I have not written much about the COVID-19 inquiry on this site. In part this is because, having been very heavily involved seeking to support clinicians and others trying to maintain some form of functioning health and social care system (and having been involved in the ‘real time’ inquiry conducted by the JCHR at the time), I frankly could not face going back over history. However, the most recent report published, addressing the impact on healthcare in the UK is one that I could not ignore. I want, in particular, to emphasise two recommendations made by Baroness Hallett that resonate extremely strongly with my experiences at the time.
The first relates to the allocation of resources – triage. Reading the underlying evidence brought back memories of late nights and Sundays in meetings with exhausted intensivists fresh from the ward, the marks of PPE lined deeply on their faces, seeking ways to proceed ethically and lawfully, and looking in vain for guidance from ‘upstairs’ (and the case of Thomson – sadly not mentioned by the report – in which the courts declined to require the powers that be to undertake such an exercise). I therefore very strongly endorse what Baroness Hallett says in this regard.
Recommendation 7: A framework to guide the allocation of intensive care resources in the extreme event of saturation
The UK government and devolved administrations should publish a UK-wide framework setting out ethical and operational principles to guide the allocation of adult intensive care resources in the extreme event that they are saturated during a pandemic.
That framework must:
• be informed by comprehensive engagement with the public and developed in conjunction with professionals across healthcare, law and ethics, as well as with regulators of healthcare professionals; [1]
• set out clearly established triggers for its use, based at least in part on a UK-wide system that measures critical care capacity strain and facilitates mutual aid (such as the CRITCON tool used in England);
• establish clinicians’ legal and professional duties in applying the framework, which should be clearly explained to clinicians through guidance; and
• be regularly reviewed with reference to contemporary patient data during a pandemic, and any future use of it must be evaluated and reported on publicly.
A plan and timeline for completing this work should be published within six months of this Report.
Application of the framework should be tested as part of the pandemic response exercises recommended in the Inquiry’s Module 1 Report (Recommendation 6)
The second relates to DNACPR recommendations / advance care planning. Again, the evidence recorded in the report chimed very strongly with my experiences at the time: indeed, the very first shedinar I recorded in 2020 was on advance care planning, arising out of my profound concern as to what was going on (a revised and updated version is here). The relevant recommendation is:
Recommendation 9: A standardised process for advance care planning across the UK
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive, working with trusts and health boards, should establish and promote one standardised process across the UK (such as ReSPECT, the Recommended Summary Plan for Emergency Care and Treatment) for clinicians to ascertain and record their patients’ wishes and preferences for future care and treatment in order to inform individualised decision-making, including Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) notices.
Whilst we know that such standardisation will not be a cure for all ills, and no form can ever be a substitute for the carrying out of a process which carefully and appropriately identifies a person’s preferences so as to formulate clinical recommendations, a proper, and properly funded process (including, in particular, mechanisms to record such recommendations, alongside ADRTs) would be a hugely important start.
[1] I was part of an attempt during the pandemic to engage in deliberative democracy to see how those in the catchment area of one London Trust felt about different types of measures that might be used: Should age matter in COVID-19 triage? A deliberative study | Journal of Medical Ethics. It self-evidently could not be a substitute for the work recommended by Baroness Hallett, but did at least perhaps show how public engagement can be undertaken in a non-tokenistic way.
