The scale of coronavirus in the UK means we need a clear framework on who should be treated The most certain feature of a pandemic is uncertainty. For NHS health workers, this is all around us. Many doctors are now being “side-skilled” (a new term) so they can help provide intensive care to patients. It’s important that the public understand what intensive care units (ICU) are, as this will make clear what faces us in the coming weeks and months. In all major hospitals, the ICU is for patients with an illness that immediately threatens their survival. Treatment is provided with machines and drugs that take over the roles of their organs, while sedation suspends the patient and allows their body to recover. These kinds of treatment cannot happen on normal wards. Skilled care is provided by an army of nurses, physiotherapists, pharmacists and dietitians. ICU doctors work together with radiologists, microbiologists, surgeons, cardiologists, physicians and pathologists. This level of intensity is normal for ICUs, but Covid-19 isn’t. Coronavirus patients needing ICU will be among the sickest – almost all will need breathing support, or what’s known as “level 3” care. On top of this, precautions to prevent infection among staff and other patients will increase work intensity even further. increase sevenfold. In every NHS hospital, normal activity is being diverted towards this end – but it requires planning on four major fronts: space, staff, stuff and standards. The space required in ICUs is enormous: it includes side rooms for safe care, facilities such as oxygen, air, suction, IT and lab support and storage space. Staff who are trained are scarce, and many will be absent due to illness or isolation during the epidemic. Stuff is the hardware and disposables that are needed in abundance, and are currently procured through fragile supply chains. Standards are the complex working practices required to provide the best quality care we can deliver. In larger hospitals many patients undergoing complex surgery are subsequently admitted to ICU for treatment and monitoring. If this routine surgery requiring ICU can be paused, the four key needs of ICU capacity may be rapidly available. Beyond that, it becomes challenging. In smaller hospitals, where almost ICU admissions are on an emergency basis, demand just can’t be put on hold during a crisis. One solution is to take over hospital operating theatres. ICU medical staff may need to be supplemented by anaesthetists, all of whom will have ICU experience, and nurses by theatre staff, not all of whom will. Staff will need to work differently. In ICU it’s normal for one nurse to care for one patient. In the heat of the crisis this may need to change: one ICU trained nurse, supported by those with different training, could care for several. No healthcare system can be prepared for a crisis of this magnitude and speed. Staff across the country are taking extraordinary actions to create space and service. Hospitals are building their defences as best they can, but we do not yet know how high and hard the wave will hit. In normal times, ICU treatment saves many lives, but it is not a quick fix – and it may not be right for all patients. At their sickest, ICU patients will be sedated and their bodily functions performed for them; as they recover, they must repossess those faculties. Treatment in an ICU itself often leads to further frailty or new illnesses; as the body lies ill, it ages. Survival may be impossible, or it may be accompanied by a slow and incomplete recovery that can take months or even years. A central tenet of medical care is that it should benefit the patient and be consistent with what they would want. Too often, discussions about risks to the patient’s life, the burden of treatment and the quality of life that follows, are not considered until the patient is too ill to be involved. Doctors and family must then work together to balance risks against benefits and act in the patient’s best interests. The ethical framework of medical care is centred on doing good, avoiding harm, being fair and ensuring patients are enabled to make their own decision. These principles guide every decision to admit or not to admit patients to ICU. The magnitude of the coronavirus pandemic will involve making decisions that, in normal times, doctors aren’t confronted with: decisions about which patients to treat in ICU when not all can be. In Italy, doctors have been forced to make these choices. This kind of decision-making, known as triage, is a practice borrowed from the battlefield, when doctors had to make decisions about where to focus their stretched resources. Some have stated that “doctors make these decisions all the time”. I disagree. Every day, doctors wrestle with decisions about what is right for the patient in front of them. But when resource-based triage occurs, the decisions become about what is in the “greater good” and “doing the best for the most”. This is a fundamental change. Where normally the doctors’ focus is solely on what is in the best interests of an individual, when resources are overwhelmed and not all patients can be fully treated, doctors may instead have to focus on what is in the best interests of society. In normal circumstances, the General Medical Council state that doctors must avoid such decisions. If this comes to pass in the UK, doctors will be making some of the hardest decision we have ever had to make. But we can’t do this alone. If it becomes necessary, a framework to inform these decisions should be shared with the rest of society. In this urgent crisis we need a public discussion to help guide these difficult decisions, and clear advice from our medical, philosophical and political leaders. In the meantime the government and NHS are making unprecedented efforts to prepare the health service for the pandemic. The public can help reduce peak demand on the NHS by following the government’s social distancing and self-isolation advice. Heeding this guidance will reduce the risk of infection for you and others. It will create space in ICUs and may even save someone’s life. • Tim Cook is a doctor in an NHS intensive care unit Source
