Doctors ‘less likely to resuscitate’ very ill patients after Covid pandemic

Covid-19 may have made doctors in the UK more unwilling to resuscitate very ill and frail patients, a survey suggests.

The findings, published in the Journal of Medical Ethics, point towards a shift in attitudes after the pandemic forced medics to make thousands more end-of-life decisions.

Researchers were keen to find out if Covid-19 had significantly changed the way in which doctors take such decisions, with particular interest in controversial ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ (DNACPR) decisions and treatment escalation to intensive care (ICU).

These aspects of end of life care were chosen as the focus due to the increase in cardiac arrests associated with Covid infections, and concerns about ICU capacity, sparked by soaring demand during the pandemic.

The researchers opened the online survey to doctors of all grades and specialties between May and August 2021, when hospital admissions for Covid in the UK were relatively low, for which it received 231 responses.

Of those respondents, 15 were foundation year 1 junior doctors (6.5 per cent), 146 were senior junior doctors (SHOs) (63 per cent), 42 were hospital specialty trainees or equivalent (18 per cent), 24 were consultants or GPs (10.5 per cent), and 4 were categorised as “others” (2 per cent).

In respect to DNACPR - referring to the decision not to attempt to restart a patient’s heart when it or breathing stops - over half the respondents were more willing to do this than they had been previously.

When the responses were weighted to represent the different medical grades in the NHS national workforce, the results were: “significantly less” 0 per cent; “somewhat less” 2 per cent; “same or unsure” 35 per cent; “somewhat more” 41.5 per cent; “significantly more” 13 per cent; and “not applicable” 8.5 per cent.

Asked about the contributory factors, the most frequently cited were: “likely futility of CPR” (88 per cent pre-pandemic, 91 per cent now): co-existing conditions (89 per cent both pre-pandemic and now): and patient wishes (83.5 per cent pre-pandemic, 80.5 per cent now).

Advance care plans and ‘quality of life’ after resuscitation also received a large share of the vote.

The number of respondents who stated that patient age was a major factor informing their decision increased from 50.5 per cent pre-pandemic to around 60 per cent.

Meanwhile, the proportion who cited a patient’s frailty rose by 15 per cent from 58 per cent pre-pandemic to 73 per cent.

But the the most notable shift in vote-share was resource limitation, which soared by 20 per cent, from 2.5 per cent to 22.5 per cent.

Asked whether the thresholds for escalating patients to ICU or providing palliative care had changed, the largest vote-share was the “same or unsure”.

But a substantial minority said that now they had a higher threshold for referral to intensive care (22.5 per cent weighted) and a lower threshold for palliation (18.5 per cent weighted).

The impetus to make more patients DNACPR, prompted by pressures of the pandemic, persisted among many clinicians even when Covid-19 hospital cases had returned to relatively low levels, noted the researchers. The factors informing it were compatible with regulatory (GMC) ethical guidance—with the exception of limited resources.

The researchers said: “At the start of the pandemic, the BMA advised clinicians that in the event of NHS resources becoming unable to meet demand, resource allocation decisions should follow a utilitarian ethic.

“However, what is clear from our results is that for a significant proportion of clinicians, resource limitation continued to factor into clinical decision making even when pressures on NHS resources had returned to near-normal levels,” they write.

The survey results also suggest that the pandemic has helped clinicians gain a greater understanding of the risks, burdens, and limitations of intensive care and had further educated them in the early recognition of dying patients, and the value of early palliative care, they add.

“What is yet to be determined is whether these changes will now stay the same indefinitely, revert back to pre-pandemic practices, or evolve even further,” they conclude.