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.

Is there actually any evidence that being put on oxygen or (weird suggestion in my view) IV fluids would help you survive COVID or is that just an assumption people are making? In March/ April we had no proven effective treatments at all. It's now thought that Ventilation might actually have made people worse. Not sure that being admitted to hospital for a disease without any proven effective therapy really means much sadly.

However in March/ April hospital was certainly the best place to catch Covid if you didn't already have it.

Given all the above I would have chosen not to go to hospital under almost any circumstances if I was over 80 and living in a care home (which by definition means my lifespan was limited). I would choose to be palliated under those circumstances and have a chance of perhaps having family or at least familiar staff with me when I died.

My dad probably wouldn't even want to be treated for a heart attack now he's over 70 although he has a good quality of life and is fully independent. Extreme view maybe but his greatest fear is dying slowly of dementia in a care home as both his parents did.

I honestly cannot understand all the hand wringing about rationing. ICU beds are rationed all the time. General hospital beds are a bit rationed in normal times and should be much more so and then we wouldn't have people getting admitted futilely just to die. For most people in their 80s and in particular those frail enough to be in full time care being admitted to hospital is prolonging the inevitable for questionable purpose in my view. Once you are frail and elderly and start having multiple hospital admissions in a year this is a sign that you are dying and this should be accepted and planned for COVID or no COVID.

Who honestly wants to have a few more months or years confined to a care home unable to do anything for oneself. I will be signing an advance directive for nothing beyond oral antibiotics if I should ever have the misfortune to end up in that situation.

@HesterShaw1 an excellent summary, especially the "not allowed to have medical treatment".

Story government bots want to pretend this was about not giving inappropriate treatment - it was about an NHS that has been denied enough resources being instructed by the government to deny medical care.

The reason this is being put out now is because the government is doing the same thing, although in a slightly different way. Instruct the NHS it must do normal care, fine them if they dont and you deny beds to covid patients, who then have to be "triaged" in this way.

The government wishes to kill off anyone who costs it money - but they dont wish to be seen to be doing so.

Apologists for this should hang their heads in shame - but they have no shame.

I believe the article also quoted that out of 57,000 excess deaths, only 8,000 died in hospital, so nearly 50,000 died in either private homes or in care homes, either with covid or without it. Intentional or not, the majority of people received no treatment for covid.

I don't believe this is a new policy though. 2 of my grandparents died from pneumonia, one in a care home and one at home, there was never a suggestion of treatment as both had advanced heart disease. Both were over 80. People over 80 should not be receiving intensive care at the expense of younger people or not. I'd have thought for basic quality of life this would be a barbaric step. Makes a sensational headline though!!!

This is what is happening in Poland tvn24.pl/poznan/gorzow-wlkp-pacjenci-z-koronawirusem-w-hali-wjazdowej-dla-karetek-4731027

It is not happening in Germany because they have a better funded health service.

I'm proud of the way the NHS expanded capacity so it could treat more people, I'm beyond disgusted by anyone who thinks its acceptable to effectively withold any care.

Oxygen and IV fluids are not part of palliative care either so no-one had a worse death for not receiving g these. Sub cut palliative medication via syringe driver was available at all times for community patients.

I don't know why people are obsessed about hospital admission the whole time for everything and see this as a marker of good care and not having it as being bad. Community treatment is a much better idea most of the time especially for frail older people. Hospital admission causes harms of hospital acquired infection and debilitating loss of skills and fitness.

For myself personally and my family and speaking as a hospital Dr I try to avoid hospital admissions unless the treatment required is really only available there eg surgery.

No-one was or is witholding effective care. There is almost no proven effective care for this illness. All RCTs so far are negative.

It is hard to save the life of a frail person over 80 with any illness COVID or otherwise and if you do the subsequent quality and quantity may be small. The right thing to do may very well be not to admit to hospital and to allow a dignified natural death. We should be doing a lot more of this anyway Covid or no COVID

I honestly don't know what care people think is being withheld or why they believe with a total lack of evidence that such care would be life saving.

I am a die hard Labour supporter and no fan of this Tory government but it is stretching credulity to say they are deliberately killing people off to save money by not admitting them.

I think I'd count oxygen as palliative care if I was drowning in my own lungs. Not a nice way to go at all.

[quote RedToothBrush]@pmdfoster did an interesting thread on this yesterday.

The story was covered by the FT in April but the story wasn't elderly patients 'being denied' treatment. The reality is (and this seems to hold water on statistics on this) that the over 80s simply dont survive ventilation anyway. So they weren't being denied treatment, they were being treated appropriately and with dignity.

The problem was actually to do with delays in results from tests.

So an elderly patient went into hospital was tested and came back with a negative and was sent back to their care home. The issue was at the time of testing they probably were negative but they were on a ward with other people also with unknown covid status who were also being tested. It was taking up to seven days to get results back so in the time between being tested (and getting an accurate negative) these elderly patients were exposed to someone who was positive and so by the time they were released back to their care home their covid negative status on paper didn't match their actual now infected status.

And this was one way that covid was getting into care homes unwittingly.

I do think that the scandal is in this issue and not in the potential triaging of patients who almost all wouldn't have benefitted from ventilation anyway.[/quote]
This is not the same story that the FT covered in April. It's really REALLY not about ventilation. Elderly patients absolutely have been denied even basic treatment.

Delays in test results is a scandal but that's not what this is about either. There was deliberate government policy to discharge elderly patients back to care homes even with a positive test. There was nothing unwitting about it, the government just didn't give a shit.

It's a long read but it's definitely worth reading it all.

www.thetimes.co.uk/article/09645538-1616-11eb-aa30-eaa5079247bf?shareToken=59d3fda5c60fd140cc18f68439e3d4f9

Honestly we don't give palliative patients oxygen. We give them morphine. My mum just died in a hospice no oxygen involved at any time. Looked after loads of dying patients in hospital and we take them off because it's uncomfortable to have the mask or nose spikes and dries your mucosa and it doesn't help anywhere near as much as morphine.

Any way to go is much the same (ie you don't know about it) if you have a syringe driver up in my personal and professional experience.

'I think I'd count oxygen as palliative care if I was drowning in my own lungs'

Unfortunately it isn't always that simple, administration of oxygen can cause problems in itself.

'Honestly we don't give palliative patients oxygen. We give them morphine. My mum just died in a hospice no oxygen involved at any time. Looked after loads of dying patients in hospital and we take them off because it's uncomfortable to have the mask or nose spikes and dries your mucosa and it doesn't help anywhere near as much as morphine'

100% this, and also from professional experience.

Anybody who doubts the government mistreated the elderly in the first wave needs to read the Amnesty International report “As if expendable.” It’s shameful.

www.amnesty.org.uk/files/2020-10/Care%20Homes%20Report.pdf?kd5Z8eWzj8Q6ryzHkcaUnxfCtqe5Ddg6=

Why are people assuming that anyone elderly who catches covid is automatically a 'palliative patient'?

When does the 100% CFR kick in? 75? 80? I must have missed that terrifying bit of news.

@LangClegsInSpace

Why are people assuming that anyone elderly who catches covid is automatically a 'palliative patient'?

When does the 100% CFR kick in? 75? 80? I must have missed that terrifying bit of news.

I noticed one of the guides published in the times started point scoring triage from 50.

It also stated no admissions for care home residents. No mention of age. Many residents are not 80+. Young disabled people live in care homes.

This was/is not about not attempting treatment on frail patients who might not survive. The guidelines were done solely on age (and disability) and NOT on medical grounds, which varies by individual patient.

LangCleg thanks for the share token. I have now read the whole article

The first half of it IS about denial of ICU to over 75s in particular though.
I still say there is no evidence that this was the wrong thing to do.
ICU is not usually recommended for over 75s for acute illness. The article itself says only 30% of over 75s who were given ICU care survived and usually that stat means survived until discharge. The numbers who die shortly thereafter are huge and those permanently debilitated almost universal. I would not want this for myself or a loved one.
The drop in the proportion of older people in Covid times vs normal I suspect is due to cancellation of planned surgery which sometimes requires ICU post op and has a better prognosis.
The worst they could get Drs to day was that some patients who 'might have been given a try' weren't. This hardly sounds as though many people who had a good chance were denied.

The Covid ward does sound horrible but any ward where all the patients were dying would be emotionally horrible I think. It doesn't mean any of them could have been saved somehow with a bit of oxygen. Usually dying patients are spread around wards and offered side rooms and have their families with them. That's why I would choose for myself or a loved one never to be admitted in the first place if I had a poor chance of survival as these folk. An acute hospital ward is a horrible place to die at any time and especially now.

My anecdotal experience is similar to that reported by the ambulance service ie that many people died suddenly of MIs at home without reaching hospital but this was
not due to neglect they usually hadn't tried to access any service as they didn't know they were ill. A very few awful cases of people being turned away and dying were reported in the press and that I agree is a scandal.

Also the Morecambe one where the guy was not consulted about his DNAR is a scandal. An increased rate of asking people about DNAR and preferences for care though is a good thing.

There should be more people dying at home and in care homes than in hospital if they are very frail and old. Hospital cannot always save you and it is no place to die. If I was over 75 and in care I'd only agree to go if I'd broken my leg. If I had an MI or a CVA then let it take me and certainly
if it was pneumonia.

The decision support tool was

• a support tool not a binding instruction
• never actually officially issued or acted on
• doesn't sound like an especially stupid idea to me at all. NEWs scores are totally and utterly standard as is the frailty index but they are always just a guide and any Dr can take a different decision if they feel it's justified.

Still can't see a huge scandal here but going to read amnesty report in case that changes my mind.

'It also stated no admissions for care home residents. No mention of age.'

I can confirm however that many elderly care home residents were admitted and did receive treatment (for example oxygen and IV antibiotics) before being discharged back to their place of care. I know this because I nursed them.

Not everyone over 80 who catches COVID dies obviously. Many of my frail elderly patients survived and some were barely ill at all.

However if you are ill enough with it to be admitted to hospital and for oxygen and then ventilation to be required it has to be admitted that your odds are poor and we have no proven effective treatments that have been shown to work in that scenario. Anyone suggesting otherwise is in cloud cuckoo land.

Therefore if it was me and I was ill enough with Covid to require hospital admission aged over 75 and living in a care home I would decline and request supportive care where I was. I think I would likely make the same decision if I was over 80 and living at home and certainly if I had any other illnesses.
If I was 75 and very fit and well maybe I'd want to be treated but most likely I would not as I regard 75 as a good innings and my professional experience is that it's usually downhill from there in terms of quality of life for most of us thereafter. Some may feel that is a bleak assessment but I find it realistic and pragmatic.

Not sure I agree with you Theld. Other countries have found that early intervention with oxygen and steroids significantly decreases mortality across all age groups. Certainly if you do sweet fuck cos "they're old" then people dont tend to respond well.

However if you are ill enough with it to be admitted to hospital and for oxygen and then ventilation to be required

What if you're just ill enough to need oxygen? Like Boris?

I don't think you should be mixing up your experiences as a hospital dr with your personal views of what age constitutes 'a good innings' and how you imagine you will feel when you reach 75, as it may lead people to give undue weight to your personal opinions.

Aren't there rules about this sort of thing for doctors posting on social media?

Also just out of interest, roughly how old are you?

I am not the thread police I know, but please could people read the whole article before commenting.

It really isn't about ventilation being denied to the frailest people.

@Porcupineinwaiting

Not sure I agree with you Theld. Other countries have found that early intervention with oxygen and steroids significantly decreases mortality across all age groups. Certainly if you do sweet fuck cos "they're old" then people dont tend to respond well.

Germany is a good example. Early treatment is key (as with any illness).

Quite a few of our MPs are 'elderly' (the number varies depending on what you count as elderly. Some parts of the NHS or it's management seem to think 50+). I bet they'd get treatment if they or their families wanted it.

Thinking about the suggested points system. Boris already fails two. Over 50, overweight. Add in any possible comorbidities, hypertension perhaps, and he's getting close to No Admission (if we're busy) criteria.

This whole thing is utterly terrifying for older people who are otherwise fit and well but fear that they may be denied treatment due to age. PIL are not worrying about the virus itself but about being bottom of the list for treatments. Whether it is accurate or not even the idea that this might be on the cards it is very very worrying for those concerned. Like they don't have enough to worry about.

Proper RCT evidence though?
Has anyone done an RCT of giving steroids and oxygen to over 80s vs not? If they have then I'll accept that's true although it would not make me want to have it.
If we are just talking those people that had it seemed to do a bit better than those that didn't with no randomisation or blinding then that is very clearly confounded by severity for me and I would not accept that as proper evidence of effective treatment being available.

My understanding is that even remdesivir was negative in properly
conducted trials. I see there is evidence for steroids but you could easily have those at home come to that like with COPD exacerbation.

Maybe a few more people do survive than if you 'do nothing' but my point is that just offering best supportive care and allowing people to die is an OK thing to do. It is not automatically the right and ethical thing to do to try to save everyone all the time so they can die slowly of dementia later.