Coronavirus: Medics get guidelines on 'difficult decisions to be made'

The Government has published ethical advice for front-line healthcare staff dealing with resource shortfalls and challenging decisions that may emerge as the healthcare system grapples with the Covid-19 pandemic.

The advice, which was published by the Department of Health over the weekend, was drawn up in recent weeks in response to the outbreak. It is designed as an aid to front-line healthcare workers and managers "in thinking through the difficult decisions that will need to be made".

Across 19 pages, it details the range of ethical considerations which may come into play, as well as the anticipated emotional and psychological impact on healthcare workers. It is intended to help policymakers, healthcare planners and providers in acute and community settings, as well as assisting clinicians.

Medical intervention

At the core of the document is a paradigm shift in how healthcare decisions are made. A spokeswoman for the department said: “While the ethical principles are the same, it is necessary to switch from a strictly medical ethics approach to decision making (aimed at the individual level) towards a public health approach (population level) and this ethical framework takes cognisance of that.”

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As the framework itself explains, “ensuring the health of the population often entails imposing limitations on the rights and preferences of individual patients”. The document outlines the stark realities and difficult choices that may lie ahead if the healthcare system comes under severe pressure.

“Once the healthcare system reaches capacity, everybody will be cared for, but may not have the same access to different levels of medical intervention. Decisions will, therefore, have to be made regarding who should be prioritised to receive intervention,” the document states.

It indicates that priority may have to be given to certain groups for treatment, such as for at-risk groups, as well as “those essential to managing a pandemic”.

It also raises the complex impact pandemics may have on the healthcare system, even with so-called “surge capacity” put in place.

“Since overall healthcare resources are finite, it must be recognised that efforts to increase care capacity will have a knock-on effect on other resources and services in the healthcare system. This will, ultimately, require difficult decisions to be made in relation to which services to maintain and which to defer.”

Clinicians and managers will have to make complicated decisions, the framework advises, citing seven guiding principles: minimising harm, proportionality, solidarity, fairness, duty to provide care, reciprocity and privacy.

Complicated factors

It discusses some of the complicated and interdependent factors that should be considered when making decisions during a pandemic, for example, how a “multi-principled approach takes into account estimates of the total number of lives saved; the total number of life years saved; and long-term functional status should patients survive”.

The possibility that such decisions may be necessary should come as no surprise. On March 13th, The Irish Times reported a statement by the Intensive Care Society of Ireland that said: "We aim to provide care of an appropriate nature to our patients as always, but we do expect that we will have to make triage decisions, which will be challenging."

Commenting on the publication of the framework, Dr Donal O’Hanlon, president of the Irish Hospital Consultants Association, said “clinical teams make very difficult decisions on a daily basis in our hospitals. The current coronavirus crisis has created unprecedented conditions in which these decisions are being made.”