Covid-19: most patients require mechanical ventilation in first 24 hours of critical careBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m1201 (Published 24 March 2020) Cite this as: BMJ 2020;368:m1201
All rapid responses
The biggest take-away from this article, is surely the TWO-THIRDS of patients requiring critical care who received ventilation. Why aren't we talking about what this means NOW? The Italians have warned us (1).
And NEJM has produced some initial ideas about explicit rationing of ventilators (2) This suggests that volunteers to a committee should 'shoulder the burden of responsibility'.
Now please don't think I am saying here that I know the answers to this terrible problem.
However, decades ago, I led the first explicit rationing of health services in England, This was in a much less life and death situation than now, but maybe some of the lessons I learnt could be helpful?
So here goes:
1.Start with the evidence about benefits and costs. We’ll need to collect more of this, fast, as we go along. But an up-to-date evidence-based policy is much easier for the patients, families - and the clinicians - to accept.
2. One key part of any rationing is saying what will be done instead of the rationed intervention. In my example, all that time ago, we wanted less people to have cosmetic removals of lump and bumps and more people to have hip replacements. Now, we need to be able to offer supportive care if a ventilator is not available. Palliative care needs to be immediate, not only at the last minute.
3. Explain the policy clearly - to patients, families, communities, clinicians and the press. When I did this all that time ago, there were meetings with the local GPs where we discussed and made small amendments to the policy. There were public meetings too: the largest overflowed out of the main chamber of a Town Hall onto the street. Of course we can’t have traditional meetings now. And you might say we haven’t got time for involvement. But I think we haven’t got time not to have some (fast!) involvement, because of my next point
4. Protect the clinicians who are actually making the hard decisions on the frontline. Clinicians need to know what to do, rather than spending time and agonising energy trying to make a decision. A clear policy, with proper buy-in, makes this easier. We found written resources really helpful - even if they were very difficult to write. Now, social media and internet resources can be made available. It’ll still be difficult to write!
5. NEJM suggests that a specific group of volunteers make the most difficult decisions. To minimise the agonising, we had a no-exceptions ‘rule’ to our clear criteria. With a swift system for the small number of exceptions that inevitably did need to be considered. Those of us looking at the exceptions were protected too: we explicitly looked after each other. A specific non-clinician could make decisions about the ‘exceptions’ that weren’t really exceptional (and we looked after her). It was really helpful when we enrolled a lay person to be part of the decision-making process.We might have been hesitant about doing this to start with, but she was quickly worth more than her weight in gold and I would definitely recommend finding the right sort of lay person/people and paying them for the difficult job you are going to ask them to do.
6. Handling the press. Get this right, and the media can be very helpful. Get it wrong ,and they’ll eat you for breakfast, lunch and tea. See 3 above, and spend enough time tailoring your message. if you think you don’t have time for this - think again. You definitely won’t have time after you get it wrong!
As before, I don’t mean to say that this is THE definitive answer.
But I hope it might be a start.
Competing interests: I'm being shielded (I prefer to follow the Irish and think of myself as cocooned). Even though I have lots of useful experience, with my sort of ill-health retirement, I'm not allowed to volunteer for NHS work. So I'm volunteering to ask one of the questions that it seems no-one is.