Silver Linings Handbook: Tips for the Covid Cohort 4 - Ethical dilemmas and the decision to admit
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My cycle home after a busy day at work is often my most introspective time, trying to process thoughts and emotions that emergency department shifts don’t often allow. In the last few weeks, I have found my reflective rides more affecting than ever, only partly explained by the eerie silence of London streets. These shifts during the surge in COVID cases have amplified the consequences of admitting someone to hospital as well as the ethical framework we should be working within when making these decisions.



The Decision to Admit

 


An 80-year-old man with a history of diabetes, hypertension and benign prostatic hypertrophy presents with a four-day history of abdominal pain, dysuria and loose stools. He has a mild fever (38.1) and has fluctuant disorientation to time and place (GCS14/5) with a normal cognitive baseline. His bloods show WCC of 13 (Neut: 12.1, lymph: 0.9) and a CRP of 55. Urine dip is +ve for blood but nil else. CT KUB is -ve. A COVID swab has been taken and will not come back for over 12 hours.


Would you admit this man? Should they be admitted to COVID ward or not?

 


I have been in this position, and I think it is important to be aware of the risks of admitting anyone to a hospital even before the COVID outbreak. This has of course been amplified manifold by grouping together huge numbers of infected patients of a particularly infective pathogen under one roof. We know that around 10% of reported cases in China (1) and Italy (2) have been in healthcare workers, highlighting the increased risk of transmission in healthcare settings, even adjusting for the confounder of higher numbers of testing in these cohorts. This, of course, puts COVID negative patients admitted to hospital (e.g. STEMIs, strokes, falls) at risk of developing a severe nosocomial infection, even with the best zoning, personal protective equipment and hand-washing that can be done.

 

Of course, the answers to the above questions are very situation-specific and should be guided by local guidelines (the magic answer to any medical question when stuck) with the input of senior clinicians. It would be tough to clinically justify discharging a delirious elderly patient without a known focus of infection, so he will likely be coming into the hospital for further treatment. 

 

The next Catch-22  is whether he gets admitted to a COVID/Red ward - I can’t keep up with the changing nomenclature in my hospital alone - while his swab is pending. And with a sensitivity of around 70% from early PCR studies (3), an initial negative result could also be falsely reassuring.  This is a difficult decision, do we send this man who is at high risk of developing a severe infection to a COVID ward (if he doesn’t have it) or to a negative ward and potentially infect another vulnerable group (if he does)? Again, no magic answer but cohorting patients into wards with similar risk profiles (positive patients, high risk and low risk) and while also maintaining the best infection control possible seems the most pragmatic solution. The Australasian College of Emergency Medicine has come up with a comprehensive but accessible document if you want to think more about this



And hopefully, as test turnaround times and sensitivity improves, this will hopefully become an increasingly infrequent dilemma.  






Who gets the vents?

 

 



The media and by extension, the public are talking about mechanical ventilation as if it is a magical cure to the overwhelming viral pneumonitis that affects a small proportion of COVID patients. As medics we know of course this is not true and is solely a means of respiratory support to buy time to allow the immune system to try and fight the virus (while there are no evidence-based treatments known yet). Plus the most recent ICNARNC (Intensive Care National Audit and Research Centre) makes for pretty grim reading for outcomes for the first 4000 patients admitted to ICU’s in the UK with COVID (4), with a mortality of 66% of patients requiring advanced respiratory support. But for patients and their loved ones in this position, that 34% chance of survival is the last hope they have, so how do we decide who gets a ventilator?

 

The main components of this are individualised patient factors and prognosis as well as the limits of resources available. It is important to remember that people were deemed not suitable for intensive care long before the COVID pandemic and will continue to do so when the lockdown ends. As stated in the 1999 BMJ article ‘Criteria for Admission’, “The decision to admit a patient to an intensive care unit should be based on the concept of potential benefit. Patients who are too well to benefit or those with no hope of recovering to an acceptable quality of life should not be admitted (5).” Intensivists make these difficult decisions on a case by case basis taking into account clinical frailty, physiological reserve comorbidities, and illness severity scores. NICE have come up with a pretty non-committal flow chart to aid this decision process, which only really suggests the use of the Clinical Frailty Score in over 65-year-olds, so the impetus is still on the intensive care team to make case-specific assessments as per their usual practice (6).




 

The difference comes when local intensive care resources start to become the limiting factor by the increase in demand. This is when decisions change from being made solely in individual patients ‘best interests’ (as above) and have to start factoring in prioritising those most likely to benefit from the limited resources, the murky world of ‘distributive justice.’ The Northern Italian experience highlighted that even incredibly developed intensive care systems could be rapidly overwhelmed by the sheer number of patients needing ventilation, with the Italian College of ICU describing it as like practicing “catastrophe medicine”, with some areas having to create arbitrary age and frailty cut-offs for admission to help doctors with the impossibly hard decisions of allocating the limited resources available (7).

 

Thankfully, we have not reached this level of overcrowding in UK intensive care units, in large parts due to rapid upscaling of beds and redistribution of staff from non-traditional intensivist roles. The hospital I work in has more than doubled its intensive care capacity and has rapidly trained staff like me to help assess and manage ventilated COVID patients to help staff these areas. Despite this, we have had issues of depleting supplies of sedatives like propofol and fentanyl, a critical shortage of renal replacement therapy and of course, personal protective equipment. In response, colleagues have been amazing at adapting protocols and learning rapidly to work with new equipment in unusual environments. I think patients have received the best care possible in the circumstances. As cases plateau, it is inevitable there will be a second surge social lockdown gets lifted, I just hope all of our preparatory work avoids us having to make the extraordinarily difficult decisions that our colleagues in Italy did. 


Next Chapter

 


In the next blog, I will focus on communicating with patients and families around the end of life and ceilings of care. This is always going to be one of the hardest things we have to do. Still, COVID has highlighted even greater challenges when navigating these conversations, particularly when it can’t be in person.


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References

World Health Organization (WHO). Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19) 2020 [cited 1 March2020]. Available from: https://www.who.int/docs/default- source/coronaviruse/who-china-joint-mission-on-COVID-19-final-report.pdf            

Istituto Superiore di Sanita' (ISS). Sorveglianza Integrata COVID-19 in Italia 2020 [updated 26 March 2020; cited 26 March 2020]. 

https://pubs.rsna.org/doi/10.1148/radiol.2020200642

https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1115908/

Originally published 02 May 2020 , updated 10/06/2020

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