The mention of front lines conjures up images of soldiers in battle gear facing the enemy head on; engaging an unknown and unseen enemy all around them. The front line of COVID-19 looks pretty similar, except not all the foot soldiers have the protection of their battle armour. The Royal Society of Medicine (RSM) has launched a series of webinars for members to help support them with the difficult life and death decisions they are going to have to make in the coming months during the height of the COVID-19 pandemic.
The first episode was chaired by Sir Simon Wessely, professor of psychological medicine at King’s College London, president of the Royal College of Psychiatrists, and a consultant psychiatrist at King’s College Hospital and at the Maudsley Hospital.
All health care professionals are having to make decisions during COVID-19 that they never thought they would, and the decision in life and death situations nearly always rests ultimately with the doctor in charge of the case. During this pandemic, doctors are working under extreme pressure. Many are being diverted into new and unfamiliar areas of practice and are finding themselves working at or even beyond the ordinary limits of their competence or expertise. It is possible that serious health needs may outstrip availability and difficult decisions will be required about how to distribute scarce lifesaving resources.
Ethical Dilemmas
Complex ethical decisions may have to be made under extraordinary circumstances. The British Medical Association (BMA) has produced a set of guidelines to help doctors make difficult decisions during the COVID-19 pandemic and the Royal College of Physicians has published a document called 'Ethical dimensions of COVID-19 for frontline staff'.
Because the pandemic is unpredictable, fast moving and of uncertain duration, resources are becoming increasingly scarce and choices of care limited. It is no wonder that doctors are worried about the threat of litigation should they make what could be perceived as the 'wrong call' in a patient’s best interest. Even the BMA can only say that "doctors should be reassured that they are extremely unlikely to be criticised for the care they provide during the pandemic" (COVID-19 – ethical issues. A guidance note, p. 1).
If doctors have to implement difficult choices, it may mean some patients are denied intensive forms of treatment that they'd normally have received outside a pandemic. Such decisions are inevitably going to weigh heavily upon a doctor’s conscience. Decisions of such magnitude must be made not just on the individual's own moral and ethical compass but must also be guided by the principles of law.
In order to guide and support doctors through this challenging time, the RSM first webinar discussed this difficult area with Dr Rachel Clarke, a specialist in palliative care for the NHS, now also currently working in A&E in her local hospital in Oxfordshire. She discussed the challenging topics of bereavement, dying and decision-making during COVID-19.
The Most Shocking Upheaval of Our Times
She began the session by saying: "It's really hard for most people to consider their mortality, even in the best of times, the most calm and placid and least tumultuous of times. Of course, right now is the very farthest thing from that. We are going through the most shocking upheaval, probably any of us will ever have been through in our lives. Our entire society is locked down, and there's no escaping the fact that there is a new invisible silent threat that’s seemingly in the air around us. Anybody could be infected, even if they're not displaying symptoms. That's incredibly hard for everybody because it means that we can't really avoid thinking about our mortality."
Asked how doctors and other healthcare professionals should respond to that, Dr Clarke admitted that "the idea of losing our lives, requires us to consider the enormity of everything, and every single person that we love in the world, potentially, slipping through our grasp".
She suggested that, "precisely because we're in these very daunting times right now, it's never been more important to do what we as healthcare professionals would describe as advance care planning. So, this is the time to reflect upon and chat with your loved ones, about what intensity of medical care they would wish for if the very worst happened."
Difficult Conversations With Loved Ones
Dr Clarke accepted questions from RSM members who were logged into the webinar. One of the questions asked was, "How do we start those difficult conversations with our relatives when we are in lockdown?" She responded that "one of the particular cruelties of this illness, because it’s an infectious disease, we are separated from each other, we are separated from our loved ones, and sometimes that means that the best circumstances for this kind of difficult conversation, which should normally be face-to-face, calmly, with a rapport and intimacy between you, are now denied."
She added that the restrictions on visitors to all hospitals and hospices in this situation were making it incredibly difficult to provide the normal high-quality palliative care. Dr Clarke added that "the intimate physical presence at the bedside of a patient's loved ones, when you are potentially facing the end of your life, is a vital component of the care process, but there are two sets of enormous challenges at the moment. One is the physical symptoms, which we are good at managing. But the other set of issues is around the psychological, or existential aspects of confronting the end of your life: there is a great fear and often a great loneliness that people feel as they approach the end of their life. The key drug for that is not morphine but a human presence, ideally the presence of the people you love, and that’s what we can’t provide at the moment."
Dr Clarke went on to explain about all the various alternatives to actually being there, such as emails, FaceTime, recording videos, and that they will do "everything we can to get you there virtually, so that you can communicate".
Importantly, she added that "every single doctor, every single nurse, cares more than you could ever imagine about the importance of ensuring that patients who are dying from coronavirus receive the very best substitute love and care at the bedside that we can provide".
Doctors Now Making Unpalatable Choices During COVID-19
Professor Sir Simon Wessely asked Dr Clarke "doctors are now having to make what previously were inconceivable, unpalatable choices. Do you feel you need any guidance on this issue?"
Dr Clarke responded: "So, this is an issue that I think has created an enormous amount of stress and anxiety and fear among the British population, not helped actually by some very irresponsible reporting." However, she pointed out, the National Institute for Health and Care Excellence (NICE) and others have published national guidance on the dilemmas and judgements around who goes to critical care and who gets a ventilator. In the UK, the key factor that underlies the decision-making is based on frailty (not age as it was in Lombardy, Italy). Frailty is important, she said "because it is linked to your chances of surviving COVID-19".
Even in ordinary circumstances, in the NHS, "intensive care beds are a scarce resource, and intensive care doctors are having to weigh up, every day, who they think is most likely to benefit".
Extraordinary Times
Dr Clarke ended the webinar with an uplifting note, she said: "We are living in extraordinary times and important truths are being revealed... It is inspirational and extraordinary to see not only what the NHS is capable of, but also, this incredible outpouring across the NHS and across the country as a whole, of all the very best bits of human nature, so our determination to fight for each other and to do what's necessary for each other, to rally together, all of us to help in the little tiny ways we can, whether we're a doctor or nurse, a bin man, a delivery driver, it doesn't matter. Everybody is showing the very best of human nature. And I think that is inspirational, and I think that is going to endure long, long after this pandemic is over."
She ended with some final advice for the public: "Tell your loved ones all the things they need to hear about why you love them, and make sure they know how loved they are…that's it, that is the most important thing."
