COVID 19 Blog

Updated analysis in light of conflicting advice The Resuscitation Council and Public Health England regarding chest compressions being an aerosol generating procedure.

Is it unethical to ask staff at some risk due to health conditions to be patient facing, when their pregnant colleagues who are at no/very little additional risk (on the basis of very limited evidence) are given the choice of being patient facing?
This Moral Balance Analysis was carried out by Nottingham University Hospitals NHS Trust’s Ethics of Clinical Practice Committee on the 8th April 2020.

The full analysis can be downloaded here.

CRITCON Levels are based (though for some reason are in reverse order) to DEFCON levels which tells us how close we are to nuclear war.

They have been modified for use by critical care networks in Winter Flu to describe the strain an ICU is under. See London Critical Care Network example.
CRITCON levels for Winter Flu do not work as well in pandemic situations. The difference is that the CRITCON levels for Winter Flu were designed to describe the current number of ICU patients and how they may, or may not be exceeding normal bed capacity. The desired ambition is to get the numbers of patients back within the normal bed state.

Mass Casualties

Pandemic

We need different ethics.
And the answer is not reverse triage!

We have created a new one-page version of MORAL Balance.

It lacks the Balancing Box - but may allow for quicker use and documentation.

First - be clear about what decision you are trying to make.

Second - identify and Make sure of the facts and Outcomes of Relevance to the Agents (an agent is anyone who cares about or is impacted by the decision).

Third - Level out the arguments. Try and achieve a Balanced decision.

The below is the Ethicus 2 study. In the UK, for patients who die in the ICU, intensivists are nearly two times more likely to have made a treatment withdrawal decision compared to our Southern colleagues in Italy and Spain.

In Ethicus 1 (2003) we were 2.6 times more likely.

What can be seen is that Southern intensive care has become more like Northern intensive care over time.

MORAL Balance up on the Journal of Medical Ethics Blog.
Our thanks to David Shaw for leading this piece.

There is lots of discussion in ICU circles about reverse triage.

It goes something like this:
“Two people need a ventilator, one is in the emergency department, young, needing intubation, the other is on the ICU, elderly perhaps, not doing so well. If they had both arrived into the ED simultaneously and there was only one ventilator; the ICU doctor would have triaged to treat the young person first. So, given the actual scenario, reverse triage suggests the ICU doctor should go up to ICU and remove the ventilator and adopt palliation for the current patient already in the ICU, to make the ventilator available for the young person in the emergency department who has a greater chance of benefiting.”

Adapted from NHSBT’s Deceased Donation Course for Intensive Care Medicine Trainees, which has provided end of life communication training to over 350 delegates and faculty. Download.

Accuracy #

• say truth, admit if you don’t know
• it is ok to mention resource constraints and its decision impact

Brevity #

• don’t fill the silence with your voice
• in grief thinking slows, even on the phone allow silence
• listen and give time for questions, “What questions do you have?

Clarity #

• use unambiguous language, simple non-medical words
• “can’t save, going to die, dying, won’t suffer”

Delivery #

• structure as a narrative - warning shot (sets scene), circumstances (explains reasons, telegraphs decision), decision then silence
• use appropriate non-verbal technique, if phone tone of voice

Empathy #

• explicitly state your sympathy “I am so sorry” “it is awful”
• give comfort

#

Additional Hints

There is an episode in South Park – can’t remember which one, which goes something like this….

A blizzard hits South Park and some adults are stranded in a building.They propose drawing straws and cannibalism in order to stay alive.“What are you diabetic,” the short straw drawer begs.
They had only been stranded for a few hours!

COVID-19 will hit different regions and different hospitals, differently.
We must individualise our ethical response and use of resources.
Some patients – even non COVID patients – need our help now.