Life or death choice

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Covid-19
Covid-19

The criteria to ration ventilators and critical care beds once the surge of Covid-19 patients hits the country’s hospitals has caused an ethical nightmare for medico-legal ethicists.

With guidelines already issued by the Critical Care Society of Southern Africa in the event that the demand for ventilators will be greater than the available units, a local ethicist has added his input, saying the measures are justifiable in a pandemic.

The document suggests several stages of assessment and scoring for all patients in need of ventilators — not only those with Covid-19 — taking into account each individual’s frailty and medical history. In the event of a “tie” between two patients, it suggests the younger person should be prioritised.

It also proposes “heightened priority” to people “who perform tasks that are vital to the public health response — specifically, those whose work supports the provision of acute care to others”.

South Africa has about 7 000 critical care beds, of which 3 000 are not occupied at any one time, and about 6 000 ventilators.

Medico-legal ethicist Professor Jerome Singh said Covid-19 may tragically impact those resources, resulting in deaths that would have been preventable under normal circumstances.

“It is evident from the experience of advanced economies, such as Italy, Spain and the United States, that critical care resources in SA, which are already under resourced, could experience unprecedented strain if Covid-19’s presence in SA mirrors the exponential growth patterns seen elsewhere.

“The rationing of intensive care beds and ventilators will be crucial to mitigating this scenario,” added Singh.

The guidelines are based on the maxim “doing the greatest good for the greatest number”, rather than the traditional focus of medical ethics, individual well-being, and include a number of triaging steps.

After confirming if a patient wants intensive care — possibly in a living will in which the patient has set out their wishes — an assessment should be made about whether it will be beneficial.

The next step is to score each patient on the clinical frailty scale with those scoring six or above excluded from intensive care.

Singh said the scale was good at detecting “older adults at high risk of complicated treatment and prolonged longer stays”, but its application was not limited to such patients.

Those who make the cut will then have a sequential organ failure assessment (Sofa) that looks at the likelihood of them surviving until they are discharged from hospital.

Their prospects of long-term survival will also be assessed based on the presence or absence of other medical conditions (comorbidities) like diabetes, hypertension, cardiac disease, chronic lung disease, HIV and moderate Alzheimer’s disease.

The short-term and long-term scores will be combined and those with the lowest scores — giving them a higher likelihood of benefiting from critical care — will be placed in one of three priority groups: red (high), orange (intermediate) and yellow (low).

According to the guidelines, “all patients are eligible to receive critical care beds and services ... but available resources will be allocated according to priority score”.

In the event of a tie, the guidelines propose four age groups, in descending order of priority — 12 to 40, 41 to 60, 61 to 75 and 75-plus. The reason for this is based on the goal to give individuals equal opportunity to pass through all stages of life: childhood, young adulthood, middle age and old age.

“The justification for this principle does not rely on considerations of one’s intrinsic worth or social utility. Rather, younger individuals receive priority because they have had the least opportunity to live through life’s stages.

“Evidence suggests that when individuals are asked to consider situations of absolute scarcity of life-sustaining resources, most believe younger patients should be prioritised over older ones,” the guidelines say.

Health workers given heightened priority “should be broadly construed to include those individuals who play a critical role in the chain of treating patients and maintaining societal order”.

Singh said while it was not clear how clinicians would be able to decide who to put in this group amid a pandemic surge, such prioritisation is ethically defensible.

“This should be implemented to preserve a highly skilled and limited healthcare resource during the pandemic, and beyond,” added Singh.

Real-time availability of critical-care resources and the predicted volume of new cases presenting for care immediately thereafter should dictate the determination.

Patients admitted to critical care should be reassessed after 48 hours, then daily, with those showing improvement continuing to receive critical care services.

“If there are patients in the queue for critical care services, then patients who upon reassessment show substantial clinical deterioration ... that portends a very low chance of survival, should have critical care withdrawn, including discontinuation of mechanical ventilation, after this decision is disclosed to the patient and/or family,” reads the guidelines.

They also stipulate that these patients should then receive “medical care including intensive symptom management and psychosocial support”.

Where available, specialist palliative care teams will be available for consultation with families.

Such decisions, said Singh, were ethically defensible during a pandemic, although they would have to be made “virtually instantaneously” if a surge of Covid-19 patients hit the health sector.

frailty scale:

1. Very fit – people who are robust, active, energetic and motivated. These people commonly exercise regularly. They are among the fittest for their age.

2. Well – people who have no active disease symptoms but are less fit than category one. Often, they exercise or are active occasionally.

3. Managing well – people whose medical problems are well controlled but are not regularly active beyond routine walking.

4. Vulnerable – while not dependent on others for daily help, often symptoms limit activities. A common complaint is being “slowed up” and/or being tired during the day.

5. Mildly frail – these people often have more evident slowing, and need help in high order IADLS (finances, transportation, heavy housework, medications). Typically, mild frailty progressively impairs shopping and walking outside alone, meal preparation and housework.

6. Moderately frail – people need help with all outside activities and with keeping house. Inside, they often have problems with stairs and need help with bathing and might need minimal assistance with dressing.

7. Severely frail – completely dependent for personal care, from whatever cause (physical or cognitive). Even so, they seem stable and not at high risk of dying within six months.

8. Very severely frail – completely dependent, approaching the end of life. Typically, they could not recover even from a minor illness.

9. Terminally ill – approaching the end of life. This category applies to people with a life expectancy of less than six months, who are not otherwise evidently frail.

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