Critical care
the beginning of the pandemic, before testing became more widely available, many hospitals also had to send large numbers of staff with suspected Covid-19 symptoms home to self-isolate. “When you put all that together, you can quickly see how you end up with a higher number of patients, more complexity, more time needed to care for each patient and fewer people to do it,” Martin says. “That really adds to the uncertainty of, ‘How do I take care of these patients?’” With no national guidelines on managing such dilemmas, hospitals on both sides of the Atlantic have grappled with the ethical considerations around how to allocate resources if it came down to deciding between two patients for one bed or ventilator. Under normal circumstances, Cook explains, doctors are able to make choices based on which treatment is in an individual patient’s best interests. Without adequate resources, though, treatment options are more limited, and those decisions become much more difficult. “The fear in March was that the demand from Covid would outstrip resources, and that treatment decisions would have to be made based on an inadequate resource,” he says. In NHS ICUs, Cook feels these quandaries have, by and large, been avoided – both by reducing demand through national lockdowns and by diverting resources away from other, less urgent medical care. But, while NHS staff have worked hard to deliver care to their usual high standards, he adds, “At times it’s clear that the quality of care delivered has not been the same as normal.”
Morale hazard
These compromises on care, as understandable as they are, add to the already overwhelming toll on staff morale – and Covid’s grip on ICUs is not loosening any time soon. While much of the world looks optimistically to the roll-out of vaccines as a glimmer of light at the end of the tunnel, critical care staff continue battling in the dark. “I am gaining confidence that we’re getting there. But, for staff working in ICUs, the pandemic is still very much going on,” Martin says. “We still have severely ill Covid patients in our ICUs who are suffering every day, and we still have the challenges of keeping family members away from them because it’s not safe. There’s not necessarily an end to that in sight.”
For Cook, the situation is “less worse” than it has been, but the impact of lockdown measures and the vaccine roll-out will take longer to reach the ICU than the general hospital population because of the complexity and duration of care their patients require.
In the longer term, he adds, the legacy of the pandemic must be a change in the way ICUs operate. “There needs to be a bigger plan that enables us to
Practical Patient Care /
www.practical-patient-care.com 49 Care in the committee
The pressure Covid has put on high-performing ICUs around the world has no parallel in modern times. At the most desperate moments, health systems have had no choice but to ration care. Most, governments and health services have recommended that these decisions should be made by triage committees, but a recent paper by Alexander Supady et al in The Lancet (entitled ‘Allocating scarce intensive care resources during the Covid-19 pandemic’) found that this is ultimately impractical given the complexity of Covid-19 and the range of pressures it puts on hospitals, not least because the most important members of triage committees are often the ICU clinicians whose time is being rationed. As a result, triage committees have rarely been used, and the burden of making the hardest decisions has fallen squarely on the shoulders of individuals at the bedside. Moreover, the majority of the recommendations and guidelines triage committees have been given to assist them in making difficult rationing decisions are based on utilitarian calculations about likely outcomes that simply weren’t possible in the early days of the pandemic. Particularly when it comes to highly resource-dependent therapies like dialysis and mechanical ventilation, they are still difficult to perform with any confidence even now. Over-reliance on utilitarian principles also increases the risk of discrimination against poorer, less educated populations, as well as racial minorities and people with disabilities, as they tend to have worse health outcomes and higher rates of mortality. As such, Supady et al’s ‘Covid-19 informed approach’ to making rationing decisions in times of crisis incorporates egalitarian principles that help ensure equity – and are easier to implement for individuals in chaotic environments – alongside utilitarian considerations about how to efficiently distribute resources. The authors also recommend that triage committees set policies that help clinicians make quick decisions at the bedside, rather than try and take direct decision-making responsibility. These standards and guidelines should take some of the moral strain from clinicians by giving them tools for balancing complex competing demands (such as how to assess the different staffing requirements required for ECMO treatment versus mechanical ventilation alone) and helping them avoid biased decision making.
flex up and have increased overall capability, but also increased surge capability,” he says. This will mean investing in all four of those ‘S’s to better meet the needs of ageing populations and ensure that ICUs are prepared for scaling up in any future crisis. More immediately though, Cook says staff will need time and support to take the annual leave they’ve missed out on, see their families and recover mentally. Those needs may well find themselves at odds with a drive to resume other services as quickly as possible – but, if it is to be sustainable, getting back to normal will require patience and careful planning.
In the UK, the ratio of specialist nurses to Covid-19 patients in ICUs has been stretched from 1:1 to 1:3 – and sometimes even further.
Alexandros Michailidis/
Shutterstock.com
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