Over 30,000 people are in hospital in England with Covid. What does this mean?
The British Medical Association says doctors are stressed, anxious about their own health and that of their families, working more than normal hours and possibly beyond their competence in order to avoid serious harm. Final year medical students are fast-tracked, retired doctors are returning to practice. Doctors are working outside their normal specialty. The BMA drily states, “The skills of these professionals may not meet pre-pandemic expected standards of fitness to practise”.
The General Medical Council, appointed to govern doctors’ fitness to practise, reassures doctors that their careers will not necessarily be affected. They will take into account “the stress and tiredness that may affect judgment or behaviour”.
Hospitals lose their ability to admit patients for other matters. It is a terrible time to have a heart attack, stroke or cancer. GPs will be dealing with most health need, and so will cancel non-essential services, and use telephone or video consultations.
Where all facilities, equipment and staff that could be used to meet patient need are at capacity, “resource allocation decisions between individuals would become inescapable”. Rather than meeting individual need, the health service has to “maximise overall benefit”. This means refusing treatment to some patients. Normally, there is an “obligation to persevere in the face of an extremely ill patient”, leading to breaking ribs attempting to resuscitate a patient on ventilation. Some patients may have treatment withdrawn, even if they are slowly improving, to enable others to be treated, who have a “higher survival probability”.
It is lawful and ethical for a doctor to refuse potentially life-saving treatment where someone else is expected to benefit more from it. Doctors are not assessing the suggested value of a person to the community- younger or older, family responsibilities, work eminence- but their capacity physically to benefit. Individual doctors should be making these decisions according to rules set by their employers. The rules should be open and transparent.
Where care is withdrawn, patients will receive symptom management and end-of-life care for the dying. These decisions have a significant emotional effect on health workers.
Triage is a form of rationing of scarce resources. It sorts patients according to needs and probable outcomes. It can identify those who are so ill they are unlikely to survive, who will be given symptom relief. Priority “will be given to those whose conditions are the most urgent, the least complex, and who are likely to live the longest”.
These decisions should not solely be based on age or disability but likelihood of benefiting from available resources. Where patients cannot be admitted to intensive care they will not receive cardio-pulmonary resuscitation (CPR).
Where large numbers of people have apparently equal chances of survival and length of stay in ICU, at first there will be a queuing system- first come, first served. If patients are not improving, there may be a time-limited trial of therapy, and treatment withdrawn. In overwhelming demand, where a patient’s prognosis worsens care may be withdrawn.
Sometimes a patient’s contribution to essential services, where the workforce is severely depleted, may be taken in account. This means that sick doctors may be prioritized. Well, I would not object to that.
Hospitals are reporting shortages of oxygen. Blood oxygen saturation of 95% is considered normal, but in Southend the target was reduced, to 88-92%.
Cases in England are still rising, because of the Conservative government’s ridiculous promises of association indoors over Christmas, and failure to implement lockdown until after schools were opened on Monday 4th January. Deaths will continue to increase for four weeks. Hospitalisations will continue to increase for two weeks. Hospitals in London are overwhelmed. People who could have been saved with normal health resources will die.