The coronavirus pandemic is forcing people to confront dilemmas around how much medical care should be given at the end of life. The emergency situation means doctors and patients are having to rush controversial decisions about turning down certain treatments, say palliative care experts.
鈥淭he crisis has brought to the fore a lot of the problems with decision-making around the end of life which have been simmering for ages,鈥� says Celia Kitzinger at Cardiff University in the UK. 鈥淐oronavirus has lit the fuse.鈥�
There has long been concern over whether some people receive excessive medical intervention at the end of their lives, when it merely prolongs the dying process. The best known such case is cardiopulmonary resuscitation (CPR), which is usually futile in those who are very old or sick.
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Now, attention is also falling on whether someone should get ventilation if their lungs are failing, especially as there may not be enough machines to go around. Ventilation can be distressing and has little chance of success in those who are very elderly or were in poor health beforehand.
People need to think about whether they would want to go on a ventilator, or even if they would want to go to hospital at all, says Kitzinger. She says those in the UK should make an advance decision, a legally binding document about someone鈥檚 medical choices, or give a relative lasting power of attorney so they can make decisions on their behalf 鈥� although this process can take months. Kitzinger is a founder of Advance Decisions Assistance, a charity that helps people take these steps.
In the UK, many family doctors are now phoning or sending letters to their patients who are elderly or have underlying health conditions to discuss opting out of CPR and other interventions. 鈥淧eople are essentially being cold-called to make really difficult decisions,鈥� says Kathryn Mannix, a palliative care doctor in northeast England.
However, even if someone says that they would want to receive CPR, doctors can legally still decline if they think it would be futile.
Medical bodies also seem to be rushing into preparations amid the surge in people becoming seriously ill. The UK鈥檚 National Institute for Health and Care Excellence (NICE) recently changed its new guidelines on who should get ventilation in response to claims these discriminated against people with autism or learning disabilities.
The original version was released 21 March and said people shouldn鈥檛 get ventilation if they are classed as frail, as gauged by a medical rating scale designed for elderly people. This category covers people who have problems with dressing or bathing, for instance. People with autism or learning disabilities may be cognitively unable to carry out such tasks, yet still be physically robust enough to benefit from ventilation.
A few days later, NICE changed its stance to say the guidelines don鈥檛 apply to younger people or those with autism or learning disabilities. They were developed in 鈥渁 very difficult period of intense pressure鈥�, a spokesperson told 快猫短视频.
Advance Care Planning Australia last month urged people to write down their preferences in an advanced directive and to tell their relatives and family doctor about it.
In the US, the federal health insurance programme Medicare encourages doctors to discuss end-of-life care, and about a quarter of people have made some kind of advance decision. But covid-19 is making such conversations more common, says Shoshana Ungerleider, founder of End Well, a charity that promotes end-of-life discussions. 鈥淢ore people are talking about it. I can鈥檛 imagine that [covid-19] won鈥檛 shift our perspective on this, at least for a short period of time.鈥�
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