UK intensivists are better prepared for the COVID moral test ahead

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.

Taking responsibility for actually making a decision regarding patient prognosis and discussing this with families and moving to comfort care and palliation. Rather than allowing nature to take its long course on an intensive care ventilator (holding death artificially at bay over many days) until an ‘outside force’ intervenes such as cardiac arrest or brain death occurs.

It’s about leadership, it’s about being willing and able to look yourself in the mirror at night, it’s about patient (minimising suffering) and family (not offering false hope) care.
UK intensivists have been trained for this, though the fear of overwhelming numbers and the moral distress we will all feel is very real at the moment.

The tragedy of COVID-19 is that our Southern friends and colleagues are being forced to learn this in days and weeks rather than over a culture change of years. Ethicus 3 will look very different, even after COVID-19.

The USA has its own set of problems (yep, huge ones) as well illustrated in the proposal.
https://www.health.ny.gov/regulations/task_force/reports_publications/docs/ventilator_guidelines.pdf

“A patient’s attending physician provides all clinical data to a triage officer/committee. At Steps 2 and 3, a triage officer/committee examines a patient’s clinical data and uses this information to assign a color code to the patient. The color (blue, red, yellow, or green) determines the level of access to a ventilator.”

Which has been repeated in this week’s NEJM
https://www.nejm.org/doi/full/10.1056/NEJMp2005689?query=RP
Where it is proposed that, “Rationing is performed by a triage officer or a triage committee composed of people who have no clinical responsibilities for the care of the patient.”
This is a derogation of responsibility and it won’t work.

It comes from US system where intensive care doctors work for patients not with patients like we do in the UK.

Sadly, USA intensive care doctors seem not to be used to making patient decisions with families and want someone else to shoulder the moral responsibility.

Or like the NEJM paper says the responsibility in the triage committee will be application of exclusion criteria, such as:

irreversible shock (ah yes, that is sort of obvious)
assessment of mortality risk using the Sequential Organ Failure Assessment (SOFA) score (so its a magic number – Pallis said it right in 1983 “Many Americans have a touchingly naive faith in the supremacy of machines.”
repeat assessments over time, such that patients whose conditions is not improving are removed from the ventilator. (Ok I accept this one but that’s the day job of an intensivist not a triage committee)

NEJM also says, *‘Similarly, the physicians, nurses, or respiratory therapists who are caring for the patient should not be required to carry out the process of withdrawing mechanical ventilation; they should be supported by a team that is willing to serve in this role and that has skills and expertise in palliative care and emotional support of patients and families.”*Once again delegating responsibility and care to others.

I wonder if the problem is that intensivists in the USA not only work for patients and their families (rather than with) they also work for ‘ologists’.
Cardiologist, neurologist, pulmonologist and surgeons (not an ‘ologist’ but you get the idea).

See open (USA) and closed (UK, Australia) models of intensive care.

Who is even going to be on these triage committees? I would be astonished if it is an intensivist – someone who actually understands intensive care?

Leaving all that aside it just won’t work.

This committee will be death by magic number rather than individualised patient care.
They will not have all the facts and outcomes of relevance at their disposal to make individual patient care decisions.

Front line doctors will quickly learn they should just duck responsibility:
Family saying please save my relative.
Doctor says - if it was me yes - but not me - it is the panel that decides.

Families will quickly learn to game the system – learn the rules that are being applied and lie.

If you want to know who is better placed for the moral test of our time?
It’s here in the UK.

We have been making patient centred decisions for years in intensive care.
And we have the national leadership to support it.

Look and compare UK national intensive care guidance:

Ensure you have a shared understanding of what the problems are (e.g Covid is suspected; known heart disease requiring frequent hospital admissions with limited exercise tolerance, this means the patient is at high risk of severe illness and may die).
Discuss what the likely outcomes are. Try to help the patient identify which outcomes are most important to them and their family.
Be clear about what treatments are being proposed or available. If a treatment is not considered sufficiently beneficial to be offered, this will need communicating carefully and compassionately.
Agree the proposed treatment plan and care you will be organising, for example treatment on the ward, treatment on intensive care, or links to palliative care.
Include discussion of specific treatments that are important to the patient, e.g CPR.

UK intensive care doctors will not be sacrificing what my own ethics committee recently restated for our Trust and the NHS; that even in a time of global pandemic we must prioritise the ethics of:

Individualised care decisions
Shared decision-making
Explanation
Meet the health needs of non COVID-19 patients
Have trust in NHS staff

Dale