Intended for healthcare professionals

Letters Misusing “criteria to reside” for hospital inpatients

The ethics of transferring adult patients to paediatric services

BMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m4089 (Published 23 October 2020) Cite this as: BMJ 2020;371:m4089
  1. Thomas Hampton, otorhinolaryngology specialist registrar,
  2. Victoria Sadlers, paediatrics specialist registrar
  1. Alder Hey Children’s NHS Foundation Trust, Liverpool L14 5AB, UK
  1. thomas.hampton{at}nhs.net, v.sadlers{at}doctors.org.uk

Oliver discusses some ethical issues that arise from changing pathways of care to manage demand.1 We present another altered treatment paradigm from the first wave of covid-19 that required novel ethical decision making. Similar to Massachusetts General Hospital for Children,2 Alder Hey Children’s NHS Foundation Trust accommodated adults in its paediatric intensive care unit. Fortunately, few local children with covid-19 were admitted to hospital, so the trust offered to relieve pressure on adult services.

Anticipating major pressures on services, our institution formed a clinical decision making committee and a clinical ethics committee.3 This multidisciplinary team met daily to provide guidance and support and to tackle any ethical matters that arose. A substantial concern remains, however, regarding the lack of consent for transfer of critically ill patients to units that do not usually treat adults.

The General Medical Council’s new decision making and consent guidance4 intends to foster shared decision making so that patients can make healthcare decisions that are right for them. This almost directly contradicts the pandemic mindset that resource allocation is a key part of distributive justice from a utilitarian perspective. Many patients accept that usual services might not be available in the event of unprecedented demand. The previously mentioned adult transfers were undoubtedly undertaken with good intent, but the question must be raised: with the rise in patients with covid-19 requiring hospital admission in the north west of England,5 could transfer of adult patients into paediatric intensive care units be justified again?

Staff in the paediatric intensive care unit were extensively supported by colleagues in adult medicine from other sites in Liverpool, but the definite quality of care provision is not quantifiable, and mortality cannot be compared between sites, so the care received cannot be proved to be equal or superior to that provided by our counterparts in adult medicine. The moral injury suffered by repurposed healthcare workers has been documented.6 Can we expect staff to seek informed consent from patients for their transfer between hospitals when the objective details of outputs and outcomes are not yet appreciated by the staff themselves?

Footnotes

  • Competing interests: TH receives grant funding from the Wellcome Trust. Neither author has any other conflict of interest, financial or otherwise.

  • Full response at: https://www.bmj.com/content/370/bmj.m3747/rr.

  • TH and VS are joint first authors.

References