Covid-19: A wake-up callBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2021 (Published 21 May 2020) Cite this as: BMJ 2020;369:m2021
All rapid responses
Covid-19 has indeed been a wake-up call not just in medicine but also society and the environment [1-3]. It is important that we learn from this pandemic and use it to make positive changes to our futures. One interesting area has been with regards to cardiopulmonary resuscitation (CPR) and treatment escalation and limitation (TEAL) decisions.[4,5] An area that has not been addressed is the positive impact of coronavirus on these discussions.
I have carried out a neurology inpatient based audit entitled “Covid-19: The impact on CPR and TEAL decisions”. This assessed the choices made pre and post the United Kingdom's nationwide lockdown at a tertiary referral centre in Birmingham for neurology inpatients during the month of March. The audit standard adopted was the professional guidance published jointly by the British Medical Association, Resuscitation Council and Royal College of Nursing in 2016.
The first audit cycle looked at the three weeks prior to the SARS-CoV-2 lockdown (23rd March 2020). The reason behind this audit was two-fold: firstly the observation that decisions often weren’t made and secondly, the impending coronavirus pandemic. It is important to remember the consequence of 'no decision'. It is the default presumption of full escalation on the basis of 'least harm'. However this may not have been the patient’s wishes nor in their best interest. Furthermore, the need to don personal protective equipment and the increased risks for the medical staff carrying out the resuscitation complicate the estimation of 'least overall harm'.[4,5] Within the first 3 weeks in March we had 47 neurology inpatients of which 13 had been admitted within that time frame and 21 were discharged. CPR and TEAL decisions were only made in 8.5% of this group. This is likely to be in keeping with the experience of colleagues from across the country as this is a common topic for audit in most specialties with marked variability.[8,9] From a neurology perspective the care of a large proportion of our patients is, by the nature of their problems, palliative. However this situation may last for decades thus resuscitation and escalation plans are generally not required acutely.
The Covid-19 pandemic rapidly changed all our lives including potentially cardiopulmonary resuscitation decision making as highlighted in the BMJ editorial by Zoe Fritz and Gavin Perkins published on 6th April 2020. There has additionally been variability in the guidance across the United Kingdom. Prior to this audit’s second cycle NICE published their Covid-19 rapid guideline regarding critical care in adults (20th March 2020). This recommended the assessment of frailty in all adults admitted to hospital with an algorithm to aid escalation decisions. It is important to note the need for individualised assessment in any patient under 65 or of any age with stable long-term disabilities.
The second audit cycle addressed the weeks following the lockdown (from 23rd March 2020) with a dramatic increase in the decision rate initially to 87% during the first week then 100% decision rate following this. The intervention of Covid-19 made a significant difference to the process (Chi squared 33.3, p<0.00001). However this increase was marginally in favour of resuscitation 12 (52%) and full escalation 14 (61%) for those decisions made subsequent to the UK lockdown.
The reasons behind the increased resuscitation and escalation plans made is multifactorial and the outcomes can be dependent on how the topic is broached. More receptive patients, relatives and medical teams as well as realistic prognostic and multi-disciplinary discussions are all likely to have contributed to the decision-making process. In these challenging times CPR and TEAL decisions have additionally often had to be discussed over the phone, which one might have thought would have had the opposite effect to the one found by this audit. There has also been a greater focus on these decisions from management with the regular Trust coronavirus emails that, we are all familiar with. If these results are replicated across specialties and hospitals, then now could be an important time to shape the future of escalation decision making.
The real test will come following this acute phase, with its constant media coverage, fear, and lockdown. We need to decide as a medical community and as the United Kingdom how to remove the taboo surrounding discussions on death and how it occurs.
1. Godlee Fiona. Covid-19: A wake-up call BMJ 2020; 369 :m2021
2. Alderwick Hugh, Dunn Phoebe, Dixon Jennifer. England’s health policy response to covid-19 BMJ 2020; 369 :m1937
3. Renee N. Salas. Lessons from the covid-19 pandemic provide a blueprint for the climate emergency. BMJ Opinion 2020. https://blogs.bmj.com/bmj/2020/04/23/renee-n-salas-lessons-from-the-covi...
4. Fritz Z and Perkins GD. Cardiopulmonary resuscitation after hospital admission with covid-19. BMJ 2020; 369 :m1387
5. Mahase E and Kmietowicz Z. Covid-19: Doctors are told not to perform CPR on patients in cardiac arrest. BMJ 2020; 368 :m1282
6. British Medical Association, the Resuscitation Council (UK) and the Royal College of Nursing. Decisions relating to cardiopulmonary resuscitation. 2016. 3rd edition (1st revision).
7. Fritz Z, Slowther A-M and Perkins GD. Resuscitation policy should focus on the patient, not the decision BMJ 2017; 356 :j813
8. Perkins GD, et al. Do-not-attempt-cardiopulmonary-resuscitation decisions: an evidence synthesis. Health Services and Delivery Research. 2016.
9. Pitcher D, Fritz Z, Wang M and Spiller JA. Emergency care and resuscitation plans. BMJ 2017; 356 :j876
10. National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults [NG159]. 2020. Accessed at: https://www.nice.org.uk/guidance/ng159.
Competing interests: No competing interests
A healthy diversity of views and untrammelled discourse is essential in any decent society. The editorial scepticism directed toward the current UK government does, I believe, reflect a general consensus view - both public and professional - and no hint of an apology is required. Supporting a government that has so conspicuously and horrendously failed the nation, no matter how frenetic their post hoc gyrations, would be a mistake.
Pandemics are foreseeable and foreseen.
On current evidence it is reasonable to assert that this Tory government and its immediate predecessors have demonstrated unequivocal maladministration, negligence and incompetence resulting in the largest loss of life in peacetime for a century, for which they must collectively bear direct and personal responsibility. No amount of misdirection of public attention to scientific advice received, referencing of ideological idées fixes, pleas of national poverty, lack of clear advance warning, simple force majeure or act of God will suffice as exculpation.
The Tories have been in office for more than a decade and have so damaged our country in that time that many tens of thousands of avoidable deaths are directly attributable to their acts and omissions. No other UK government has precipitated a reduction in life expectancy. The pandemic is not the only cause of excess deaths. There is no one else in the dock to share responsibility.
The central conceit in the Tory mindset is that a low tax, low regulation, small government posture is an intelligent or practical approach to government in the 21st century. This Tory approach is, in fact, a purposive abdication from the central responsibilities of government - to govern for the benefit of all. Laissez faire neocon free market ideology is no adequate substitute for effective government. Corralling a population without adequate regulatory safeguards in an economic free fire zone is unforgivably barbarous.
Modern, first world countries, like the UK, are terrifyingly expensive to run properly. Positing, as a policy virtue, not raising and spending the sums required to achieve a decent, equitable, educated, healthy, harmonious, productive, peaceful and orderly civil society is simply culpable idiocy of a very high order and, in our current predicament, the direct cause of death for many of our fellow citizens.
Aux armes citoyens!
Competing interests: No competing interests
The current COVID-19 Pandemic has changed the education system, destroyed the economy, devastated tourism and dismantled health infrastructures. It has also increased joblessness, distanced love, introduced risk in shopping, fear in travelling and threatened life in all age groups irrespective of socioeconomic status.
In thes 21 weeks, COVID-19 infection has spread across 213 countries. It has affected 5.2 Million people and it has caused over 3.3 lakh deaths.
As of now only 0.07% of the world population are affected by COVID-19 infection. But the vast majority of people are at increased risk because of lack of social distancing and self hygiene. Lack of specific antiviral drugs and vaccines have also added more difficulties in the management and prevention of COVID-19 infection.
The current COVID-19 Pandemic has exposed public health and other primary and tertiary health care infrastructure inadequacies in almost all countries.
Many factors like ego, blaming others and cutting the funds to control COVID-19 spread as revenge are not a good sign in tackling the worldwide problem that arises out of the current COVID-19 Pandemic.
This is not a time to blame and find fault with each other. But it is time to act jointly to beat the COVID-19 spread with like mindedness.
It is not a war against many enemies. But now the common enemy is a single agent in the air and by that everyone is facing the same risk.
So a global cooperated action with individual self hygiene and social distancing will help to avoid COVID-19 infection. The early invention of vaccine will helpful to prevent and eradicate COVID-19 spread.
Competing interests: No competing interests