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Legal Implications of Palliative Care Decisions in Covid-19 - Dr Mark Burgin

10/05/20. Dr. Mark Burgin BM BCh (oxon) MRCGP raises concerns about the approaches taken by health care systems in dealing with those too frail to benefit from admission.

Many people have raised concerns about the high mortality in care homes where the very vulnerable who need shielding are living.

Many care homes have had outbreaks of Covid 19 suggesting breaches in the strict precautions that should have been taken.

The death rates in the homes appear higher than would be expected even considering the vulnerability of these people, although proof will need further analysis.

The use of virtual assessment without a pulse oximeter reading has raised concerns because some seemingly well patients have very low oxygen levels.

NEWS score. (1)

The normal way of assessing a patient with respiratory problems uses a measure such as a NEWS which includes measuring oxygen levels.

There have been some concerns that without the oxygen sats the score is potentially unreliable as the blood pressure, temperature, respiration and pulse can be normal in a COVID patient.

The RCP state that changes to the level of consciousness can be subtle so that confusion, disorientation and/or agitation can be missed and this is particularly true in the elderly.

The decision to move to triage with virtual consultations in primary care has led to worsening quality of the information available to the GPs making the most difficult decisions.

Pulse Oximeter is key piece of equipment

Oxygen is rapidly becoming accepted as the only effective medical treatment for COVID 19, ventilation has been shown to cause damage to the lungs - called ‘ARDS’. (2)

As the ventilator attempts to force oxygen into the lungs it damages the delicate tissues causing worsening of the inflammation and more fluid.

Most of those who survive are treated with high dose oxygen and good nursing which should not be difficult to deliver within a community setting.

A nurse with a pulse oximeter could ensure that the patient is correctly positioned (face down if severe) with the correct amount of oxygen.

Complications of hypoxia

Without enough oxygen the blood become sticky and clots form in the heart, gut, kidneys and brain causing damage to these organs.

Delivery of oxygen early in the disease (before the patient collapses) can protect these vital organs and allow the patient to recover.

The options for oxygen delivery are piped oxygen from a tank (in hospitals), oxygen bottles (bottles are refillable) or oxygen concentrators.

The technology in oxygen concentrators is based on the ability of zeolite minerals to absorb nitrogen from air under pressure and they are available for about £1000.

Palliative care

The numbers of deaths in care homes are unclear due to lack of COVID testing but likely to be a significant proportion of the total excess death from the outbreak.

The NICE guidance suggests ‘older patients with comorbidities need monitoring or more intensive management’ but then ‘when oxygen is available, consider a trial of oxygen therapy’. (3)

There appears to be an inconsistency between the NICE guidance and the availability of the equipment necessary to deliver the best care. (4,5,6)

Treatment in the community early in the disease has the greatest chance of success and requires a trained nurse, a pulse oximeter and a source of oxygen.

Conclusions

There are many vulnerable people living in the community especially in care homes where social distancing is impossible.

Palliative care should only be considered after all reasonable steps such as nursing, oxygen and monitoring have been tried.

Pulse oximeters and oxygen concentrators remain widely available suggesting that there has not been any coordinated attempt to increase provision for care homes.

Lawyers may wish to examine the records of those dying in care homes for evidence that their oxygen levels were monitored and appropriate treatment was given.

Doctor Mark Burgin, BM BCh (oxon) MRCGP is on the General Practitioner Specialist Register.

Dr. Burgin can be contacted on This email address is being protected from spambots. You need JavaScript enabled to view it. and 0845 331 3304 website drmarkburgin.co.uk

1. National Early Warning Score (NEWS) respiration rate, oxygen saturation, systolic blood pressure, pulse rate, level of consciousness or new confusion, temperature. https://www.rcplondon.ac.uk/projects/outputs/national-early-warning-score-news-2

2. World Health Organization 2020 http://www.emro.who.int/health-topics/corona-virus/questions-and-answers.html#:~:text=There%20is%20no%20specific%20treatment,the%20patient's%20clinical%20condition.

3. NICE guideline COVID-19 rapid guideline: managing symptoms (including at the end of life) in the community Published: 3 April 2020 www.nice.org.uk/guidance/ng163

4. Bertè 2020 Covid-19: The role of palliative care had to be adapted to manage this “ultra-emergency” British Medical Journal.

5. Covid-19: a remote assessment in primary care BMJ 2020;368:m1182

6. Covid-19: Patients who are improving could have treatment withdrawn if others could benefit more BMJ 2020;369:m1382

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