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The waiting game

Who has the right to decide who lives or dies?

Dr Renée Hoenderkamp 

These are difficult times. Understatement of the century. But of course true. And so I find myself asking if it's okay for the medical world to be discarding ethics to bulldoze through decisions which are costing lives in the name of saving lives? What on earth am I talking about…?

The NHS is throwing every department, every ‘elective’ procedure, screening programme and non essential service out of the window in its national fight against the new enemy, Covid-19. Now, whilst I accept that the nasty little critter that can’t be seen until it announces its unwelcome arrival is one of the most catastrophic health emergencies we have ever seen during the life of the NHS (caused predominantly by its infectiousness and thus clustering of illness and sadly death), I am massively concerned that we are blinded by the headlights and the resultant deaths will be equalled if not excelled by other causes that we are now ignoring.

I had a bad day today, so I need to write this. I had four patients brought to my attention who are somewhere along the cancer pathway. All had their next procedure/appointments cancelled in the last week. We are being told that cancer services are being protected - not as far as I can see. Let’s look at those patients. The first, a very fit and healthy 70-year-old woman, with no comorbidities and who had never smoked, listed for a curative pneumonectomy, that’s right, curative. Cancelled today.

So here is a woman with potentially 20 to 30 years of life ahead of her. Someone’s mother, sister, wife and friend. Someone somewhere has taken a red pen and drawn through the list with her name on. Not looked at her individually. Not weighed up the benefit of the surgery to her and the life she would gain. Just gone. Taken away, most likely. Who knows when she might get listed again. There is every chance that at that point, it will no longer be curative. Who has the right to make that decision. Who knows that the patient who ultimately takes her bed will have more right to a healthy life than she?

Then one of my close friends. She is an anaesthetist working at the frontline in London. Her nan arrived at hospital on Tuesday for a lumpectomy for her newly-diagnosed breast cancer. It was cancelled on the day. No-one even came to tell her. As she sat there in the hospital, filled with nerves but also excitement at getting the surgery she needs, they phoned her granddaughter and left her to break the news. And no one has even contacted her since. She is now at home, isolating, lonely and is angry as she faces what may be her last few months alone.

We are sentencing non-Covid-19 patients to death with these decisions we are now making

The next patient has been valiantly fighting cancer for three years. He has defied all odds. He is 78. His last staging scan showed no progression, so he has not had treatment for three months, and had a scan today to see if there was any progress and if so to restart treatment. He tolerates the treatment well and has just travelled to the Caribbean alone for a holiday! So the scan today was a big deal. It has been cancelled due to Covid-19 measures and he has been told: ’you are no longer a candidate for treatment’. I had to have the conversation with his understandably distraught daughter. What should I say? ’Yep he’s had a good innings, we can’t fit him in any more’?

And then the final nail for me was a message about a patient having palliative immunotherapy which was being tolerated and working well. They had a call to say that all palliative chemotherapy and immunotherapy is now cancelled. They, too, are devastated.

These are not people who were making plans to die. They were not expecting these phone calls. And they rightly feel that they have been tossed on the scrap heap and effectively told that their lives are less valuable than the potential Covid-19 patient lives that the NHS will try to save come what may. They are the come what may.

So it got me thinking about the many telephone triage calls I have had these last two weeks where I have said: ‘well, lets wait until this is over and then I can refer for that scan/expert opinion/steroid injection’. Small things that are not urgent and certainly can wait, but where does this stop?

We have been told that if UK GDP drops by 6%, more people will die of the consequences than of Covid-19. That is going to happen according to most economic pundits, so amongst all of this we are crashing the economy in order to fight this so called war.

We are sentencing non-Covid-19 patients to death with these decisions we are now making. What about the many patients who also lose out in more subtle ways when we reach the point of capacity and there are no beds? The COPD patient who does well when admitted and then gets back home, but in this period can’t get a bed. The stroke patient who can’t get thrombolised within the four-hour window. The MI patient who gets sent home too soon. The elderly patient with a UTI needing IVs who becomes septic. The child well-known to paediatrics who needs intensive inpatient support occasionally. The patient not presenting with cancer red flags to GPs, who we eventually see in three to six months when things are much more advanced. The list is endless, and will, I fear, result in many many deaths of people who were not going to die if they got admitted.

We are playing God in a way never seen before. Of course, this sometimes happens when there is a need for two HDU/ITU beds and only one is free. But never on this scale. And what concerns me is that it is being done on the hoof, there is no deep thought and it is all broad brush strokes affecting individual people, each with an individual story, prognosis and chance of life years ahead of them which is just being ignored.

The ethical dilemmas are just vast. We are crashing the economy for years to come to save hundreds of thousands of lives, ignoring the hundreds of thousands of hidden deaths that will be an inevitable side effect. So as bitter a pill as it is to swallow, should we have approached this differently? Should we have locked down the vulnerable and the elderly two months ago and allowed the virus to exist amongst those who would mainly not be badly affected by it so that they could continue to keep the economy afloat and ensure that we have a health service that we can afford at the end of this thing?

Alongside this, people are dying in ITU with no family around them - tonight, a 13-year-old boy. The relatives aren’t coping with this any better than I can when I consider it. We are creating a maelstrom of mental health damage, from every aspect of the way we are approaching this pandemic - the economics, the isolation, the PTSD from being on ITU if one comes out, and the trauma of the relatives who can’t even be with their Mums, Dads, siblings and children when they die, let alone attend their funerals. It's horrific. It defies description.

I don’t know what the answer is, but I am bloody angry at the casualties at the side of the field that are being left because everyone is too busy focusing on the goal at the other end of the pitch.

Dr Renée Hoenderkamp is a GP in North London

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Readers' comments (32)

  • well said ,could not agree more.
    what happened to the ethics ?
    my sister is a Gp and a professor in ethics and no one is listening.

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  • Really really thought provoking article.

    Thank you

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  • This is one of the most pertinent and well put articles I have read in this crisis and deserves more public airtime. It gets to the heart of the debates we should be having in the NHS and more widely.

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  • Cobblers

    Couldn't agree more. The UK runs a half arsed Health Service and has been caught with its pants down. Eyes on the only ball in town aka Covid-19 but dropping all the other balls which would have been bread and butter had this minor plague not been.

    Make no mistake that Covid-19 kills and not just due to the bug. The sepsis, infarcts, cancer deaths will go down as what they are and not as indirect Covid-19 deaths.

    I don't now the answer but we need a grown up discussion about our so called NHS. And soon.

    And we missed a bullet too. Low flu season. Thank you God.

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  • Great article.
    Clearly there are many other victims of corona virus that are well under the radar and are completely forgotten by the media especially TV who seem obsessed by the current death rates.

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  • Renee, sorry for your bad day. Even more sorry for your 4 patients. I cannot get the image of the bureaucrat putting the red cancel line through your patient out of my head now

    India has had less than 50 deaths are no mass panic

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  • Thought provoking and right on the money - already had 2 2 week wait referrals I made rejected today and am trying to fight for at least one but it looks like there is no hope for the other one unless a miracle happen!

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  • I hear you loud and clear. I’m spending my days trying to keep cancer care moving on for my lung cancer patients. Still giving chemo and immuno therapies, radiotherapy also.
    Trying to shield those who are maybe just too frail . But days spent trying to reinstate scans for those patients , rope in their families and do what we can. But I think all this maybe ended soon when there is no one able to give the chemo or the radiotherapy .../

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  • I think there is a lot of truth in what you say. We are casting aside normal work in favour of the ‘cause’. And, is there sometimes a little bit of relief that we can advise the patient to leave us alone for a few months? Only me? I think we are so worn down and NHS feels so weakened, it’s hard to do anything but batten down the hatches and hope for the best. But maybe it wouldn’t have been this way if we’d fought harder for better funding, more resources, better preparedness. Something was obviously going to overwhelm us sooner or later. Here it is. What will we do with it?

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  • We all hear you loud & clear but there's no time for these considerations, sadly.

    Covid19 is here, right now.

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