Whither ethics – on triage and Nightingales

“It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm.”

Florence Nightingale, Notes on Nursing: What It Is, and What It Is Not.

The coronavirus disease 2019 (COVID-19) continues to define 2020. Across the world it is causing medical, financial and social distress. It is destructive both physically and psychologically. Many countries have been grappling with national lockdown and wholescale reorganisation of their healthcare systems to cope with the expected epidemic surge (or wave) of cases – the purpose of social distancing (perhaps better referred to as aiming for people to be physically distanced and socially connected) and latterly lockdown, has been to flatten the wave from a tsunami to something smaller, and the purpose of the healthcare reorganisation has been to scale up services to deal with that wave.

In the UK we have been luckier than some. In Wuhan, China the healthcare system was rapidly overwhelmed by an epidemic surge it could not have prepared for. One well-highlighted response was to build several new hospitals – at breakneck speed and to use other communal areas for stepdown-care and oxygen delivery. Outside of the hospitals the country was put into a rigorous lockdown and this reduced R₀ to < 1 and controlled the epidemic in the rest of the country – at least for now. When Lombardy, Italy became the epicentre of the emerging pandemic, its healthcare system was also overrun with Northern Italy and then the whole country entering a strongly policed lockdown.

The ‘fortune’ we have had in much of the UK is both time and information to make preparations. To get our health service in the most suitable state to deal with the pandemic effects of COVID-19, major changes to all aspects of care have been implemented. All but the most urgent surgery has been stopped. Non-urgent outpatients ceased. Hospitals have been emptied in preparation. Staff have been given crash courses in use of PPE and skills that may aid the respiratory and critical care services. ‘Cross-skilling’ has entered the medical lexicon.

Despite the time for preparation and the enormous efforts on all levels to be ready, the UK NHS has, in some parts, struggled. Hospitals have been overwhelmed by the scale of admissions, leading one to put out a desperate call for volunteer assistance to transfer critically ill patients to other hospitals when the scale of its influx was too high. In another incident, hospital oxygen supplies failed, again requiring urgent transfer of critically ill patients to other hospitals. Behind these front-page stories there are likely many more hospitals operating at or beyond their limits – even after increasing their capacity as much as they can.

So why the title of this blog? At first glance the topics seem unrelated; but some thought reveals that triage and the new Nightingale hospitals, rapidly commissioned and brought into service across the UK, are two sides of the same coin – or perhaps two solutions to the same problem.

The models have predicted that, despite best preparations within and outside hospitals, the service will be stretched or overwhelmed in most parts of the country for a sustained period of time. That the surge of patients needing admission, oxygen and ICU care may all be several-fold too high for even the maximum capacity. There are, broadly speaking, two potential solutions: triage and Nightingales.

Triage

Triage is a term borrowed from the battlefields of war and usually involves attempting to select, in a mass casualty situation, those patients who are most in need of immediate medical care in order to survive. The walking wounded and those unlikely to be saved are not prioritised. In the pandemic situation the process may be turned on its head (so called reverse triage) and, in the setting of inadequate resource, selection seeks to identify those patients unlikely to survive. These patients are then not offered advanced treatment but must be cared for differently, treating them symptomatically and compassionately in anticipation of their death.

A central tenet of any medical care is that it should provide benefit and be consistent with what the patient would want. It should only be for those who can survive and only for those for whom it offers a future with a quality of life they would want. The treatment itself should not cause suffering that the patient would find intolerable. Where possible, the question of benefit is grounded in clear knowledge of what will happen to that patient, but in truth clinicians are not great predictors of outcome and so we often err on the side of caution and offer trials of treatment, including ICU care in the hope it will work. In normal circumstances the ethics of patient care is straightforward, even if predictions of outcomes and decisions are not. The ethical framework of medical care – beneficence, non-maleficence, justice and autonomy – means that the basics of decision-making around critical care (both starting and stopping it) are entirely focused on the individual. In some countries, ‘community’ is also considered a part of the ethical framework – what is right for society.

For COVID-19 in particular, we lack clear predictors of good or poor outcome, relying instead on univariate predictors of mortality such as age, high blood pressure and cardiac disease which may in reality all co-exist. We also may not have the luxury of offering trials of intensive care treatment. For it must be remembered that when COVID-19 causes critical illness, it kills most patients. Studies of those requiring ICU care, and particularly ventilation, from China, Italy and the US have all reported mortality rates of half to two thirds of patients. In the UK outcomes are the same, suggesting this illness is twice as deadly as other viral pneumonias. The myth that those dying are old and dependent is slowly being dismantled as we realise what a truly awful disease this is. Perhaps the cruellest element of the illness is that patients admitted to ICU will receive no visitors, and although who die there will not die alone, they will be surrounded only by caring staff, rather than family.

If the number of COVID-19 cases is such that capacity is overwhelmed the prospect of triage is a real one. And this is a completely new ethical arena. It may be necessary to choose for instance between two or more patients needing one ICU bed or one ventilator, or to decide whether to stop ventilating one patient in order to offer it to a patient who is more likely to survive. These are extraordinary concepts for extraordinary times. The ethics of decision-making changes to what some describe as societal or public health decisions. Those who have argued that ‘doctors make these decisions all the time’ are wrong. Although we wrestle with decisions every day about what is right for our patient, balancing burden against benefit, this decision is about an individual. But when triage occurs the decisions are about what is in the ‘greater good’, ‘doing the best for the most’ and ‘the best for society’. This is not normal decision making but something quite alien, and which even the GMC states in normal times must not happen.

In this setting doctors need help because the wider ethical environment must be considered, and the choice is—put simply—too important to be made just by doctors. Decisions about how we choose between members of society require a discussion about what society wants and will accept. A framework is needed (not a checklist) which will enable doctors to step away from the bedside, pause, consider and reach a decision which 100 days ago none of us would ever have considered. Numerous documents have been published in the last months that consider these issues – some in journals and some by learned bodies. Several are vague and opaque and some wise and helpful, particularly that from the BMA. Some of the ethical factors are shown below. It is worth pausing and contemplating these. But these frameworks need operationalising – turning conceptual and discursive documents into SOPs that real clinicians use make real decisions for real patents.

Figure 1. Some key ethical considerations for COVID-19. *Examples include healthcare workers, vaccinologists, farmers or politicians.

These are complex matters and the decisions are high-consequence. In a truly open and honest society, government or the central NHS would be providing national guidance, drawn up by our medical, philosophical and political leaders, and the National Health Service. However, that is not the case and the result is a vacuum which is being filled by necessity. The decision of how to turn principles into actions is delegated to regional networks or individual hospitals. The result is that guidelines may be drawn up by too small a group, of critical care clinicians alone, or a wider pool of doctors perhaps supported by hospital management. These guidelines may not account for the shift of focus from individual to society or factor in ethical challenges, resulting in blunt tools to score them with. With poor guidance, there is cloistered thinking and with it, the potential for moral, ethical and legal jeopardy.

The possibility of having insufficient resources to care for all, and how that is managed has, with a few notable exceptions, not been well-grasped. But when there is inadequate resource those decisions must and will be made. Much work has been done by general practitioners and other outside hospitals to prepare the frail and ill. To advise them that hospital care may not be the right journey for them if severe COVID-19 affects them. To enable family discussions and decisions and to put alternative pathways in place, perhaps to stay at home if illness strikes. There is no doubt that this has saved many from a death alone, perhaps in distress, in hospital. This is something to be welcomed.

Nightingales

An alternative to accepting that we have insufficient resource and planning for triage is to expand the resource to meet the demand. In the first weeks of the epidemic this effort focussed on ICU capacity – and specifically on ventilators (though now kidney machines may in fact be the greater problem). Hospitals were encouraged to expand ICUs internally up to sevenfold. The NHS ventilator challenge was established. But as well as ventilators, critical care requires (amongst many other things) space and staff. Expansion requires somewhere to else work and a bigger workforce. This was acknowledged with the GMC and other bodies writing to all doctors about the need to work in unfamiliar settings and a loosening of regulatory governance as a consequence. NHS workforce planning proposed a major change from normal standards of care (one trained ICU nurse at the bed of every ventilated patient and one intensive care consultant for each group of eight) to something quite different. In the revised guidelines, each ICU-trained nurse might have responsibility for six ventilated patients and each critical care consultant for 60. While tiers of support are layered below, this is provided by nurses and doctors who are either less experienced or whose training is from other areas of practice. It is hard to imagine that this will not have an impact on quality of care delivered – these are truly extreme measures.

The Nightingale hospitals are a proposed solution. Rather than making ICUs out of repurposed wards, operating theatres and recovery units staffed by theatre staff, it is possible to create purpose built (or at least purposefully redesigned) mega-ICUs on a warehouse scale. These are the Nightingale hospitals, first in the Excel conference centre in London and now planned in a host of settings in the UK including Birmingham, Manchester, Harrogate and Bristol. The Excel Nightingale hospital has the capacity for 4000 ventilated beds – this alone is far in excess of all the ICU beds in the UK before the current epidemic – and the other Nightingale hospitals are each designed to care for many hundreds of patients. The vast majority of these hospitals planned to admit only patients needing ventilation. Scale can provide efficiency and workforce planning breaks down the normal bedside delivery of ICU care into an almost bewildering list of teams – one each for airway, lines, nutrition, turning, comfort etc. At first sight this is a perfect solution to the capacity problem – physically expand the system to the extent that the capacity is sufficient, and the problem is solved. Hospitals will have their space back and may be able to start to recommence services they have had to mothball. Perhaps a semblance of normality can return to NHS services.

However, this solution has its own challenges. The Nightingale hospitals solve only one of the main challenges to ICU expansion: space. ‘Stuff’ (equipment) and staff remain constrained. The Nightingale hospitals will necessarily be staffed by the same skilled staff who would otherwise be working in the hospitals they serve. And these staff will no longer be available there. As the Nightingale hospitals are set up on a regional basis this may mean either staff commuting long distances or relocating for a period. These staff will be working in a new environment in new teams and both changes will require training and adaptation. The same is true for equipment – if a ventilator or renal replacement machine is sent to a Nightingale hospital it cannot be used at a local hospital. So, it should be clear the Nightingale hospitals whose scale may be beneficial in providing economies of effort, are using staff and equipment that would otherwise be at the hospitals they serve. They are not so much additional capacity as relocated capacity. In order for patients to be treated at the Nightingale hospitals patents must be transported there – another service requiring significant redeployment of staff and equipment. The Nightingale hospitals are a bold and ambitious attempt to solve an extraordinary problem. Judging if, when and how to use them will be the challenge. The already stretched service will undoubtedly be further stretched by deployment of the Nightingale hospitals.

Hope

As always, we finish with a message of hope. If the surge of cases becomes too much for our NHS, either the Nightingale hospitals or triage may provide the necessary solution to the problem. And it is essential that we are prepared. Far better would be that neither are needed. Across the world, the impact of lockdown is being felt psychologically and financially – but it is working. It worked in China, it is working in Italy and Spain. It is starting to work in the UK. There is evidence that the rate of new cases is falling and the epidemic curve is flattening – with correlation between a region’s compliance with lockdown and the local flattening of the curve. Although the death rate is distressingly high there is evidence that the rate of new cases is falling. As deaths lag new cases by several weeks, it will take some time for this change to be seen. In a week or ten days a reduction in new infections will translate into a fall in hospital admissions, then to a reduction in ICU bed requirement and in a few weeks to a fall in deaths. Projections are changing rapidly but the evidence is mounting that the national effort — by the government, the NHS and the whole population— is working. If we are lucky, both triage and the Nightingale hospitals will become important academic projects but neither needed to be put fully into action.