Elderly people were denied treatment to stop the NHS being overrun

[Redolent]

This is being reported in The Times today:

“How the elderly paid the price of protecting the NHS from Covid-19”. .

Full article here:

archive.fo/anmfT

Parts of it make for difficult reading.

“The chief medical officer, Chris Whitty, commissioned an age-based frailty score system that was circulated for consultation in the health service as a potential “triage tool” at the beginning of the crisis. It was never formally published.
It gave instructions that in the event of the NHS being overwhelmed, patients over the age of 80 should be denied access to intensive care and in effect excluded many people over the age of 60 from life-saving treatment.

Testimony by doctors has confirmed that the tool was used by medics to prevent elderly patients blocking up intensive care beds.”

Triage tool that was circulating online from April, attached.

Are we going to see a return to this over winter? There has to be full transparency if so.

Those sort of decisions are taken every day in hospitals, Covid is irrelevant to that. ITU beds are very precious. The NHS has underinvested for decades.

I don't find it shocking. Nor is it news.

*Clinicians make decisions like this in the NHS every day, they always have to decide which patient to prioritise and sometimes the consequences can be severe.

Transparency wouldn't change this. On a lower level this is why some couples aren't entitled to IVF and some are, why some cancer treatments can be funded and others cannot. It's based on cost benefit because we can't supply endless capacity for all kinds of treatment.*

This.

I'm surprised that some find this shocking or newsworthy.

As a country we have limited resources. We need to decide how to best allocate them. Sometimes this means denying someone something. That's life unfortunately.

@Sunflowers246

Those sort of decisions are taken every day in hospitals, Covid is irrelevant to that. ITU beds are very precious. The NHS has underinvested for decades.

I don't find it shocking. Nor is it news.

But isn’t the point that they “rationed” treatment excessively? And that people who would have benefited from treatment, weren’t given it?

Two excerpts:

—-

“When they then compared the numbers of deaths from the virus in the normal wards with the number of intensive care beds said to be available in the UK, they came to a disturbing conclusion. Hospitals not only appeared to be withholding intensive care from patients who might benefit from such treatment, but they were actually being too overzealous and doing so more than was necessary given the available”capacity.”

——-

The doctor described how the tool was followed so carefully at his large Midlands hospital that dozens of intensive care beds were kept empty in readiness for younger, fitter patients. He said almost all patients in his hospital aged over 75 died in the non-critical care wards without emergency treatment during that period. If they had been given intensive care, they might have survived.

@Sonnenscheins

As a country we have limited resources. We need to decide how to best allocate them. Sometimes this means denying someone something. That's life unfortunately.

In that case we'd better stop wasting those limited resources (which would be less limited if more people smoked).

We could start by no longer throwing away money on failed companies like Serco.

Also probably a good idea to limit the need to use the resources, i.e. contain Covid.

Oh - and I say it again. If 60 is deemed too old for medical treatment (when the decision is based purely on age) it's old enough for a pension.

I don’t get it. People seem to readily grasp that the older you are (mid-70s onwards) the less likely to be admitted for treatment. But then there’s a widespread denial - seen elsewhere - of the fact that ICU beds are largely occupied by those of working age population: people in their mid-50s and 60s. Presumably because they’re the ones who are seen as most likely to benefit.

It is more nuanced than this. Moving an elderly patient with dementia to an ICU ward might not be the best treatment with the best outcome for that patient. Less invasive treatment in by specialist dementia nurses could have a better outcome.

The outcome for cardiac resuscitation for someone who is 90 is very poor. It is quite a traumatic procedure for someone to undergo at the end of life.

There are humane arguments to be made for doing things more gently. In the situation at the end of March, there needed to be plans in place for every patient.

These plans needed to be discussed in advance with patients (if the patients could understand them) and with families, before a crisis came, as this gave more time for thoughtful discussion and reflection.

So there was an element of thoughtful clinical practice, and in fact, as evidence emerged that ventilation could be actively unhelpful, this clinical caution may have saved lives.

There is also the element of chronic inadequate funding of the health service in the face of high demand.

If people voted Conservative in the last few elections, they were voting for less funding to the Health Service, and we are living with the consequences of that now.

I guess we'd need to know whether the over 75s not being admitted to intensive care were kept out solely because of rationing. It's possible to envisage a situation where even if there were beds it still wasn't judged to be in their best interests. I wouldn't assume that because a patient hasn't been moved to an available bed, that means there must be a problem.

@Redolent

I don’t get it. People seem to readily grasp that the older you are (mid-70s onwards) the less likely to be admitted for treatment. But then there’s a widespread denial - seen elsewhere - of the fact that ICU beds are largely occupied by those of working age population: people in their mid-50s and 60s. Presumably because they’re the ones who are seen as most likely to benefit.

Good point.

People also continue to ignore the risks of Long Covid (individually, and - for wider society - economically).

Funding of the NHS will never be enough though. You need to budget and work within that. Watching the BBC documentary on doctors working on the edge of life, they are spending tens of thousands of pounds, on debatably limited benefit treatments. Most of their patients die. Their rationale is that it allows experimental treatments to be developed. Great. We need new and effective treatments. On the other hand they could use that money to do 20 hips, or 100 cataracts.

Every day decisions are made. Some people benefit, some don't.

Here’s the response to the Sunday times article on behalf of named clinicians who were at the forefront of the Covid response: www.england.nhs.uk/2020/10/nhs-and-other-professional-bodies-response-to-sunday-times/

I think this quote from Stephen Powis is particularly helpful: “The Sunday Times’ assertions are simply not borne out by the facts: it was older patients who disproportionately received NHS care – over two thirds of our Covid-19 inpatients were aged over 65”.

We need to be really careful about where our facts come from at the moment.

@Baaaahhhhh (are you a fellow 🐑?), are you suggesting middle-aged and older people should be left unable to work in terrible pain? Apologies if I've misunderstood. You refer to operations required by those age groups (hip and cataract). Incidentally many will still be of working age. Their tax is good enough to take...

So. Again. Smoking 🚬. It's the answer. Shorter (but less stressed) life AND billions of tax for the NHS.

The part in the article that saddened me was where the nurse was in tears and told the sisters, the reason was that her patients were all left in to die alone. Thats the hardest and cruelist part of this virus, if they werent suitable for ventilation due to the poor outcome thats one thing, but the description of those 8 elderly men left alone in nappies to face the end, made me well up.

That's sickening @Jenasaurus
People earnestly dismissing it as 'that's life' and purporting to be for the 'kinder' option because there might be less chance of success in ICU. Not treating is one thing. Leaving to a painful or undignified or frightening death is quite another. How anybody can possibly argue that's better than a quick morphine overdose is beyond me.

I think it disgraceful the number of hospital beds, high dependency beds and ICU beds are much lower (so it seems) than other western countries.
However, elderly people would rarely benefit from long term ventilator use. By which I mean, I understand that Covid patients on ventilators were often on ventilators for many days / weeks. Ventilators are usually much more short term, (operations, etc)
The question is - how elderly is elderly? As someone who is now retired, i hope it means someone older than me!
Obviously there is a debate to be had in how severe this Covid pandemic is/was. However, in the event of a serious pandemic on the scale of , say, the Black Death, then hospital treatment is definitely going to be rationed.

As other have said, ventilation decisions are based on outcomes. Older people have poorer outcomes. No surprise there.
Surely no one is surprised by this?

HesterShaw1 is correct. The Government have been underfunding the NHS for over a decade now. We were called to 'save the NHS' last March onwards because of the severe lack of resources and staff. We have way fewer ICU beds than countries such as Germany, the Government's fault. Voting Tory = a vote for a reduction in NHS services.

The NHS is buggered for sure if the narrative of its only the Tories continues. It's been a mess for more than a decade. The Blair and Brown governments are equally responsible.

This is no surprise, but not really a covid issue.

My GP tried to persuade me, years ago, to have a different diabetic drug, because it was basically 'more cost effective'. = cheaper.

The plan was never actioned.

Scaremongering fiesta, however.

@SheepandCow it is certainly true that a country as rich as the UK should be able to offer its citizens as comfortable and dignified and humane a death as it is possible for them to have. And, in the case of COVID, that should involve nursing care, and oxygen and whatever else is necessary to ease suffering, even if a cure is not possible.

@Oblomov20

This is no surprise, but not really a covid issue.

My GP tried to persuade me, years ago, to have a different diabetic drug, because it was basically 'more cost effective'. = cheaper.

The bizarre thing is the contrary policy wrt psychiatric drugs. The push to give anti depressants over benzodiazepines when the former are strongly linked to obesity and consequently diabetes (therefore costing the NHS more money). The older sedatives were arguably less damaging.

Yes, definitely. I'm more concerned about palliative care than not offering ventilation. There's zero excuse for us not doing the former properly.

Intensive care is brutal. A ventilated patient loses 2% muscle mass per day. The estimate is that for every day spent on intensive care, about a month will be required in rehabilitation.

Patients receiving intensive care are liable to develop delirium. Delirium is a life-threatening condition in itself and the risk of delirium is heightened if you are over 65, have health conditions already, or have multi-organ failure/illness. Patients with Covid requiring intensive care are more likely to tick boxes in all 3 areas.

In every day life there is such a thing as being "too sick for ICU". If there's little realistic chance of becoming non-dependent on the ventilator, it's unethical to put someone on the ventilator in the first place. You're just consigning them to a painful death. Because ventilation is incredibly painful. Sedatives and pain relief are given, but it's still uncomfortable to have a tube down your throat and suctioning is also painful.

Hospitals should also be practicing "intensive care without walls" which means that ICU support can be given to patients without moving them. If a patient isn't suitable for ventilation, they can still be given the expertise of ICU on the ward. Palliative care is sometimes the very best care.

It's so much more complicated than "too old for ICU".
It is so much more complicated

It's the transfer of Covid patients Into care homes that is the outrage re treatment of the elderly. That and the heartless deaths in solitude of some patients as @Jenasaurus mentions.

My dad was one of those Covid deaths in a care home. Fortunately it was where he lived anyway, so he had carers around who knew him, and it happened very quickly so that he didn't suffer for long. He was in his 90s and had dementia which left him confused and unhappy much of the time. I wish it hadn't happened and I wish I'd been able to be with him. But we already had a proviso in place that if he became seriously ill he was to be treated and made comfortable in his home if at all possible rather than taken to hospital, and if he had been admitted, I would have refused ventilation and other such treatment for him in favour of good pain relief and a comfortable, dignified end. I fully agree with @Porcupineinwaiting:

I do not think the elderly are disposable, as some do on here, but I do believe in quality of life and knowing when to quit.

The 'disposable' attitude was what led to the transfer of infected patients into care homes and the spread of it to other residents and staff. That was horrific and deserves justice.