George Louw investigates how doctors make the difficult ethical decisions including how to distribute scarce resources
As the number of COVID-19 infections climb, there are concerns around the difficult ethical decisions that medical staff need to make around the care of patients. George Louw reaches out to Dr Virginia Wilson, chairperson of the Southern African Spinal Cord Association and the South African Society of Physical and Rehabilitation Medicine, to learn how these difficult decisions are made.
George Louw: Dr Wilson, thank you for taking the time to talk about this very emotive topic of difficult choices in the face of limited resources. In this season of COVID-19 where resources are being overwhelmed by massive patient needs, the obligation to make choices that determine the survival of one at the expense of the potential loss of life of another, on a daily basis, must be heart-wrenching. How do you cope?
Virginia Wilson: All of us working in acute rehabilitation at present need the full support of a sound ethics committee, which clearly outlines the basis for clinical assessment of all patients, based on current parameters and guidelines in use both locally and internationally. It is critical that no one doctor plans a decision alone. It must be in consultation with a minimum of two external doctors. So, we cope by supporting each other.
GL: In management decisions, doctors are trained that age, gender, race, lifestyle, or disability should not influence treatment decisions. Yet, recently there was a case in the United States where a person with quadriplegia was COVID-19 positive and in need of ventilation, but was declined because, as I understand it, the physician thought that the patient had “a lesser quality of life” than the person who was authorised for ventilation.
What factors influence choices between aggressive intervention and palliative (perhaps terminal) care? How do factors like age, frailty, comorbidities, breadwinner, value to society, mental status (dementia for example), physical disability fit into the picture?
VW: As mentioned, there are scores (in widespread use in critical and palliative care) when assessing the patient. For example, the Clinical Frailty Score, the Eastern Cooperative Oncology Group (ECOG) and others, which clearly guide the doctor when assessing the patient. The use of these scores helps the decision making in truly difficult situations.
The triage considers the availability of resources. A quadriplegic may require ventilation for a much longer period, denying a scarce resource, the ventilator, to others. In a disaster, one must do the best for the most.
GL: Let us look at communication. I have found that decisions that involve the lives of other people are best taken in consultation with the affected people. In a situation of limited resources, how do you approach a patient and loved ones with a decision that a lifesaving treatment is not available to that patient? What are the roles of patient choice and family choice in this?
VW: Patient and family (or nominated person) have to be involved from the start of admission and be made fully aware of the possibility that these choices will need to be made, as well as thinking about end of life choices.
This is extremely hard for most and the support of the social worker and possibly a psychologist is essential to support and guide patient and family. In our multicultural society, it is essential to ensure translation is provided for the patient and family, if necessary, so that all reasons for decisions can be understood clearly.
GL: I have come across triage tools and scoring protocols for critical care management decisions in hospital emergency care units. Some seem very complicated. What is the value of such tools and protocols? Do they help to take the emotiveness out of a decision?
“In a disaster one must do the best for the most.”
VW: As already mentioned, these scores/tools are essential and invaluable. They have been developed over many years and are used extensively in intensive care unit (ICU) settings and palliative care.
Some are complicated and not applicable to the acute rehabilitation setting. Yes, the scores do help to remove emotion from the decision, but not entirely as we are dealing with human lives.
GL: If a patient on a ventilator is not improving and there is a backlog of patients in dire need of ventilation, how do you go about calling it a day and transferring the patient to palliative and probably terminal care?
VW: This question would best be directed to an intensivist or critical care specialist. However, the principles of discussion with the family and, if possible, the patient before such a situation arises should always be followed. I feel one should envisage oneself in the same situation with a family member.
GL: In such situations, what influences your decisions to either retain the patient in hospital or allow the patient to return home for palliative terminal care? And in the latter, what advice would you give the family?
VW: All the factors about the patient, such as their preadmission function, current function, their wishes, the wishes of their next of kin, will influence such a decision. If palliative terminal care is advised, the advice for the family is to find the most caring, suitable facility and be aware that finding the “perfect” place is extremely difficult.
GL: My next question is perhaps unfair in that it is a theoretical consideration that underpins practical realities, but it is a question that I frequently hear voiced. What are the ethical considerations that underpin all of what we have just discussed?
Are choices made for the greater good of society or for the best chance of survival of the individual or towards the person that in all probability would provide the greater future economic or social benefit to their communities? If you have three patients and one available ventilator and all three score equally in triage, what ethical consideration drives the final decision?
VW: This is a dilemma as the ethical choices conflict with the legal obligations. All ethical guidelines are based on sound accepted principles, and yet these may conflict with the law.
GL: We have analysed the processes and ethics that drive decision making in situations of constrained resources as it pertains to the population at large, but how does the process differ when say, a person with quadriplegia is admitted in distress with COVID-19?
VW: In general, a quadriplegic should be no different to any other patient and the same principles apply in screening and decision making. Involve the patient and the family from the day of admission and prepare them for confronting a possibly very difficult situation.
GL: Any last words from you?
VW: My advice to any colleague is never feel you are alone in a tough situation. Seek advice constantly and keep very open communication with the patient and their family. COVID-19 has made us all think “out of the box”, hopefully improving the comprehensive care of all our patients.
GL: Dr Wilson, thank you so much for taking the time to share with us the immense stress and emotional trauma that healthcare workers in ERs, ICUs and hospital wards are experiencing in the decisions that you have to take.
Thank you also for sharing with us that your decisions are not taken without consideration; that guides like triage tools and scoring protocols provide some objectivity to this very emotive experience. It has given us more clarity around the difficult decision medical staff make. Health workers are the true heroes in the frontline of this war against COVID-19.
