Thread by @pmdfoster

NEW: We all know doctors are having to make "difficult" decision during the #COVID__19 #Coronavirus crisis - but HOW do they make those decisions? A mixture of art and science - and a scoring chart I've obtained. My latest 1/Thread

ft.com/content/d738b2…

First the chart itself - it makes for 'scary reading' BUT two important things to note

1) it creates a structure/ensures this is not random or on a whim

2) NOTE the 'caveat' - clinical judgment is still key here

3) Docs do this all the time, #COVID19 just foregrounds it /2

Of course this all throws up very difficult/painful questions.

Is a patient that scores >8 and doesn't get sent to ICU/ventilation being triaged that way because of a) lack of resource b) they aren't likely to make it c) better for them medically? /3

The answer, talking to docs on #COVID__19 frontline - and you're gonna hate this - is a bit of all three.

BUT, as doc tells me, the thing about #Coronavirus is that there is NO cure. Which means ventilation and organ support, but not like you go to ICU to 'cure' disease /4

I put these Qs to a frontline doc. This is what they told me - while admitting that NONE of this is easy. But the chart is a 'tool' - it is NOT the be-all, and end-all.

A judgment can still be made on an older patient in good 'nick' - with solid BP/Heart-rate/history etc. /5

Some people will think this is all very grim/morbid/callous even...I find the opposite.

It demonstrates how much thought goes into this - the blend of art and science as the doctor says.

Of course, one Q is IF intensive capacity runs low, HOW does that shift balance /6

The other side of this equation is what his happening to those patients who are NOT suitable for ICU - some in carehomes, some in hospices, some in the home.

There are very tough decisions there too. That means families having difficult conversations in advance. /7

I wrote last week, after chats with @hospiceuk staff about how quickly #COVID__19 can strike down the vulnerable - to the point where many are waiting TOO LONG to get palliative drugs under so-called Shipman rules...but there is more./8

https://twitter.com/pmdfoster/status/1248146681784393728

Last week, as @bethanstaton co-reports with me, NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions - this has led to some hasty calls, made harder coming out of blue /9

@bethanstaton But as @CaroleWP1 the chief clinical officer of @hospiceuk tells me, there is a need for a 'gentle haste' on this - for the hard reasons outlined above - and it's made HARDER that social distancing means using skype; and that hands can be held only by gloved hands /10

@bethanstaton @CaroleWP1 @hospiceuk As you'd expect @hospiceuk are very good about talking about death and Ms Walford explains emotively why this is not an 'either/or' decision.

Instinctively we think ICU care is the best care - but for some it may not be so. /11

@bethanstaton @CaroleWP1 @hospiceuk A similar judgment is made with 'Do Not Resuscitate' or 'DNR' notices which, as @naomi_rovnick adds in our story, naturally leads some to question themselves, and their doctors. There are a lot of Audrey's out there....BUT /12

@bethanstaton @CaroleWP1 @hospiceuk @naomi_rovnick A lot of of this is about communication. About reassuring people the are doing the right thing.

Am told the data shows resuscitation doesn't work well with elderly; more likely to lead to broken ribs, brain damage and only mildly prolonged life.

So better to go in peace?/13

@bethanstaton @CaroleWP1 @hospiceuk @naomi_rovnick These are REALLY tough discussion and choices - and I've tried to address them in that piece as sensitively as possible - but it is IMPORTANT, as @hospiceuk keeps saying, that we have them. Because "you don't want to having them in a panic" /14

@bethanstaton @CaroleWP1 @hospiceuk @naomi_rovnick There will be a time - not now, but soon - after the #COVID__19 to discuss HOW we fund end-of-life care.

As @TraceyBleakley the @hospiceuk boss told me, are we comfortable that this incredible hospice service is funded mostly via donations? /15

@bethanstaton @CaroleWP1 @hospiceuk @naomi_rovnick @TraceyBleakley Hospice movement @hospiceuk helps 225,000 families a year - raises £1.1bn (!!!) via marathons, jumble sales and the like. It is currently facing a £70m-a-month drop-off in donations as demand sky-rocket.

Perhaps #COVID19 will raise Qs over these vulnerabilities? /16

@bethanstaton @CaroleWP1 @hospiceuk @naomi_rovnick @TraceyBleakley And of course, this #COVID19 wave, now cresting, is breaking over a social care sector already hammered by austerity. Local authority funding falling as aged population rising. @healthFDN estimated £6bn shortfall in 2018. The sector has 120k vacancies. Avg wage c.£16k p.a. /17

@bethanstaton @CaroleWP1 @hospiceuk @naomi_rovnick @TraceyBleakley @HealthFdn We know how reliant carehomes are on EEA workers - but the @patel4witham immigration rules have been published BEFORE the cross-party cmme on social care has reported. Cart, horse etc.

After #COVID19 perhaps this will be ONE area that actually does change. ENDS