Doctors coping with the coming peak of the coronavirus outbreak will have to “score” thousands of patients to decide who is suitable for intensive care treatment using a Covid-19 decision tool developed for the National Health Service.
With about 5,000 coronavirus cases presenting every day and some intensive care wards already approaching capacity, doctors will score patients on three metrics — their age, frailty and underlying conditions — according to a chart circulated to clinicians.
Patients with a combined score of more than eight points across the three categories should probably not be admitted to intensive care, according to the Covid-19 Decision Support Tool, although clinical discretion could override that decision.
The UK exceeded 84,000 coronavirus cases on Sunday and 10,000 deaths in hospital with government models showing the peak of the outbreak is now expected to be reached over the next two weeks, leaving the healthcare system facing arguably its toughest challenge since its inception.
The scale of the pandemic and the speed at which Covid-19 can affect patients, has forced community care workers, GPs and palliative carers to accelerate difficult conversations about death and end-of-life planning among vulnerable groups.
The NHS scoring system reveals that any patient over 70 years old will be a borderline candidate for intensive care treatment. A patient aged 71 to 75 would automatically score four points for their age and a likely three on the “frailty index”, taking their total base score to seven points.
Any additional “comorbidity”, such as dementia, or recent heart or lung disease, or high blood pressure will add one or two points to the score, tipping them into the category suitable for “ward-based care”, rather than intensive care, and a trial of non-invasive ventilation.
Although doctors and care workers stress that no patient is simply a number, the chart nonetheless codifies the process for the life-and-death choices that thousands of NHS doctors will make in the coming weeks.
A frontline NHS consultant triaging Covid-19 patients said the “game-changer” for assessment of patients with coronavirus was that there is no available treatment, meaning doctors can only provide organ support and hope the patient recovers.
“If this was a bacterial pneumonia or a bad asthma attack, then that is treatable and you might send that older patient to intensive care,” the consultant said, adding that decisions on patients were “art not science” and there would be exceptions for patients who were fit enough.
“The scoring system is just a guide; we make the judgment taking into account a lot of information about the current ‘nick’ of the patient — oxygenation, kidney function, heart rate, blood pressure — which all adds into the decision making,” he said.
But it is not just hospital doctors who must make tough decisions. GPs, hospice workers and families with vulnerable members are also involved.
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Last week NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions, leading to many difficult conversations. These have been made harder by the need to conduct them on the phone or via Skype to observe social distancing rules.
Ruthe Isden, head of health and care at Age UK, the charity, said the need for haste had unsettled many elderly patients, who have felt under pressure to sign “Do Not Resuscitate”, or DNR, forms.
“Clinicians are trying to do the right thing and these are very important conversations to have, but there’s no justification in doing them in a blanket way,” she said. “It is such a personal conversation and it’s being approached in a very impersonal way.”
The subject of DNR notices is particularly unsettling for individuals and families who want the best care for their loved ones, but often feel the choices have not been fully explained.
The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering — including broken ribs and brain damage — while extending life only by a matter of days.
Audrey, who cares for her 90-year-old mother in Tyne and Wear, north-east England, spoke about how her mother signed a DNR order during a recent visit to hospital but it had remained in place even after she had recovered and returned home.
“Mam asked me what CPR was,” Audrey recalled, adding that no one from the hospital had contacted the family, raising worries about how actively her mother’s consent had been obtained.
Carole Walford, the chief clinical officer at Hospice UK, a charity that provides end-of-life care to 225,000 families each year, acknowledged the difficulty of broaching the DNR question, but said the speed at which Covid-19 is advancing is leaving less time for niceties.
With some patients dying within 24 hours, decisions on whether to die at home or go to hospital or a hospice are being compressed in ways that are forcing hospice workers to change the way they prepare individuals for death and families for bereavement.
“Coronavirus is pushing us to the limit as we try to hold on to to the ethos and practice of palliative care,” said Ms Walford, urging families to understand that demanding intensive care or hospital treatment might not be the best course of treatment.
Admission to hospital also means no contact with family, making homes — rather than hospices or hospitals — the haven for many patients.
“It’s important that we don’t see this as an ‘either-or’ decision. If someone is sedated and put on ventilation, is that better than having them on a ward or at home having a different death with dignity — still able have their hair combed, their teeth cleaned, their hand held?” said Ms Walford.
Despite the huge focus on building NHS capacity, the front line against coronavirus is often being fought in care homes and hospices already scarred by a decade of austerity that has placed immense strain on the social care system.
According to the Health Foundation, a charity, per person government spending was facing a £6bn shortfall by 2018, with local authority funding falling in real terms in a period when the over-85 population has risen by more than 14 per cent.
Even before the coronavirus pandemic caused up to 30 per cent of care home staff to report sick, the combination of spending cuts and low wages — the average full-time care worker earns little more than £16,000 a year — had left 120,000 vacancies across the sector.
This article has been amended since publication to clarify that the NHS decision tool was not developed by the National Institute for Health and Care Excellence