Where I can’t treat everyone, can I prioritise some patients over others?
Although we hope that the current efforts to maximise resources and limit demand for treatment will be successful, it is possible that, at times, the need for some forms of medical treatment may exceed the resources available.
Should this situation arise, all patients should continue to be given compassionate and dedicated medical care including symptom management and, where patients are dying, the best available end-of-life care.
Nevertheless, it is legal and ethical to prioritise treatment among patients where there are more patients with needs than available resources can meet. Such decisions must be made on the basis of clinically-relevant factors.
Senior leadership at your organisation should make decisions about how resources are to be allocated in difficult situations. These decisions must be:
- reasonable – including based on sound principles
- based on the best available evidence and opinion
- agreed on in advance where practicable, while recognising that decisions may need to change rapidly
- consistent between different professionals as far as possible
- communicated openly and transparently
- subject to modification and review as the situation develops.
How do I decide on which patients to treat?
You need to follow your organisation’s guidelines and protocols, including relevant procedures for making complex ethical decisions. The speed of a patient’s anticipated benefit will be critical. Other relevant factors include:
- severity of acute illness
- presence and severity of clinically relevant co-morbidity
- frailty or, where clearly linked to clinically relevant factors, age.
Managers and senior clinicians will set thresholds for admission to intensive care or the use of highly limited treatments such as mechanical ventilation or extracorporeal membrane oxygenation based on the above factors.
Patients whose probability of dying, or requiring prolonged intensive support, exceeds this set threshold would not be considered for intensive treatment. They should still receive other forms of medical care.
Prioritisation decisions must be based on the best available clinical evidence, including clinical triage advice from clinical bodies.
These criteria must be applied to all presenting patients, not only those with COVID-19.
Can I withdraw treatment from patients who are currently being treated but are not responding?
Yes – you can withdraw treatment in accordance with agreed guidelines and protocols. Although the emotional impact is likely to be greater, it is widely agreed that there is no intrinsic ethical difference between this and withholding life-sustaining treatment, where other clinically relevant factors are the same.
Equality legislation – do I risk breaching the law when making these decisions?
No. Although a ‘capacity to benefit quickly’ test may have a disproportionate impact on the elderly or those with clinically relevant existing health problems, in the circumstances it would be ‘a proportionate means of achieving a legitimate aim’ under equality law.
Simple cut-off policies, such as not offering specific interventions to those over 70, or to those who are disabled, are unlikely to be lawful. Decisions must not be made using non-clinically relevant factors such as discriminatory beliefs about the value of an individual’s life.
Reasonable adjustments for disabled people – what are the obligations?
The NHS needs to comply with equality legislation. This includes making ‘reasonable adjustments’ so people with disabilities can use NHS services in the same way as those without disabilities. The duty primarily falls on the institution delivering the services, not individual doctors. This could, for example, include permitting a learning-disabled patient to be accompanied by a carer even if that is generally not allowed as part of infection control rules.
Working outside my specialty during a pandemic – can I do this?
Yes – it is reasonable for you to be asked to work outside your specialty. However, you should work within your competence.
You should explain your concerns immediately to your manager and ask that other arrangements are made if you are asked to perform tasks you do not feel competent to carry out. In an emergency, where there are no alternatives available, you should provide the safest care that you are able to provide in the circumstances, with the aim of providing overall benefit for the patient.
My personal protective equipment is inadequate – what do I do?
Where you reasonably believe that your protective equipment is inadequate, you need to raise this urgently with your managers. Your manager should carry out a risk-assessment and find alternative ways of providing the care and treatment.
There are limits to the risks you can be expected to expose yourself to. You are not under a binding obligation to provide high-risk services where your employer does not provide appropriate safety and protection. Read more guidance for doctors who are concerned their PPE is inadequate.
GMC fitness to practise questions – will circumstances of the pandemic be considered?
Yes. The GMC has made it clear that it will consider:
- the facts of the case, including the environment in which the doctor is working;
- the pressure doctors are working under, the resources available, and the scale of the challenges in delivering safe care;
- relevant information, guidelines or protocols in place during the pandemic.
The primary requirement for all doctors is to respond responsibly and reasonably to the circumstances they face.
These FAQs were produced by the medical ethics committee and secretariat of the British Medical Association and have been widely circulated for comment.
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