Dr John Ashton, a former director of public health, explains why it is wise to give thought during the COVID-19 pandemic to those life and death concerns we never usually want to confront.
The news that Boris Johnson has been admitted to hospital 10 days after first experiencing symptoms of the Coronavirus has raised concerns about his condition. Having presumably begun to feel unwell with the commonest symptoms of a high temperature, dry cough and perhaps some shortness of breath, the failure of the Prime Minister to show improvement by now indicates that he may be at risk of developing complications.
Perhaps the most detailed knowledge of the virus we have so far comes from a World Health Organisation (WHO) report published in February, based on 56,000 laboratory confirmed cases from China. This found a mild illness in 80% of cases, whilst 15% went on to become severe and patients becoming critically ill and requiring intensive intervention occurred in 5% of cases. The point at which escalation of care is necessary seems to come at eight to 10 days, with the development of a severe shortness of breath, potentially going on to pneumonia and respiratory distress syndrome requiring intubation and transfer to an intensive care unit with the option of assisted ventilation should this become necessary. The case fatality rate in this Chinese series was 4%.
So far, statements from Downing Street give hope that, in the case of the Prime Minister, his transfer to hospital last night was a precautionary one and that there is no cause for serious concern.
As the UK epidemic unfolds, teams around the country have been digesting data such as this and developing their own clinical protocols to guide their clinical decisions – not least with regard to determining whether or not it is appropriate to transfer patients from a domestic to a hospital setting.
Take the triaging of the over-65s. Beginning with a clinical assessment at a GP surgery, in a NHS 111 call or via the local corona command centre, decisions are taken as to whether patients might benefit from hospital admission taking into account other factors, including their level of frailty as assessed on the Rockwood Clinical Frailty Score – a nine-point scale in which a cut-off point of seven or more indicates severe or very severe frailty or being terminally ill and approaching the end of life. Tools such as this and the National Institute for Health and Care Excellence’s COVID-19 rapid guideline for critical care in adults, published on 20 March, are intended to bring some objectivity into a process that must, in the end, be a highly personal and subjective one.
In recent days, with the rapidly increasing numbers of COVID-19 cases and deaths – and as the potential for so-called ‘exceedence’ of critical care in our hospitals has loomed – some commentators have tried to initiate a debate at a community and family level about end of life choices. This has sometimes been clumsy, with more than a eugenic tinge to it. However, at this moment above all, each of us should give some attention to the issues raised by such matters of life and death, and our own and our relatives’ important wishes.
Many people find this subject uncomfortable and difficult to broach. But, what we know in this regard is that most people nearing their end of life wish to die at home, although sadly many relatives are not keen because of their concerns about adequate family support from the NHS and social care community services. The recent publication of a most sensitive and practical guide, ‘Caring for Your Dying Relative at Home with COVID-19‘, by Hospice UK Vice President, Professor Baroness Finlay of Llandaff, should give plenty of wise support and advice to those who find themselves in this position in the days and weeks ahead.
Ten years ago, over a period of two years, an extensive programme of community-based workshops was held across Cumbria encompassing ‘Conversations for Life’, to encourage and support people to give thought to these delicate matters and make their wishes known to their loved ones. As a 72-year-old with Type 2 diabetes, I have since made sure that my own ‘living will’ or advance directive is firmly in place. I also note that my own general practice has this week written to each of its older patients encouraging us to make sure that we have our own care plans thought through and written down.
Those for whom hospital admission with a severe Coronavirus infection is the right course of action are likely to find themselves in the middle of a contested, now acrimonious, debate about the value of medical treatments.
From the early days of the pandemic in China, physicians there began to try established medicines that had been used in previous viral epidemics, including the anti-malarial drug hydroxychloroquine and the antibiotic azithromycin for chest complications, as well as other antiviral agents and drugs used to treat HIV. Claims have been made for the value of some combinations of these medications but, to date, most Western countries have shown a reluctance to use them without the usual rigorous clinical trials that normally precede their licensing for a new use.
In Bahrain, a combination of hydroxychloroquine and azithromycin is being used and, in New Brunswick, Canada, there use has been agreed under medical supervision with a central research register to evaluate their effectiveness. This is a rapidly moving issue and the conventional consensus is currently fraying with the likelihood that the therapeutic use of these medicines will be allowed in more countries in the near future.
This debate highlights the limitation of current approaches to drug trials faced with a pandemic of a novel virus with an unknown treatment. We might do well to remind ourselves of other examples from public health history, including the pioneering use by one of medicine’s American greats, Simon Flexner, who controversially used a novel and untested serum in the treatment of diphtheria, reducing the mortality rate from 80% to 18%.
Despite our best efforts, we are still confronting potentially tens of thousands of deaths in the UK before this scourge is defeated. The challenges this poses range from the bio-secure care of the deceased to the very human issues surrounding funeral ceremonies and the mental health of the bereaved. There is particularly confusion with regards to the funeral practices of devout believers of different faiths, accustomed to large gatherings. This is now a matter of acute concern to funeral directors, celebrants and public health practitioners alike with apparently secondary Coronavirus outbreaks being associated with a number of funerals both in the UK and internationally. This has led to a call for a moratorium on attended funerals and much clearer Government guidance backed by the force of law.
What is clear about about these uncomfortable challenges is that, however uncomfortable, we must confront them and it is best that they be discussed openly and widely. The remarkable address to the nation yesterday by the Queen, whose ability to to look at the highs and the lows of this and previous threats over an 80-year sweep of history, must give us the courage to see the distant light beyond the pandemic. We will surely rise to the challenge of her leadership and be grateful.
Dr John Ashton is a leading international authority on public health and a member of the Crown Prince of Bahrain’s Corona Task Force.