Catholic Medical Quarterly Volume 70(3) August 2020
Coronavirus and Access to Treatment: grave concerns and call for a public inquiry.
The National Institute for Health and Care Excellence produced very worrying guidance on Coronavirus management which appeared to suggest that anyone with mild dementia or mild frailty would be denied access to critical care. The Catholic Bishops of England and Wales issued a helpful statement on access to treatment when resources are constrained. As it turned out, the NHS was not overwhelmed by the first wave of this pandemic.
However, grave concern rightly arose as a result of the wrongful and inappropriate discharge of Covid-19 positive patients to care homes with the result that many more of the most vulnerable in our society became infected and died as a result. It is very clear that the NHS prepared for the Covid19 pandemic by seeking to empty as many beds as it could, while also seeking to reduce admissions from care homes etc. One way in which that was done was “end of life care planning”
The BMA produced a worrying video (see link in references below) in which Helena Mckeown spoke, She is the BMA Representative Body Chair (and we are also told in the video that she is a senior contraception and sexual health consultant who works in a psychiatric secure unit) spoke. While rightly protesting about shortages of personal protective equipment (PPE) she stated that on their secure unit they had been focussing on end of life care plans. That is worrying for a psychiatric secure unit. People in secure units are generally not dying. We know that end of life care planning was widely encouraged in care homes as a substantial part of the preparation for the virus. When in fact, of course, most of all, we needed to see the virus being kept out of the homes as much as possible. Especially when we see that people who were Covid positive were sent from hospital into care homes, people have a strong sense that the frail elderly have been let down. End of life planning is no substitute for protecting older people from a deadly virus.
Fr Patrick Pullicino, a neurologist who was ordained in 2019, told the Catholic Herald that an inquiry must be independent of the government, whose handling of the pandemic has been widely faulted. He said: “If we really want to move ahead, it has to be independent and people have to ask: why were the elderly treated in this way? And we have to have a change. We have to have a complete new way of looking at the elderly and their potential in society.”
“There has to be an inquiry,” Fr Pullicino said. “A fifth of the population has been basically denied reasonable healthcare and in an arbitrary fashion. Look at Captain Tom, what wonders he did. These are the people who are the backbone of the country. You can’t just say that they’re too expensive, they’re ‘bed-blockers.’You have to set up new systems to deal with the elderly.
Fr Pullicino was critical of NICE rapid guidelines, headed “COVID-19 rapid guideline: critical care in adults”, NICE presented a flowchart, updated March 27, helping doctors to decide whether adults admitted to hospitals with coronavirus symptoms qualified for critical care, which usually takes place in intensive care units.
Fr Pullicino highlighted a path on the flowchart that concluded with “end-of-life care” if a patient’s condition worsened after they were determined to be “more frail” but not suitable for critical care.
He argued that this encouraged doctors to treat sick elderly people who fell into this category as if they were dying, rather than as if attempts should be made to treat them.
Fr Pullicino said: “A major problem with those guidelines was that they said that those people who were not appropriate for ventilators, if they were over 65 and if they deteriorated, there was a line going to ‘end-of-life care,’ which was really wrong.
He continued: “When this whole COVID crisis started, people realized that there weren’t enough ventilators compared with other countries. We didn’t have a lot of NHS beds either because the number has been run down over the last number of years. So I think there was panic.”
“They decided to clear the hospitals to make a lot of space ready. The hospitals were cleared of the elderly and many of them were sent to nursing homes.”
The rapid NICE guidance clearly suggests that anyone who is more than mildly frail (struggling with heavy housework, or walking outside alone and shopping) should receive end of life care instead of critical care if they deteriorate (a clinical frailty score of >5). The clinical frailty score (https://www.bgs.org.uk/sites/default/files/content/attachment/2018-07-05/rockwood_cfs.pdf) states that in mild dementia, symptoms include forgetting the details of a recent event, while still remembering the event itself, repeating the same question and social withdrawal. Which is indeed, very mild dementia. Mild physical frailty includes people who are “slowed up” and need help with transportation, finances and heavy housework. Levels of frailty which the NICE guideline used to recommend that end of life care be considered instead of critical care.
Dr Adrian Treloar, a consultant and former senior lecturer in geriatric psychiatry, told Catholic Herald that he shared some of Fr. Pullicino’s concerns.
Referring to official guidance on care of those dying at home, updated April 8, he said: “The guidance on ‘caring for someone who is dying at home from COVID-19 infection’ is in fact very carefully written and very compassionate. And only to be used when absolutely certain that the person is dying and does not want to go to hospital. It is basic palliative care. But if it is used inappropriately for someone who has COVID-19 (and respiratory depression) it may be rapidly lethal.”
He continued: “Care homes saw considerable efforts to prepare for the pandemic by promoting end-of-life care planning, alongside a NICE guideline which denies critical care for people with mild to moderate dementia and which promotes end-of-life care as the alternative.”
Fr Patrick Pullicino, Lord Alton of Liverpool, a member of the House of Lords, have appealed separately for an inquiry into care home deaths.
COVID-19 rapid guideline: critical care in adults (Last update: 27 March 2020) www.nice.org.uk/guidance/ng159/resources/critical-care-admissionalgorithm-pdf-8708948893
Coppen, Luke. Catholics call for public inquiry into UK nursing home deaths. Catholic Herald May 25, 2020 https://catholicherald.co.uk/catholics-call-forpublic-inquiry-into-uk-nursing-home-deaths/
Hospice UK (2020) Caring for your dying relative at home with COVID-19 (updated 8 April) www.hospiceuk.org/what-we-offer/clinical-and-caresupport/what-to-expect/caring-for-your-dying-relative-at-home-with-covid-19
The clinical frailty score
British Medical Association facebook page at 1.13pm on 20th April 2020. https://www.facebook.com/TheBMA/videos/903582166744159