No, doctors are not refusing to treat older people with coronavirus – they are having difficult conversations

In recent days, fears have abounded among the older, sicker and frailer members of our nation. Fears that, in the face of a pandemic, they are the expendable part of our population. That they have become “those who shall not be treated”, the people cast aside to allow the younger, more robust and less ill a fighting chance of survival.

And who can blame them? With Italy imposing treatment cut-offs based on age and comorbidity (secondary illnesses), talk of blanket “Do Not Attempt Resuscitation” (DNAR) letters being sent out with few or no conversations with patients first, and daily discussions in the news about how the NHS should ration its resources, for anyone not in the peak of health this is a terrifying time to be alive.

Lost amid the clamour is a key point that must drive every clinical decision regardless of the pandemic, and one that this week the NHS has reinforced publicly: every life matters.

The push to have DNAR discussions has been perceived by many as a crass move to identify ways to ease the burden on critical care medicine. In fact, even during ordinary times these vital conversations are often left undiscussed because they are so difficult and sensitive.

So what is a Do Not Attempt Resuscitation letter or an Advance Care Plan (ACP)? It is important when discussing these documents to understand that resuscitation will not be appropriate for all patients. Cardiopulmonary resuscitation (CPR) is brutal, with a low success rate that many patients would not survive. To put that into context right now, evidence suggests that survival from CPR in patients whose hearts stop due to Covid-19 occurs in less than 1 per cent.

Medical dramas have led many of us to believe that no one really dies any more, if we try hard enough; we are all only an electrical pulse away from being brought back from the great beyond. That’s simply not the case. Most of us do not – and would not – come back from an attempt at resuscitation. When doctors feel resuscitation would do more harm than healing, DNARs are put into place to prevent that harm from taking place.

Similarly, ACPs help patients consider their wishes should their existing illness or condition worsen. ACPs are especially important if a patient is known to be dying. They offer an opportunity to consider options in patient care, including appropriate treatments, pain relief, location of care, and the presence of family and friends during the critical days and hours before death. An ACP also serves as a reference document for staff and family should the patient lose their ability to make their own decisions.

Having discussions about care wishes, and writing advance care plans and DNARs where appropriate, have been found to improve care and mental wellbeing for patients and their families, while also supporting the staff caring for them.

We have long known that having these difficult conversations was important but just that – difficult. Doctors have always struggled to have such conversations as regularly as we should.

It is not that the pandemic is forcing us to have difficult conversations with more patients than we should be doing; instead, it has highlighted how, towards the end of life, they must always take place. The pandemic is pushing the pace on conversations that always should have happened – and to many, the numbers of people for whom the fact that these conversations are appropriate has come as something of a shock.

For the saddest reasons, the coronavirus outbreak provides an opportunity for medicine to be brave, and for all doctors to start talking to patients about their care wishes, as they should have been doing all along.

Keeping us alive through medicine when some or all of the body has decided enough is enough is aggressive, invasive and intrusive. ​Intensive care is not a treatment in itself. It often requires as much – if not more – recovery and rehabilitation than the original illness that put a patient there. When details of such measures are laid out in their messy detail, many of us would neither want nor benefit from them.

Not everyone should or would want critical care treatment if it was going to only make them worse – but we cannot know that if we do not talk more openly about what care means to us.

But just because the most drastic of treatments may not be appropriate does not mean that such patients would receive no care at all. On the contrary. Patients for whom invasive care is inappropriate deserve and receive the care best suited to their needs. Care that helps relieve symptoms and pain, care that preserves dignity and gives them the respect due to them as individuals living their lives to the fullest extent they can.

That the options are currently being presented by some as intensive care or bust is a crass dichotomy that must be corrected.

Medicine must seize this moment, and ensure standards of care planning are finally properly met. Now is the time to ensure that having difficult conversations becomes an ingrained and regular part of all medical practice. Every life matters – and we should all start talking more about how and why they do.

This article was co-written by Dr Alexis Paton and Professor Andrew Goddard

Dr Alexis Paton is a lecturer in social epidemiology and the sociology of health at Aston University, chair of the Committee on Ethical Issues in Medicine at the Royal College of Physicians, and a trustee of the Institute of Medical Ethics. She writes in a personal capacity. Professor Andrew Goddard is the President of the Royal College of Physicians, and a consultant physician and gastroenterologist in Derby

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