Catholic Medical Quarterly Volume 71(3) August 2021

In Haec Tempora

Reflection on working in Covid times.

Many of us have thought a lot about Covid over the last year.
But here are thoughts from one of our Intensivist Consultants, honed upon the anvil of running ITU through the pandemic.

January 13:

As anaesthetists and intensivists we may have been brought up on stories of the birth of ICU in Copenhagen in 1952, in the midst of a polio outbreak. For those unfamiliar with the story, a severe outbreak of the polio virus caused paralysis of respiratory muscles in many of those affected. The high rate of survival was partly due to intubation and IPPV rather than the traditional negative pressure ventilation via Iron Lung. It also rested to a large extent on the heroism of the medical students and others who, hand ventilating these intubated patients in relays for weeks on end, did the work of breathing for them until such time as the paralyzing effect of the polio wore off.

Today, we are blessed with a plentiful supply of mechanical ventilators and could reasonably hope for an easier ride – if Covid-19 were similar to polio. Unfortunately it is not and, instead of merely weak respiratory muscles we have to contend with full-blown ARDS, widespread inflammatory responses, thromboembolic events, renal failure, etc. Despite sophisticated ventilation machines and drugs, as well as well-trained staff, the figures for mortality once patients reach ICU are stark.

We will lose patients in Intensive Care to COVID-19 despite the best available care and no matter how hard we try. This is something to feel sad about, not something to feel bad about. We have to tell ourselves that not succeeding in preventing death due to infection, where all reasonable steps have been taken, is not a failure. We have to draw optimism from witnessing the best care possible delivered despite the adverse outcome. What Dunstan said in 1984 is just as true today. “The success of intensive care is not, there­fore, to be measured only by the statistics of survival, as though each death were a medical failure. It is to be measured by the quality of lives preserved or restored; and by the quality of the dying of those in whose interest it is to die; and by the quality of human relationships involved “in each death.” (Hard questions in intensive care G. R. DUNSTAN Anaesthesia, 1985, Volume 40, pages 479-482)

Life is not fair:

Anyone who remembers being a child, or who has children will know this but it is a useful thing to remember in these Covid times when not everyone can have everything – Life is Not Fair. We will not be able to treat everyone to the utmost of our ability and in some cases, we may not be able to treat them at all. This may be a tragedy, but not one of our making; life is not always fair, we can blame who and what we like (COVID-19 seems the most appropriate) but it doesn’t change the reality and we need to be capable of putting this behind us, moving forward and preparing to manage the fresh encounters each new day will bring.If we needed a stark reminder that life is not fair, it came with the cancellation [earlier this year] of our second jabs. It may help to focus on the positive – that other people will thereby get some protection rather than the obvious negative.

A word about Decisions
(Doctors are not Gods).

We may hear a lot of talk about Doctors playing God but, unless doctors are taking decisions to deliberately end patients’ lives – active euthanasia – which is unlawful and unethical, I doubt this is the case. Most doctors I know realize they are not infallible and, even in the best of times, will reflect on decisions with serious consequences and worry about whether they did the right thing. It is wise, therefore, when choices are difficult to weigh and lives hang in the balance, to seek a shared opinion where possible.

While it is useful to have an understanding of ethical principles referral to an expert in ethics does not always provide one best answer to our difficult clinical decisions (the joke goes that if you ask two ethicists and you will get three answers). Different ethicists may, depending on the principles and values deemed most important to their ethical model, come up with differing answers. Even where only one ethical model is employed much will depend on the weight ascribed to the various facts. Decisions can be particularly difficult when we are working with suppositions and may not have the luxury of delaying our decisions until these crystallize into facts.

The cornerstone of modern intensive care and, by extension, wider medical care, is to deliver appropriate care to sick patients when it has a possibility of benefiting them and, when and if a point is reached where that treatment is no longer of benefit, to stop providing that therapy and, possibly, provide alternative therapies. Where there are no longer appropriate curative therapies, palliative and life-prolonging therapies may still be employed should these have clear benefits for the patient. At some point, active treatments may or ought to be withdrawn, if the patient is judged no longer likely to or capable of recovery and the focus switches to end of life care. At no point is a judgment being made that treatment be withdrawn from one patient in order that another, more deserving patient get it; we do not judge that some persons are worthy to continue living and others are not.

In choosing who to admit to intensive care the choice ought to reside with an estimation of the likelihood that an individual can clinically benefit from and respond to the treatment escalation rather than any value judgment of the relative worth of two individuals as human beings. And, once accepted as a patient through the good fortune of the circumstances, that patient should normally continue to receive the escalated care as long they are demonstrating a benefit, even if other, apparently more deserving, cases come along. To do otherwise would be to risk playing God.

All of this is true and yet, there are occasions like pandemics when we might question this. What if we are overwhelmed and there are patients, deserving of our intensive care but no available ventilators? Then, like those who work in war-torn areas we will just have to do our best with whatever we have, delivering the best avail­able care in the worst of circumstances. We may need to reconsider our normal practices and apply stricter and harsher criteria to determining the relative merits of continuing treatment in some cases, knowing that to do otherwise is to deny other, possibly younger, fitter patients with a much better chance of recovery any chance at all. It will not be pleasant and we can all expect to experience some degree of moral injury in the process. We must then particularly look to one another for strength, for kindness and for understanding in order to heal our wounds and fulfill our destiny as compassionate, caring human beings and as healthcare workers. I enclose as attachment a paper from the Anscombe Bioethics Centre which examines the issue and which I believe is one useful opinion, notwithstanding that it is written from a Catholic perspective. I also enclose links here to some guidance from the BMA https://www.bma.org.uk/advice-and-support/covid-19/ethics/covid-19-faqs-about-ethics
and an AAGBI webinar https://icmanaesthesia­covid-19.org/webinar/dilemmas

Although we prepare for the worst, nevertheless we hope for the best. Regardless the course of events, we can expect outcomes to be worse than at other times. Adverse events happen at the best of times; in these worst of times we can expect that these may be more frequent. All we can do is be on our guard and avoid overcomplicating the situations we find ourselves in. Keep things simple where possible. Look out for each other.

Jan 22 2021
“There’s no art to find the mind’s construction in the face.”

This phrase from Macbeth (Shakespeare) – uttered by Duncan as he ordered the execution of the Thane of Cawdor for treason and prepared to appoint Macbeth in his stead - stayed with me throughout my career as a pain specialist. I remembered it as patients told me that, because their chronic pain was not visible, their suffering went unrecognised as did their pleas for help, for understanding, and for compassion.

Just the same, the outer form of those of us with mental health problems does not always align with what’s inside - the nerves on edge, the throbbing scars gaping from the stress and strain, the stigma and the shame – shrouded even from those we call our friends. Those of us with mental health problems have long known what it is to wear a mask to work, to wear a mask out shopping, to wear a mask with family and friends. Those of us did not need Covid to teach us this, nor how to isolate in groups of one.

It is estimated that as many as 1:4 doctors are at risk of being those of us with mental health problems. What then, should we do, if as many as 25% of us are at risk and yet there is no easy way to find the mind’s construction in the face? Two things would help.

Firstly we just need to be constantly aware that, unbeknownst to us, behind their masks, others may be feeling the strain. If we can remember that, and cut each other slack, especially in these weeks of pressured time, that will go a long way. Be kind and gentle, even where we might wish otherwise. Rather than the example of power, give the power of example and treat others as we would wish to be treated ourselves.

And so we lift our gaze not to what stands between us, but what stands before us.
We close the divide, because we know to put our future first, we must first put our differences aside. (Gorman, 2021)

And, secondly, we can all acquaint ourselves with the five ways to mental health and, despite lock-down, isolation, fatigue and more, strive to

  • Connect with others,
  • Be Active,
  • Be Curious,
  • Keep Learning and
  • Give.

In that way we are less likely ourselves to be at risk.

Feb 21 2021

We continue to live in the shadow of death and dying, in a society that is unused to talking openly about death or preparing for the event.

Few of us who work in theatre or ICU have experience of nursing the dying patient on a ward or in a hospice setting over a period of weeks or months; the relationships we develop are usually with the friends and relatives of the dying person rather than with the individual themselves. For this reason we may understandably struggle to relate our experiences of looking after those with Covid­19 during their final days and hours with what we have experienced before or been trained and prepared for.

As a society we should not find the idea of death upsetting; it is after all what gives meaning to life. Conversely, as seasoned and experienced health­care workers we should not be embarrassed or ashamed of our ‘weakness’ if we still find ourselves upset by deaths of others. When it can sometimes seem as if the practice of healthcare is all about machines and numbers, our being affected by another’s death is a sign of our continuing engagement with our own humanity and that of others, however remote it may seem at times.

John Donne (1572-1631) famously wrote in Meditation XVII :

No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a promontory were, as well as if a manor of thy friend's or of thine own were: any man's death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee.

However, we are not accustomed to the numbers of deaths occurring in relatively young people that could, in other circumstances, be ourselves or our parents (for the younger among us). Apart from feeling increased emotional distress because of their relative youth, this may be a Momenti Mori or unwelcome reminder to us that we ourselves are mortal. How each of us deals with this will depend in part on our prior experiences in life, in part on our own circumstances and support mech­anisms, and in part on our own beliefs around death and dying.

During the week I came across an article entitled Protecting the wellbeing of nurses providing end-of­life care by Cedar and Walker (2020), Nursing Times [online]; 116: 2, 36-40. I attach it for any who want to read it. Along with the now familiar discussion of burnout and various strategies such as enhancing resilience, using mindfulness, etc., there were a couple of things that caught my eye. Firstly the following quote from a paper about the lived experiences of physicians dealing with patient death:

“At critical moments surrounding a patient’s death, non-palliative physicians were more likely to focus intensely on the actions of care, while palliative physicians focused on the importance of “simply being present” with dying patients when nothing else could be done.” Whitehead (2014)

Secondly, amongst all the other support, Cedar and Walker strongly promoted Healthcare chaplaincy services for nurses (as opposed to patients), emphasizing that they are available to people of all faiths and none and bring experience of death and dying in a family context.

“Healthcare chaplains offer:

  • Independence from nursing professional bodies but maintain the same standards of professional practice;
  • Confidentiality;
  • Experience of death, dying and bereavement in families, and a shared understanding of the emotional labour for nurses;
  • Pastoral or spiritual care, as required by the individual;
  • One-to-one listening;
  • A safe space and their own training and expertise in providing compassionate care;
  • A freely available service that can be accessed once or several times to suit the needs of the nurse;
  • A source of support that does not necessitate the nurse learning new skills.”

Both of these ideas resonated with me because of similarities with what I had discovered about dying practices in past ages whilst doing a degree in Medical Humanities at Swansea some years ago. In my dissertation I wrote: “In later centuries Ars Moriendi faded back into a matrix of Christian prayer and practice (Duclow, 2012). Duffin (2009), cites Falconieri (1726) in support of a tradition of ‘abandonment’ and ‘despair’ by doctors faced with incurability; they left their patient to the discretion of nature and were expected to indicate that it was time to summon the priest. Practices such as the collective praying by the attendants for the unconscious dying individual (Duclow, 2012) might fall foul of regulations in secular hospitals today. Nevertheless, in individual cases it remains possible to summon a chaplain at a family’s request.”

We should regard our chaplains as being available not just for our patients and their families, but also for ourselves as staff, and remind ourselves that they provide an additional resource alongside Trust counsellors, Charities such as Mind, and the various online resources.

Not all chaplains are religious; some are humanist or spiritual in other ways. The perspectives they bring are no less valid.