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New ethical guidelines for medical staff say 'stringent restrictions on ICU admission' are needed during the pandemic

Concerns have been raised about the guidelines in relation to disability rights.

Image: Shutterstock/Inked Pixels

THE GOVERNMENT HAS published ethical advice for clinical staff who may have to  prioritise critical care resources during a “surge” of Covid-19 cases.

The document, approved by the National Public Health Emergency Team (NPHET) on Friday, states such guidelines are needed if “resource scarcity arises and rationing decisions have to be made” in hospitals. 

The six-page report follows on from the previously published Ethical Framework for Decision Making in a Pandemic, and deals with specific measures for critical care units and intensive care beds. 

However, there have been calls to amend the document over fears that people with disabilities could be denied access to an Intensive Care Unit (ICU).

While the guidelines state that people with a diagnosis of Covid-19 and other patients requiring intensive care should be treated according to the same criteria and that resources allocated fairly and in a consistent manner, it also says preparation for “surge capacity” is necessary.

It states that healthcare resources, particularly in the context of intensive care, are “likely to be severely limited and potentially overwhelmed” as the impact of Covid-19 increases.

As the pandemic progresses, “it may be necessary for a higher threshold to be applied in relation to which patients can access intensive care treatment”, the guidelines outline. 

Faced with unprecedented demands, clinicians may need to replace normal standards of care with “contingency standards of care” until the pandemic is brought under control.

The document states that there will be “tension” between a healthcare professional’s duty of care for individual patients and the broader public health considerations with a view to maximising the number of lives saved. 

The document details how a patient should gain access to intensive care. 

It states that “it is not ethically appropriate to offer intensive care to every patient, since intensive care will not provide benefit to some patients who are seriously ill or dying”.

“Access to intensive care should generally be reserved for those patients in whom a good outcome may be expected (those who will most likely survive their acute illness with reasonable long-term status).”

It goes on to state that “it may be necessary to impose stringent restrictions on ICU admission during a pandemic in order to ensure that available resources are used to achieve the best possible outcome at a population level”.

The focus on population health in a pandemic situation means that resources which could under normal circumstances have been used to prolong lives will have to be redirected to saving the lives of those who will be most likely to recover.

The NPHET-approved document also lists a range of factors that healthcare professionals should consider during their decision-making. 

This includes the severity of the patient’s illness as well as the “frailty” of a patient. 

It states that no single factor, such as the person’s age, should be taken in isolation as a determining access to resources. 

Where intensive care is not given, other treatment will be given, with the report stating that ”withholding of critical care does not mean a patient will no longer be cared for”.

The availability of intensive care beds during a pandemic will also have a “direct impact on other clinical decision-making” for patients without Covid-19. 

Citing an example, it explains if a patient’s condition and prognosis means they do not meet the criteria to access intensive care during the pandemic, it may not be appropriate to resuscitate the patient if they collapse “since the required follow up care in the intensive care unit would not be available”.

The guidelines state that such a situation should be discussed with patients and their families in advance. 

Denying access to critical care should “ideally always be discussed by at least two senior clinicians with experience of respiratory failure in ICU”, where possible, states the document.

If clinicians who are not experienced in ICU or where junior staff have to make such decisions, they should consult with a senior member by phone.

Tom Clonan, a journalist and a disability advocate, has raised concerns about the document, specifically that it does not overtly address issues relating to disability.

He highlighted the section of the guidelines that state “frailty” will be a factor considered when determining appropriate care, irrespective of age. 

In the UK, guidance on critical care during the COVID-19 pandemic was updated over fears that people with learning and physical disabilities could be denied intensive care.

Due to those concerns about the assessment of frailty and that it could be used in relation to younger people with long-term disabilities, learning disabilities, autism or cerebral palsy, the guidelines in Britain were amended to state that individual assessments should be undertaken in these cases.

Clonan has said the same should happen here in Ireland.

“There is no such statement in this document. It should be explicitly stated,” he said. 

He said there has been a “tendency to close down discussion” during the coronavirus outbreak, but Clonan believes “it has never been more important to discuss these issues in public”. 

Clonan said that doctors that work in the ICU make difficult decisions every day in the best interests of their patients, and sometimes have to decide against treatment that would be sub-optimal to their patients. 

“What is different about ICU care decisions in a Covid-19 scenario is that decisions might have to be made not in the best interests of the patient, but on the lack of resources. This needs to be discussed as that is a fundamental change,” he said. 

He called for an addendum to be added to the guidelines or for the document to be amended, to underline how underlying disability should not be used as an index of frailty. 

Speaking about his own personal life, he explains how his son Eoghan suffers from a rare neuromuscular disease.

“His lung function is compromised and he is at risk of becoming seriously ill and going into the ICU if he contracts Covid-19. I would unlikely be allowed to go in with him, I wouldn’t be there to advocate on his behalf if these decisions were being made about him,” he said. 

“It is not unpatriotic or disloyal to question Simon Harris, the HSE or the Department of Health. It is our duty to ask questions at this time. 

“Do I trust doctors? Yes I do. Do I trust this document? No I don’t,” said Clonan.

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