COVID19 will not get terrible everywhere, in fact it is unlikely to do so in most places. However data is now showing that where it does suddenly get bad, it can overwhelm local resources quickly, which is a disastrous outcome.
The Intensive Care (and Emergency Department) world is well used to making decisions about whether someone would benefit from their particular skills and care.
No-one these days goes to ICU simply to prolong life or have futile procedures and medication. At least that is the intended best practice.
We have seen some institutions in Wuhan and Lombardy become overloaded and language like triage, ethical framework, resource allocation, flatten the curve, ventilators and war footing have become part of our every day conversation. Spain and parts of the USA are the ones to watch next.
The Intensivists of Australia and the nurses and others who work in ICUs are among our most dedicated and educated professionals.
Compassion and respect for patients and avoiding futile treatment comes first.
SOME factors they will be taking into account when deciding if a patient with COVID is suitable for ICU include
- age – over 80 will look very closely at usual quality of life (in Italy this age was dropped to 65 then 60)
- high care residents over 80 probably will not be transferred to hospital
- any significant other disease such as dementia or advanced life limiting cancer – for these patients their regular carers will be encouraged to establish clear goals of care
- what ICU capacity is available
It is likely that treatment will be withdrawn, and the patient provided only with medication to keep them comfortable, if their outlook becomes dismal (under 30% chance of survival, high chance of disability with survival) as a result of multiple organ failure.
For example, if they have severe pneumonia, are needing drugs to support blood pressure, renal failure and myocarditis (inflammation of the heart muscle) then the prognosis is poor and further active treatment is not in the patient’s best interest nor is it an effective use of resources in a limited setting.
In terms of system planning the ethical issues include considering what patients can be kept in same areas as COVID patients, therefore risking a chance of cross infection. This is a consideration of how best to manage the cohorts of different patients.
The issues affecting staff will be patient to carer ratios (typically one ventilated patient to each nurse only, but here it may be 2 or more), and what will happen if Personal Protective Equipment runs out. Some staff will then refuse to work, which is their right and obligation of course, while others will put themselves at unreasonable risk of becoming infected. This is one very important thing that is causing us to recommend delays until adequate PPE is definitely available to treat a lot of severe cases.
Having time to consider and remedy many of these issues is part of the reason we want to use social interventions to slow the disease spread, buying us time to get this right.
references to be released this week