UK Edition
Covid ‘lottery’: Doctors draw up triage protocol for patients in the event treatment has to be rationed
The draft emergency triage document is urgently circulating among specialists across the NHS in the absence of national guidelines
Covid-19 patients could ultimately be selected for treatment by “lottery” or their potential to contribute to society if the health service becomes overwhelmed, according to a draft emergency triage protocol drawn up by specialists at a major NHS trust.
The document, first published in the Journal for Medical Ethics in November, is now being urgently circulated among NHS specialists in the absence of national guidance from either the Department of Health and Social Care (DHSC) or NHS England (NHSE).
The authors stress that the tipping point has not yet been reached but on Monday the Chief Medical Officers for the four nations raised the national alert level to “Level Five” meaning there is “a material risk of the NHS in several areas being overwhelmed over the next 21 days”.
The protocol – drafted by medical, legal and palliative care specialists at the Royal United Hospital Bath NHS Trust – is the most sophisticated attempt yet to devise an ethical system for rationing care in the event that there are insufficient resources to treat everyone.
“This document is explicitly and only for use in times of inadequate resource, during which we need to change approach, and need a strong ethical framework in order to make fair decisions”, says the protocol.
“When resources are sufficient, decisions are based solely on what is best for each individual patient.
“When resources are insufficient, decisions need to include a broader view on what is ethically fair for the wider community (society).
“This means factors such as fairness to others are included in decision-making”.
The protocol aims to enable “structured, explicit, transparent decision-making in a situation we all hope will never arise”, say the authors.
Prof Tim Cook, a consultant in anaesthesia and intensive care medicine at Royal United Hospital Bath NHS Trust, said it was intended as a “practical guide” for doctors working at speed in overcrowded Covid wards and intensive care units should they become overwhelmed.
He stressed it was a draft protocol and not policy.
By providing a step-by-step procedure for ranking and sifting patients it is hoped it will encourage debate and bring consistency and fairness to the "most difficult of decision making", he added.
“This document has been produced locally as there is no explicit national guidance”, says the document.
In the event that capacity runs out, the protocol says a “four-stage process” should be followed to decide who should get treatment:
- a health assessment which takes into account the patient's survival chances and comorbidities, including alcoholism
- patient and family views
- consideration of “ethical factors” where the aim must be to “save more lives and more years of life”
- a final check by a senior clinician not directly involved in the patient’s treatment
“In summary, assess which treatment options are likely to provide meaningful benefit, discuss those options with patient and family/carers to obtain their views on the benefits and burdens of each option, discuss the ethics of the wider situation and combine this in an overall clinician judgement”, says the document.
The most difficult and potentially controversial proposals would arise where numbers rise steeply and patients cannot be separated by the four-stage process, although the authors predict this would be rare.
“For patients with similar prognosis, who cannot be separated in other ways, a random allocation, such as a lottery, may be used”, says the protocol.
“Other ethical considerations are more complex and opinions differ considerably. Some judge that an individual’s potential to contribute to maintenance of the critical infrastructure throughout the epidemic may be considered in determining priority for allocation of ICU care.
“Others have proposed that people who participate in research to improve treatments or vaccines during an epidemic should be given some priority for treatment”.
Another deeply difficult ethical decision arises, say the authors, where it may make sense to withdraw ICU care for one patient to make way for another with better survival chances.
“There is a reasonably widespread ethical view that withdrawal of treatment from one individual in order to provide it for another may be ethically justified in a resource-limited setting”, says the document.
“However, this is a high consequence action and the legal position in the UK is currently under review. Current advice is to seek an urgent legal opinion”.
A spokesperson for Royal United Hospital Bath NHS Foundation Trust described the draft protocol as a “research document for the purposes of discussion”.
It was not “trust policy and as such there is no related protocol at the RUH”, they added.
Dr Moosa Qureshi, an NHS doctor who has been campaigning to have the government release advice it holds relating to rationing or “population triage”, said there was an urgent need for the Department of Health and Social Care to release national guidance to NHS Trusts.
Dr Qureshi said a clear recommendation of Exercise Cygnus, the 2016 pandemic planning exercise which saw the NHS overwhelmed, was that national guidance should be devised and issued centrally on population triage ahead of a crisis.
“We are appalled that NHS doctors are now having to draw up their own guidelines as a direct consequence of the Health Secretary's abdication of responsibility”, said Dr Qureshi.
“One of the strengths of the NHS is that we have national integrated networks with consistent policies which are peer-reviewed and evidence-based, maximising resource allocation and delivering the best possible healthcare throughout the UK.
“Ad hoc policy-making driven by clinical teams within individual NHS Trusts – no matter how good – is the inevitable response to lack of leadership at a national level, but will lead to inconsistency, inefficiency and large numbers of avoidable deaths”.
An NHS spokesperson said: “The NHS has been clear that no patient who could benefit from treatment should be denied it and, thanks to the hard work of nurses, doctors and countless others in creating surge capacity and hospitals working together and that has not happened.
“However, it is vital that we cut the spread of the virus and everyone can play their part by following the advice on ‘hands, face, space’ and staying at home.”
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