The new reality of medical decision-making

Over the coming weeks and months, doctors will face some very difficult ethical decisions, especially involving triage and the rationing of resources

“All changed, changed utterly, a terrible beauty is born”

WB Yeats

“The whole world is in a terrible state of chassis”

Sean O’Casey

Coronavirus has forced a rapid pace of change on the world. And none are more affected than doctors and nurses, whose working lives have been turned upside down.

What follows is a somewhat random run-through on the challenges and new responsibilities faced by healthcare professionals.

Doctors are facing some very difficult ethical decisions, especially involving triage and the rationing of resources.

Rationing is defined as the allocation of healthcare resources in the face of limited availability, which means that beneficial interventions are withheld from some patients. The pointy end of this occurs in the critical care setting. I don’t envy colleagues having to decide, in an ethically appropriate way, to remove one patient from a ventilator so another person can use it. Or how to get your head around deciding which of two patients should be admitted to the last ICU bed? I can only imagine what it must be like to have to explain and communicate to a patient and their relatives why they have reached a ceiling of care and won’t be offered that bed.

Intensivists will have trained for this dilemma and probably have some practical experience of making intensely difficult decisions. But for other specialists drafted in to makeshift ICUs, it is going to be very difficult. And as for the medical students who are preparing to go on the wards immediately after their final results are published, it will be some baptism of fire.

With the Italians about two weeks ahead of us in the Covid-19 pandemic cycle, we can, and have, learned a lot about what lies ahead.

The country’s specialist anaesthesiology association says it may be necessary to establish an age-limit for access to intensive care.

“This is not a value judgment, but a way to provide extremely scarce resources to those who have the highest likelihood of survival and could enjoy the largest number of life-years saved.”

“In addition to age, the presence of comorbidities needs to be carefully evaluated. It is conceivable that what might be a relatively short treatment course in healthier people could be longer and more resource-consuming in the case of older or more fragile patients.”

As someone who meets both the age criteria and has a comorbidity, reading this is startling. Not because I didn’t know it, but because, there in black and white, is a real picture of personal relevance. And of course the rational response is to say ‘yes, of course if there is one ventilator between me and a young mother, please take me out of the reckoning’. The bed and machine must go to the person with the highest hope of survival and who has a longer natural life-span than I have.

Most doctors have their favourite “must attend” annual conferences. We are just entering spring conference season and the number of cancellations due to the coronavirus situation are beginning to mount. I’ve just been notified that one of the world’s most important infectious disease conferences – the European Congress of Clinical Microbiology and Infectious Diseases (ECCMID), scheduled for 18-21 April  in Paris – will now run as a completely online congress. If any group needs a timely conference it must be infectious disease specialists. So by not completely cancelling the event, they are facilitating a remote participation in scientific sessions.

 The organisers say livestreaming will enable active exchange with the audience: Speakers will have the possibility to introduce interactive questions in their slides and the audience can reply using the ECCMID App. And additional kudos are due for a plan to have a special arrangement for the online presentation of posters.

It is a lead that other professional organisations with conferences scheduled between now and June should seriously consider following. Managed well, it could make a huge difference to morale – although the meeting and eating together of old colleagues, such an important element of these meetings, obviously can’t happen.

I’m going to finish with some of the positive cards we medics can play during this crisis. Team camaraderie is there to be exploited and deepened. Black humour, for those who enjoy it, is a useful foil to ongoing stress. But probably what helps most of all at times like this is our innate vocational professionalism that makes me proud to be a doctor.