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Deciding on who lives or dies 'will put huge mental strain on medics'

Don't ask us to play God, says top NI doctor


Decisions: Dr Tom Black

Decisions: Dr Tom Black

Decisions: Dr Tom Black

A senior medic has said doctors here will feel "like the smallest beings on God's earth" by having to make decisions about who lives or dies during the Covid-19 crisis.

Dr Tom Black, chair of the British Medical Association (BMA) in Northern Ireland, also said that, far from "playing God", local medics will undergo immense psychological pressure when deciding which patients could have their treatment withdrawn and offered to those more likely to survive.

But he added that, in the light of these exceptional circumstances, doctors realise that prioritisation will be part of their job.

Dr Black made the comments after a stark new document issued by the BMA set out guidelines to ration care if the NHS becomes overwhelmed with new cases as the coronavirus outbreak moves towards its peak.

"This sort of decision makes you feel powerless because it's such a difficult decision which you'll not only carry home with you, but you'll carry on your mind for years. Some will end up feeling like the smallest beings on God's earth," said Dr Black.

"This is a very difficult environment and the psychological strain on doctors - who as human beings are making decisions about the provision of care when the demands are so high and the resources are limited - will be immense.

"Doctors are very keen to help people. We understand that part of the helping of people will be the prioritisation and getting the greatest benefit to the greatest number of patients, so in a pandemic and with guidance from the BMA and GMC, we'll just have to accept that that's part of our job."

Dr Black also told the Belfast Telegraph that if there is a "pecking order" of so-called important people who require treatment ahead of others, that will be up to the Government to decide.

Under the proposals, designed to provide doctors with ethical guidance on how to decide who should get life-saving care when resources are overstretched, hospitals would have to impose severe limits on who is put on a ventilator. Large numbers of patients could be denied care, with those facing a poor prognosis losing the potentially life-saving equipment even if their condition is improving.

Referring specifically to the withdrawal of treatment from some patients, Dr Black said it "needs to be done within guidelines and protocols".

"The emotional effect of this on doctors will be considerable because this is not something we normally have to do," he said.

"We normally have the resources to do the best we can for each individual but there will be competing individual needs in this environment...and, obviously, at different points in the pandemic, there will be different types of challenges presenting."

The BMA suggested that younger, healthier people could be given priority over older people and that those with an underlying illness may not get treatment that could save them.

"There will be various factors taken into account - for instance the severity of your illness," said Dr Black. "We're getting lots of experience, we know who'll survive and who won't survive.

"If you've lots of other diseases, then that really does impair your ability to respond to treatment.

"If you have a very old person with those conditions... age itself won't be a discriminating factor but age plus other things does discriminate in that if you are 95, diabetic, heart failure and Covid-pneumonia, we know that the chance of surviving in those circumstances is very low.

"And yet if there was someone in the queue - and there will be a queuing system - who's 32, needs a ventilator, who's a mother-of-three, I think all reasonable people would know what the decision is there."

The document explained that the guidance has been drawn up because when the outbreak peaks, "it is possible that serious health needs may outstrip availability and difficult decisions will be required about how to distribute scarce life-saving resources".

The BMA paper explores a range of circumstances that could pose ethical dilemmas for doctors and it suggests that patients who work in vital services and industries including the NHS, utilities and telecoms may be deemed a priority for an ICU bed.

"We think this is a very challenging area," Dr Black said.

"We will do this under clear principles and guidelines. We are very patient-centred so we would be keen to make sure that those who get the greatest benefit are the ones who are prioritised and we would not be keen to see any other prioritisation."

Expounding another potentially controversial suggestion, the document said that ICU patients who do not improve or worsen after admission may have their treatment withdrawn under a new "capacity to benefit quickly" approach.

The document said the NHS's limited supply of intensive care beds will inevitably mean that doctors will have to refuse access to some people, especially those with one or more underlying health conditions and those who are older, though it does not specify an age threshold.

Dr Black said all decisions will be based on "individual cases" - including the severity of the illness.

"You want to get the greatest medical benefit to the greatest number of patients," he said.

"The NHS is a community resource shared by all of us and everybody has a sense of fairness in this and it's all about the capacity to benefit from the resource."

Belfast Telegraph