Physicians Facing Upcoming Peak of Coronavirus Epidemic Will Need to “Mark” Thousands of Patients to Decide Who is Appropriate for Critical Care Treatment Using a Covid-19 Decision Tool Developed for National Health Service.
With approximately 5,000 cases of coronavirus appearing every day and some intensive care departments already approaching capacity, doctors will classify patients according to three parameters – their age, frailty and the underlying conditions – according to a table distributed to clinicians.
Patients with a combined score of more than eight points in all three categories should probably not be admitted to intensive care, according to the Covid-19 decision support tool, although clinical discretion may prevail. decision.
UK surpassed 84,000 coronavirus cases on Sunday and 10,000 hospital deaths with government models showing peak of epidemic now expected in next two weeks, leaving healthcare system facing challenge the most difficult since its creation.
The scale of the pandemic and the speed at which Covid-19 can affect patients has forced community health workers, general practitioners and palliative care workers to speed up difficult conversations about death and end-of-life planning among vulnerable groups.
The NHS scoring system, developed by the government-sponsored National Institute for Health and Care Excellence, reveals that any patient over the age of 70 will be a borderline candidate for critical care treatment. A 71 to 75 year old patient would automatically get four points for their age and probably three on the “frailty index”, bringing their total baseline score to seven points.
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The Covid-19 decision support tool
Any additional “comorbidity”, such as dementia, recent heart or lung disease, or high blood pressure will add one or two points to the score, placing them in the appropriate category for “indoor care” rather than intensive care, and a non-invasive ventilation trial.
Although doctors and caregivers point out that no patient is just a number, the chart nonetheless codifies the process of life and death choices that thousands of NHS doctors will make in the coming weeks.
A NHS front-line consultant sorting out Covid-19 patients said that the “game change” for the assessment of coronavirus patients was that there was no treatment available, which means that doctors can only provide organ support and hope the patient recovers.
“If it was bacterial pneumonia or a bad asthma attack, then it is treatable and you could send this older patient to intensive care,” said the consultant, adding that decisions about the patients were “art and not science” and there would be exceptions for patients who were fairly fit.
“The rating system is just a guide; we make the judgment taking into account a lot of information about the patient’s current “nickname” – oxygenation, kidney function, heart rate, blood pressure – which adds to decision making, “he said.
But it is not only hospital doctors who have to make difficult decisions. General practitioners, hospice workers and families with vulnerable members are also involved.
Last week, the NHS England wrote to all general practitioners asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end-of-life decisions, which led to many difficult conversations. These were made more difficult by the need to conduct them by phone or via Skype to respect the rules of social distancing.
Ruthe Isden, head of health and care at Age UK, the charity, said that the need for haste had troubled many elderly patients, who felt pressured to sign “Do not resuscitate” forms, or DNR.
“Clinicians are trying to do the right thing and these are very important conversations to have, but there is no justification for doing them in a holistic manner,” she said. “This is such a personal conversation and it is approached in a very impersonal way. “
The subject of MNR advice is particularly troubling for individuals and families who want the best care for their loved ones, but often feel that the choices have not been fully explained.
The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering – including broken ribs and brain damage – while prolonging life by just a few days.
Audrey, who cares for her 90-year-old mother in Tyne and Wear in north-east England, explained how her mother signed a DNR prescription during a recent hospital visit, but the one -this remained in place even after his recovery and return. home.
“Mam asked me what CPR is,” recalls Audrey, adding that no one from the hospital had contacted the family, which raised concerns about how her mother’s consent was obtained .
Carole Walford, head of clinic at Hospice UK, a charity that provides end-of-life care to 225,000 families each year, acknowledged the difficulty of addressing the MNR issue, but said the speed at which Covid -19 progresses leaves less time for the subtleties.
Some patients who die within 24 hours, decisions to die at home or to go to hospital or hospice are compressed to require that hospice workers change the way they prepare people for death and the bereaved families.
“The coronavirus pushes us to the limit as we try to stick to the ethics and practice of palliative care,” said Ms. Walford, urging families to understand that intensive care or hospital care may not to be the best treatment.
Admission to the hospital also means no contact with family, making homes – rather than hospices or hospitals – the refuge for many patients.
“It is important that we do not regard this as a decision” either or “. If a person is sedated and put on ventilation, is it better than having him in a department or at home with a different death with dignity – can you always comb your hair, brush your teeth, to hold hands? Said Mrs. Walford.
Despite the focus on NHS capacity building, the front line against coronavirus is often fought in nursing homes and hospices already marked by a decade of austerity that has put enormous pressure on the healthcare system social.
According to the Health Foundation, a charity, public spending per capita faced a shortfall of £ 6 billion in 2018, funding from local authorities shrinking in real terms at a time when the population of over 85 years has increased by more than 14%.
Even before the coronavirus pandemic results in illness reporting for up to 30% of nursing home staff, the combination of spending cuts and low wages – the average full-time worker earns just over 16 £ 000 per year – had left 120,000 vacancies across the sector.
This article has been modified since its publication to clarify that the NHS decision tool was developed by the National Institute for Health and Care Excellence