Making ordinary decisions in extraordinary times

Dear Editor

Burman et al comment about limited national decision-support guidance for the COVID-19 pandemic [1]. With respect to professional medical organisations we would contest this assertion particularly with respect to decision making surrounding admission to intensive care.

Prior to the pandemic (September 2019) the Faculty of Intensive Care Medicine published guidance on decision making, advance care planning and end-of-life care [2]. This included a three stage decision-making tool developed at the University of Warwick to enable clinicians to gather evidence, identify outcomes and then implement individualised treatment plans [3].

In the first week of March 2020, a working group representing multiple professional organisations, led by the Royal College of Physicians of London, developed detailed guidance and accompanying resources for the clinical management of patients with COVID-19, addressing:

• Clinical decision-making
• Clinical frailty
• Patient information
• End-of-Life Care

The guidance was made available on an open access website, and widely promoted by all of the stakeholders: https://www.criticalcarenice.org.uk/

The frailty guidance specifically addressed how the Clinical Frailty Scale should be appropriately used in clinical decision making. (Box 1)

Box 1 Best practice when using the Clinical Frailty Scale

DO remember that the CFS has only been validated in older people; it has not been widely validated in younger populations (below 65 year of age), or in those with learning disability. It may not perform as well in people with stable long term disability such as cerebral palsy, whose outcomes might be very different compared to older people with progressive disability. We would advise that the CFS is not used in these groups, however the guidance on holistic assessment to determine the likely risks and benefits of critical care support, and seeking critical care advice where there is uncertainty, is still relevant.
The CFS should not be used in younger people, people with stable long-term disabilities such as cerebral palsy, learning disabilities or autism.

The Clinical Decision Making framework was intended for use not only during the pandemic but in all circumstances, countering the implication of a reactive rationing approach suggested by Burman et al [1]. This practical guidance was followed rapidly by an ethical framework for frontline staff working with COVID-19, prepared by the Committee on Ethical Issues in Medicine of the Royal College of Physicians and supported by many other professional organisations [4]. This ethical guidance was openly available online from the end of March 2020.

Whilst there are undoubtedly opportunities to further develop and disseminate the guidance, particularly with our growing understanding of the behaviour of COVID-19, it is a credit to the professional bodies that they were able to work collaboratively to prepare such support for front line clinicians at very short notice.

References
1. Burman R, Cairns R, Canestrini S, et al. Making ordinary decisions in extraordinary times. BMJ 2020;370:m3268. doi: 10.1136/bmj.m3268
2. Care at the End of Life: A guide to best practice, discussion and decision-making in and around critical care. Faculty of Intensive Care Medicine, London 2019
3. Bassford C, Griffiths F, Svantesson M, et al. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. Health Serv Deliv Res 2019; 7(39)
4. Ethical dimensions of COVID-19 for frontline staff. Royal College of Physicians, London 2019.