How SA doctors will grapple with questions of life and death
As the nation faces a shortage in critical equipment, authorities face the question of who gets it and who doesn’t
Health authorities are preparing for unprecedented rationing of critical care beds and ventilators – and the ethical nightmares that will come with it.
The Critical Care Society of Southern Africa has issued guidelines “in the event that a public health emergency creates demand ... that outstrips supply”.
The warning is repeated in a SA Medical Association document giving doctors ethical guidance: “As a nation, our healthcare resources are already limited. Covid-19 may tragically constrain those resources further, resulting in the loss of lives that would have been preventable under normal circumstances.”
Setting priorities and rationing resources in this context means making tragic choices, but these tragic choices can be ethically justified. This is why we have ethics.World Health Organisation
When it comes to triaging patients for an intensive care unit bed, the Critical Care Society document suggests several stages of assessment and scoring for all patients – not just those with Covid-19 – which take account of each individual’s frailty and medical history.
In the event of a “tie” between two patients, it suggests the younger person should be prioritised. It proposes “heightened priority” to people “who perform tasks that are vital to the public health response – specifically, those whose work supports the provision of acute care to others”.
The guidelines also suggest continual assessment of patients receiving critical care, recommending it should be withdrawn unless their condition improves.
Many of the recommendations are “ethically defensible”, according to a critique in the SA Medical Journal by two of SA’s leading medical ethicists.
But some were at odds with guidance in the UK and US, said Jerome Singh, head of ethics and law at the Centre for The Aids Programme and Research in SA, and Keymanthri Moodley, director of the Centre for Medical Ethics and Law at Stellenbosch University.
Singh and Moodley said rationing in the context of a pandemic “surge” was unprecedented in SA. “Such decision-making raises profound governance and ethical issues,” they said.
SA has about 7,000 critical care beds, of which 3,000 are not occupied at any time, and about 6,000 ventilators. “It is evident from the experience of advanced economies, such as Italy, Spain and the US, that critical care resources in SA, which are already underresourced, could experience unprecedented strain if Covid-19’s presence in SA mirrors the exponential growth patterns seen elsewhere,” said Singh and Moodley.
“The rationing of intensive care beds and ventilators will be crucial to mitigating this scenario.”
They praised the Critical Care Society for swiftly producing its “moral compass” guidelines, which are based on a document from the University of Pittsburgh in Pennsylvania, US.
The guidelines are based on the maxim “doing the greatest good for the greatest number” rather than the traditional focus of medical ethics, individual wellbeing, and they include a number of triaging steps.
After confirming a patient wants intensive care, they say – possibly in a living will in which the patient has set out their wishes – an assessment should be made about whether it will be beneficial.
The next step is to score each patient on the clinical frailty scale (above), with those scoring six or above excluded from intensive care.
Singh and Moodley said the scale was good at detecting “older adults at high risk of complicated treatment and prolonged longer stays”, but its application was not limited to such patients.
Those who make the cut will then have a sequential organ failure assessment (Sofa), which looks at the likelihood of them surviving until they are discharged from hospital. Their prospects of long-term survival will also be assessed based on the presence or absence of other medical conditions (comorbidities).
Singh and Moodley said examples of comorbidities were diabetes, hypertension, cardiac disease, chronic lung disease, HIV infection and moderate Alzheimer’s disease.
The short-term and long-term scores will be combined and those with the lowest scores – giving them a higher likelihood of benefiting from critical care – will be placed in one of three priority groups: red (high), orange (intermediate) and yellow (low).
The guidelines say: “All patients are eligible to receive critical care beds and services ... but available resources will be allocated according to priority score.”
Then comes the knotty problem of “ties”, and the guidance proposes four age groups, in descending order of priority: 12-40, 41-60, 61-75 and 75-plus.
“The ethical justification for incorporating the life-cycle principle is that it is a valuable goal to give individuals equal opportunity to pass through the stages of life – childhood, young adulthood, middle age and old age,” say the guidelines.
“The justification for this principle does not rely on considerations of one’s intrinsic worth or social utility. Rather, younger individuals receive priority because they have had the least opportunity to live through life’s stages.
“Evidence suggests that when individuals are asked to consider situations of absolute scarcity of life-sustaining resources, most believe younger patients should be prioritised over older ones.”
Health workers given heightened priority “should be broadly construed to include those individuals who play a critical role in the chain of treating patients and maintain societal order”.
Singh and Moodley said it was not clear how clinicians would be able to decide who to put in this group amid a pandemic surge, but they said such prioritisation was ethically defensible “and should be implemented to preserve a highly skilled and limited healthcare resource during the pandemic, and beyond”.
The Critical Care Society said daily or twice-daily determinations should be made about what priority scores will result in access to critical care.
“These ... should be based on real-time knowledge of the degree of scarcity of critical-care resources, as well as information about the predicted volume of new cases that will be presenting for care over the [next few days].”
Finally, the guidelines say patients admitted to critical care should be reassessed after 48 hours, then daily.
“Patients showing improvement will continue to receive critical care services until the next assessment,” says the document.
“If there are patients in the queue for critical care services, then patients who upon reassessment show substantial clinical deterioration ... that portends a very low chance of survival should have critical care withdrawn, including discontinuation of mechanical ventilation, after this decision is disclosed to the patient and/or family.”
These patients should then receive “medical care including intensive symptom management and psychosocial support. Where available, specialist palliative care teams will be available for consultation ... Families are to be intimately involved in these processes.”
Again, Singh and Moodley said such decisions were ethically defensible during a pandemic, although they would have to be made “virtually instantaneously” if a surge of Covid-19 patients hit the health sector.