The Covid-19 pandemic has transformed many aspects of medical practice in the NHS, including, and perhaps especially, end-of-life care. In a new piece of research published in the Journal of Medical Ethics, we investigate how the COVID-19 pandemic is changing the ways doctors in the NHS make end-of-life decisions. The research was conducted by questionnaire sent to 231 NHS doctors between May and August 2021, during which COVID-19 hospital cases were relatively low. There were three areas that the questionnaire focussed on: DNACPR decisions, treatment escalation, and views on medically-assisted dying
DNACPR Decisions
At the start of the UK COVID-19 epidemic, there was an increased urgency amongst both hospital and community clinicians to make DNACPR decisions for their patients, in part due to the increase in cardiac arrests linked to COVID-19 infections. However, a year into the pandemic, the Care Quality Commission published their “Protect, Respect, Connect- Decisions About Living and Dying Well During COVID-19” report which highlighted several areas of concern about DNACPR decision-making during the pandemic. It found that 30% of patients surveyed with DNACPRs were not aware that a DNACPR had been put in place, and 35% felt they were not given sufficient information. The report also criticised the use of “blanket” DNACPRs across over a hundred adult social care settings.
In light of these developments and controversies, we sought to investigate if there had been a significant effect of the pandemic on DNACPR decision-making in the NHS.
Our results showed that over half of participants (54%) reported that they are now making more patients DNACPR than pre-pandemic, and this was due, at least in part, to an increased focus on factors including patient age, clinical frailty scores, and resource limitations. We suggest that this may indicate a subtle shift amongst some clinicians, away from the patient-centred ethic mandated by the General Medical Council, and toward a more utilitarian ethic as proposed by the British Medical Association near the start of the pandemic in their “COVID-19- Ethical Issues” guidance.
Treatment Escalation
At the beginning of the pandemic, there was widespread concern over the UK’s ITU capacity to cope with the unprecedented numbers of critically unwell patients. In response, the National Institute for Health and Clinical Excellence published their “COVID-19 Rapid Guideline” which stated that admission to ITU should only be considered if a patient is likely to recover. There was also increased focus on early palliative care intervention, with several influential medical journals publishing articles guiding clinicians on early palliative care for patients with severe Covid infection. These concerns around ITU capacity and emphases on early palliative care led us to investigate if the pandemic has caused clinicians to raise their thresholds for referring patients to ITU, and/or lower their thresholds for palliation.
Our research found that the largest proportion of participants had not changed their thresholds for escalating patients to ITU or palliating patients since the start of the pandemic. However, a substantial minority did report that they now had a higher threshold for escalating to ITU (i.e. escalating less; 26%) and a lower threshold for palliation (i.e. palliating more; 23%). When asked for the reasons for this, several participants cited formative experiences during the peaks of the pandemic that educated clinicians on the burdens and limitations of ITU care, and the value and appropriateness of early palliation.
Medically Assisted Dying
In 2019 and 2020, the British Medical Association, Royal College of Physicians and Royal College of GPs polled their members’ views on the legalisation of medically-assisted dying. Significantly, all three surveys were carried out before the start of the pandemic. There is little data available on how the experiences of the pandemic have changed clinicians’ views on the legalisation of medically-assisted dying, if at all. This is of clear contemporary relevance in light of Baroness Meacher’s Assisted Dying Bill which is currently in the parliamentary committee stage.
Our research found that pre-pandemic, the largest proportion of participants were opposed both to the legalisation of euthanasia (47%) and physician-assisted suicide (51%). These results were similar to those of the Royal College of Physicians’ 2019 survey. We then found that since the start of the pandemic, there has not been a statistically significant change in views of clinicians on the legalisation of euthanasia or physician-assisted suicide. The largest proportion of doctors still remain opposed to both.
Conclusion Â
In summary, our research found that over half of clinicians surveyed reported that they are now making more patients DNACPR than pre-pandemic, and a sizeable minority now have a higher threshold for referring to ITU, and lower threshold for palliation. Views on euthanasia and physician-assisted suicide appear to have stayed the same.
The aim of our research was not to judge the ethics of the various changes that have occurred since the start of the pandemic. Nor was it to suggest amendments to policies or practices. Rather, our endeavour was to contribute some initial data and discussion around the important topic of how COVID-19 is changing end-of-life decision-making in the NHS. There is much more research that needs to be done in this area, particularly as the pandemic continues to evolve and the medical profession adapts to the long-term effects of the pandemic.
Dr Benjamin Chang is a Medical Ethicist and A&E Doctor working in London. He speak regularly at conferences and universities on a range of ethical issues and debates.