It was with disappointment that I read that a Welsh GP surgery – Llynfi Surgery, Maesteg – has been dragged through the press, accused of terrible insensitivity, for raising the difficult question of resuscitation with some of their patients. While I agree that a letter, with a ‘Do Not Resuscitate’ form attached, may not be the most sensitive approach, I can’t deny that my practice has been wrangling with the same ethical quandary.
From a purely ethical viewpoint, what are we to do? In this era of Covid-19, we’re expecting an increase in mortality, especially amongst our frailer patients. Not only this, but we’re extremely conscious of the risk of contagion, especially from aerosol generating procedures. And finally, we’ve been warned that hospitals may become overwhelmed, and that there’s likely to be a need to care for patients at home. Ambulances and paramedics may be an increasingly scarce resource.
Taking all of these factors into account, how do we reconcile this with our decision making when considering whether to attempt resuscitation in the most elderly patients in the community? Out-of-hospital cardiac arrests have a survival rate in the UK of approximately 7%. This is significantly lower in older populations. And if the final destination, a hospital bed, may be either unavailable or unsuitable to provide dignified care to our older or frailer patients, then what should we do?
Are we demonstrating beneficence by taking an elderly patient from their home and transporting them to hospital, only, in all probability, to have them die without the comfort of relatives, in an overcrowded emergency department? Likewise, how does non-maleficence sit with potentially exposing household members and paramedics to coronavirus particles, potentially putting many more people at significant risk?
And justice? There’s a consensus amongst most that if we have a limited resource, such as a ventilator, it should be reserved for the person with the greatest probability of healthy life ahead, or for the young.
If a ship is sinking, difficult choices must be made, or all will drown
I’m not convinced that we’re always able to offer genuine autonomy when discussing resuscitation. It seems to be widely believed that resuscitation is usually successful. There’s little or no awareness among the public of the indignity involved. Most have never seen a resuscitation attempt, and don’t understand the sequelae arising from CPR, nor the numbers of patients who may be transported to hospital, only to die hours or days later. Is an uninformed choice, a truly autonomous one? Discussions are very different to the reality.
I can fully understand the thought process behind the letter sent by those GPs. Faced with the difficult task of communicating their concerns to a number of patients, they attempted to write an explanatory letter. They’re bound to be stressed, may not be sleeping, and are probably grappling with significant changes to their practice over the past few weeks. I have no doubt they were acting with good intentions.
So it was with disappointment that I read that the local health board has contacted the surgery, asking them to apologise to the patients. The surgery’s actions are described as ‘deeply concerning’ by their local MP, and ‘shameful and unacceptable’ by the older people’s commissioner for Wales.
I’m not saying the letter in question was perfect. Writing is clearly not the best way of communicating these issues. But in a crisis situation, which of us always acts perfectly?
‘Shameful and unacceptable’ would be to fail to address the resuscitation question; to allow our ambulance services to be overwhelmed with frail and infirm patients, with no hope of benefit, only to leave those who could be saved, without help.
GPs must be supported to have these challenging discussions. We need bold leadership from our health boards, royal colleges and Parliamentary representatives. There must be a clear presentation to the public what resuscitation involves, and why it may be futile under certain circumstances.
If Covid-19 continues to spread rapidly, it may get to the stage where ambulance services are instructed not to resuscitate certain groups, or transport these individuals to hospital. These aren’t easy decisions to make, but they could well prove necessary, and sadly the most ethical option available to us.
After all, if a ship is sinking, with limited lifeboat space, difficult choices must be made, or all will drown.
Dr Katie Musgrave is a GP trainee in Plymouth and quality improvement fellow for the South West