply.
The British authorities began issuing vague pandemic guidance more than a decade ago, telling health care providers to give preference to those most likely to benefit from access to limited resources like ventilators.The British authorities began issuing vague pandemic guidance more than a decade ago, telling health care providers to give preference to those most likely to benefit from access to limited resources like ventilators.
“Everyone matters equally, but this does not mean that everyone is treated the same,” the health department declared in ethical guidance formulated after the H1N1, or swine flu, pandemic in 2009.“Everyone matters equally, but this does not mean that everyone is treated the same,” the health department declared in ethical guidance formulated after the H1N1, or swine flu, pandemic in 2009.
“Even if existing critical care bed capacity can be maximally escalated, during the peak of a pandemic, there may be 10 times as many patients requiring mechanical ventilatory support as the number of beds available,” the health department estimated in pandemic flu guidance first issued in 2009.“Even if existing critical care bed capacity can be maximally escalated, during the peak of a pandemic, there may be 10 times as many patients requiring mechanical ventilatory support as the number of beds available,” the health department estimated in pandemic flu guidance first issued in 2009.
“Additional security measures,” the same document warned, may be needed to protect doctors making triage decisions from the wrath of people whose friends or relatives were denied life-sustaining breathing support.“Additional security measures,” the same document warned, may be needed to protect doctors making triage decisions from the wrath of people whose friends or relatives were denied life-sustaining breathing support.
But such general guidance failed to address many of the most delicate questions, including how to decide which patients stand the best chance of survival.But such general guidance failed to address many of the most delicate questions, including how to decide which patients stand the best chance of survival.
Advocates for the aged warn that older but physically healthy patients may suffer unfairly if doctors use age as a stand-in for resilience, and that decision-making may vary from one hospital to another. Diabetes, heart disease, obesity or other health risks might all be counted differently.Advocates for the aged warn that older but physically healthy patients may suffer unfairly if doctors use age as a stand-in for resilience, and that decision-making may vary from one hospital to another. Diabetes, heart disease, obesity or other health risks might all be counted differently.
Ethicists warn that the poor would probably suffer disproportionately because they are more likely to have pre-existing health problems. Without specific guidelines, they say, the decisions of doctors may be influenced by unconscious bias against ethnic minorities, people with mental disabilities and other groups.Ethicists warn that the poor would probably suffer disproportionately because they are more likely to have pre-existing health problems. Without specific guidelines, they say, the decisions of doctors may be influenced by unconscious bias against ethnic minorities, people with mental disabilities and other groups.
“This has been the most alarming concern for people with disabilities all around the world,” said Catalina Devandas, the United Nations special rapporteur on the rights of persons with disabilities. “The highlight of this drama is that it seems to be the default reasoning of the mainstream society: The lives of persons with disability are not considered to be of as much value.”“This has been the most alarming concern for people with disabilities all around the world,” said Catalina Devandas, the United Nations special rapporteur on the rights of persons with disabilities. “The highlight of this drama is that it seems to be the default reasoning of the mainstream society: The lives of persons with disability are not considered to be of as much value.”
Updated June 30, 2020
Common symptoms include fever, a dry cough, fatigue and difficulty breathing or shortness of breath. Some of these symptoms overlap with those of the flu, making detection difficult, but runny noses and stuffy sinuses are less common. The C.D.C. has also added chills, muscle pain, sore throat, headache and a new loss of the sense of taste or smell as symptoms to look out for. Most people fall ill five to seven days after exposure, but symptoms may appear in as few as two days or as many as 14 days.
Scientists around the country have tried to identify everyday materials that do a good job of filtering microscopic particles. In recent tests, HEPA furnace filters scored high, as did vacuum cleaner bags, fabric similar to flannel pajamas and those of 600-count pillowcases. Other materials tested included layered coffee filters and scarves and bandannas. These scored lower, but still captured a small percentage of particles.
A commentary published this month on the website of the British Journal of Sports Medicine points out that covering your face during exercise “comes with issues of potential breathing restriction and discomfort” and requires “balancing benefits versus possible adverse events.” Masks do alter exercise, says Cedric X. Bryant, the president and chief science officer of the American Council on Exercise, a nonprofit organization that funds exercise research and certifies fitness professionals. “In my personal experience,” he says, “heart rates are higher at the same relative intensity when you wear a mask.” Some people also could experience lightheadedness during familiar workouts while masked, says Len Kravitz, a professor of exercise science at the University of New Mexico.
The steroid, dexamethasone, is the first treatment shown to reduce mortality in severely ill patients, according to scientists in Britain. The drug appears to reduce inflammation caused by the immune system, protecting the tissues. In the study, dexamethasone reduced deaths of patients on ventilators by one-third, and deaths of patients on oxygen by one-fifth.
The coronavirus emergency relief package gives many American workers paid leave if they need to take time off because of the virus. It gives qualified workers two weeks of paid sick leave if they are ill, quarantined or seeking diagnosis or preventive care for coronavirus, or if they are caring for sick family members. It gives 12 weeks of paid leave to people caring for children whose schools are closed or whose child care provider is unavailable because of the coronavirus. It is the first time the United States has had widespread federally mandated paid leave, and includes people who don’t typically get such benefits, like part-time and gig economy workers. But the measure excludes at least half of private-sector workers, including those at the country’s largest employers, and gives small employers significant leeway to deny leave.
So far, the evidence seems to show it does. A widely cited paper published in April suggests that people are most infectious about two days before the onset of coronavirus symptoms and estimated that 44 percent of new infections were a result of transmission from people who were not yet showing symptoms. Recently, a top expert at the World Health Organization stated that transmission of the coronavirus by people who did not have symptoms was “very rare,” but she later walked back that statement.
Touching contaminated objects and then infecting ourselves with the germs is not typically how the virus spreads. But it can happen. A number of studies of flu, rhinovirus, coronavirus and other microbes have shown that respiratory illnesses, including the new coronavirus, can spread by touching contaminated surfaces, particularly in places like day care centers, offices and hospitals. But a long chain of events has to happen for the disease to spread that way. The best way to protect yourself from coronavirus — whether it’s surface transmission or close human contact — is still social distancing, washing your hands, not touching your face and wearing masks.
A study by European scientists is the first to document a strong statistical link between genetic variations and Covid-19, the illness caused by the coronavirus. Having Type A blood was linked to a 50 percent increase in the likelihood that a patient would need to get oxygen or to go on a ventilator, according to the new study.
The unemployment rate fell to 13.3 percent in May, the Labor Department said on June 5, an unexpected improvement in the nation’s job market as hiring rebounded faster than economists expected. Economists had forecast the unemployment rate to increase to as much as 20 percent, after it hit 14.7 percent in April, which was the highest since the government began keeping official statistics after World War II. But the unemployment rate dipped instead, with employers adding 2.5 million jobs, after more than 20 million jobs were lost in April.
If air travel is unavoidable, there are some steps you can take to protect yourself. Most important: Wash your hands often, and stop touching your face. If possible, choose a window seat. A study from Emory University found that during flu season, the safest place to sit on a plane is by a window, as people sitting in window seats had less contact with potentially sick people. Disinfect hard surfaces. When you get to your seat and your hands are clean, use disinfecting wipes to clean the hard surfaces at your seat like the head and arm rest, the seatbelt buckle, the remote, screen, seat back pocket and the tray table. If the seat is hard and nonporous or leather or pleather, you can wipe that down, too. (Using wipes on upholstered seats could lead to a wet seat and spreading of germs rather than killing them.)
If you’ve been exposed to the coronavirus or think you have, and have a fever or symptoms like a cough or difficulty breathing, call a doctor. They should give you advice on whether you should be tested, how to get tested, and how to seek medical treatment without potentially infecting or exposing others.
In the absence of guidelines from Britain’s top health officials, the same body that applies the £30,000 cap on new treatments — the official National Institute for Health and Care and Excellence, usually referred to by the acronym N.I.C.E. — sought to step in. Last week N.I.C.E. advised doctors to prioritize ventilator access in part by consulting a numerical score known as a Clinical Frailty Rating.In the absence of guidelines from Britain’s top health officials, the same body that applies the £30,000 cap on new treatments — the official National Institute for Health and Care and Excellence, usually referred to by the acronym N.I.C.E. — sought to step in. Last week N.I.C.E. advised doctors to prioritize ventilator access in part by consulting a numerical score known as a Clinical Frailty Rating.
But the frailty rating is a measure of physical activity and general self-sufficiency that was designed to evaluate only seniors, not the broader population. Lawyers representing people with autism and other disabilities quickly complained, and N.I.C.E. amended its guidance to specifically rule out any application to younger people or those with learning disabilities or long-term disabilities, though patient advocates argued the changes were insufficient.But the frailty rating is a measure of physical activity and general self-sufficiency that was designed to evaluate only seniors, not the broader population. Lawyers representing people with autism and other disabilities quickly complained, and N.I.C.E. amended its guidance to specifically rule out any application to younger people or those with learning disabilities or long-term disabilities, though patient advocates argued the changes were insufficient.
Then this week the British Medical Association, the main doctors trade group, issued its own general guidelines, arguing that its members and other health care providers should be given special priority. That way they might return to caring for others, the association reasoned.Then this week the British Medical Association, the main doctors trade group, issued its own general guidelines, arguing that its members and other health care providers should be given special priority. That way they might return to caring for others, the association reasoned.
“Decisions about which groups will have first call on scarce resources may also need to take account of the need to maintain essential services,” the medical association said. That should include, it said, “those individuals involved in tackling the immediate health and social care aspects of the pandemic, and particularly those with scarce and irreplaceable skills.”“Decisions about which groups will have first call on scarce resources may also need to take account of the need to maintain essential services,” the medical association said. That should include, it said, “those individuals involved in tackling the immediate health and social care aspects of the pandemic, and particularly those with scarce and irreplaceable skills.”
The association also said that health care providers should prepare not only to withhold life-sustaining treatment but also to actively withdraw it in order to transfer it to others — even when withdrawal might hasten the death of a patient who had been improving.The association also said that health care providers should prepare not only to withhold life-sustaining treatment but also to actively withdraw it in order to transfer it to others — even when withdrawal might hasten the death of a patient who had been improving.
Even if the patient is “stable or even improving,” the association said, a ventilator could be withdrawn if “objective assessment indicated a worse prognosis than another patient who requires the same resource.”Even if the patient is “stable or even improving,” the association said, a ventilator could be withdrawn if “objective assessment indicated a worse prognosis than another patient who requires the same resource.”
Some legal experts, though, argued that patients facing the withholding or withdrawal of respiratory support deserved at least a day in court. British courts should have a chance to rule on triage policies in a test case before they are applied more broadly, said Kathleen Liddell, director of the Cambridge Center for Law, Medicine and Life Science.Some legal experts, though, argued that patients facing the withholding or withdrawal of respiratory support deserved at least a day in court. British courts should have a chance to rule on triage policies in a test case before they are applied more broadly, said Kathleen Liddell, director of the Cambridge Center for Law, Medicine and Life Science.
“This maxim that we should be saving the most number of lives is not complete,” she said. “It has to be while respecting the human rights of the patient.”“This maxim that we should be saving the most number of lives is not complete,” she said. “It has to be while respecting the human rights of the patient.”
Some British doctors are already seeking to reassure frail patients that they will not be left for dead, even if efforts to save them can only go so far.Some British doctors are already seeking to reassure frail patients that they will not be left for dead, even if efforts to save them can only go so far.
If treatment becomes futile, “we will change our focus from cure but most importantly we will continue to care,” Dr. Matthew Morgan, an intensive care doctor in Wales, wrote in an open letter to vulnerable patients published last month in the BMJ, a British medical journal. “We have not forgotten about you.”If treatment becomes futile, “we will change our focus from cure but most importantly we will continue to care,” Dr. Matthew Morgan, an intensive care doctor in Wales, wrote in an open letter to vulnerable patients published last month in the BMJ, a British medical journal. “We have not forgotten about you.”