Skip to main content

Main menu

  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us

Future Healthcare Journal

  • FHJ Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About FHJ
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

User menu

  • Log in

Search

  • Advanced search
RCP Journals
Home
  • Log in
  • Home
  • Our journals
    • Clinical Medicine
    • Future Healthcare Journal
  • Subject collections
  • About the RCP
  • Contact us
Advanced

Future Healthcare Journal

futurehosp Logo
  • FHJ Home
  • Content
    • Current
    • Ahead of print
    • Archive
  • Author guidance
    • Instructions for authors
    • Submit online
  • About FHJ
    • Scope
    • Editorial board
    • Policies
    • Information for reviewers
    • Advertising

Sacrifice and risk in the time of COVID-19

Julia Simons and Jenny Vaughan
Download PDF
DOI: https://doi.org/10.7861/fhj.2020-0035
Future Healthc J June 2020
Julia Simons
ASheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
Roles: foundation interim year-1 doctor
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Jenny Vaughan
BLondon North West University Healthcare NHS Trust, London, UK and Imperial College Healthcare NHS Trust, London, UK
Roles: consultant neurologist
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • For correspondence: jvaughan@doctors.org.uk
  • Article
  • Figures & Data
  • Info & Metrics
Loading

ABSTRACT

The COVID-19 pandemic has changed the face of healthcare delivery. This article discusses the concept of medical sacrifice and personal risk, and how healthcare workers can apply these concepts when working outside their comfort zones, while remaining within the limits of their clinical competence. Guidance from the General Medical Council and the medical defence organisations is reviewed and considered in its practical application. We explore how a medical student, now a ‘fast tracked’ junior doctor, and a senior consultant, with pre-existing health issues, can feel confident working as part of the NHS response to COVID-19.

KEYWORDS:
  • COVID-19
  • competence
  • risk
  • medical negligence
  • medical regulation

Introduction

At the end of winter in 1888, 45-year-old Dr Hugh Gillies ignored family advice to rest with his mild symptoms of ‘flu’; instead, he decided to answer a desperate call-out to a miner on a remote Scottish island. His patient was alone, had suffered a stroke and was not expected to live. Dr Gillies made the treacherous journey to the house and stayed by his patient's side all night. A storm blew up on the return leg, so it took three times longer and Dr Gillies arrived home exhausted. He developed pneumonia, dying very shortly afterwards. He paid the highest price for doing his job and his community recognised him as a man of his word and a powerful advocate for fairness and equality in healthcare. Admiration of their father's principles led two of his sons to become doctors. There are now at least 10 ‘Doctor Gillies’ from his family line including Dr Kate Gillies, a general practitioner (GP), and Dr Alexander Gillies, his great, great grandson who is working as a GP in the COVID-19 Assessment Centre in Exmouth, Devon.1

Sacrifice in medicine

Dr Gillies' story illustrates his willingness to prioritise his patient's comfort above his own. Being part of the medical profession has always involved shouldering the burden of clinical risk and an implicit acceptance of personal sacrifice; both can challenge a personal sense of comfort. The current pandemic calls us to reconsider these issues within the context of additional individual and societal risk. At the start of the COVID-19 outbreak, Dr Li Wenliang, an ophthalmologist in Wuhan, China, took personal risks in the context of an authoritarian state to alert the wider medical community about the emergence of the infection. Tragically, Dr Li Wenliang died of COVID-19 on 07 February 2020.2

In the context of the COVID-19 pandemic, the assumptions that lie behind the recognition of medicine as a vocation rather than a career are more explicit. The current call upon healthcare workers globally is unparalleled. As healthcare workers are lauded as heroes, it is important to reflect upon the limits of comfort zones, personal sacrifice and how risk articulates with individual circumstances. As an experienced consultant and a newly qualified doctor, we consider how risk and comfort zones are reframed by the current COVID-19 pandemic.

COVID-19 is changing roles

Final-year medical students, now foundation interim year-1s (FiY1s), have voluntarily registered with the General Medical Council (GMC) early.3 Trusts are being told to provide additional support. In addition to normal shadowing and supervision, they are asked to provide a foundation year-1 or foundation year-2 buddy, one-to-one wellness inductions, and for work within consistent team structures. Retired doctors and nurses have returned in their thousands to be re-trained and assist in the pandemic response.4 Practice has also changed for experienced clinicians (Table 1). Face-to-face consultations for routine work have been cancelled in hospitals and GP surgeries.

View this table:
  • View inline
  • View popup
Table 1.

Personal perspectives

Principles of practice

The principles of how doctors care for patients haven't changed; the GMC has provided updated guidance for the pandemic, described as ‘extreme circumstances’.5 Preparation for new roles for both the newest and most experienced members of the healthcare workforce requires employer-led support: multidisciplinary teamwork, appropriate induction, mentoring, training and feedback, including specific resources for staff wellbeing. Redeployed healthcare workers (HCWs) must continue to work within the limits of their competence, including consideration of what is in the patient's best interests.6 There should not be an absolute obligation placed on anyone to work in a specific role if they do not feel able to perform outside their area of specialism.7

Clinicians must consider whether it is possible to perform assessments adequately by remote review, and balance must be struck between potential risk to clinicians and the best interests of the patient, eg in treatment of maculopathy in eye clinics to prevent blindness. The medicolegal recommendation is that doctors should record the reasoning behind decisions made and the information given to patients, in case it is necessary to explain the approach taken at a later date.6

Best-interest decisions are made based upon the balance of risks; professionals must communicate concerns and explain these decisions to patients. Unresolved concerns can be relayed verbally to the clinician in charge and/or in writing and advice can be taken from a medical defence organisation (MDO). Doctors should also check their MDO coverage and subscriptions to ensure they have the correct type, applicable to their role.6

Importantly, in the wake of the Bawa-Garba case, the GMC have stated that they will take account of the full context of a doctor's work including any lack of staff or resources, which may be the reality in this exceptional situation.8 The GMC has also requested that all organisations provide adequate resources, including staffing numbers and skill mix. All healthcare regulators have acknowledged that clinical duties may include working outside normal practice and have supported the need for staff to work cooperatively, in line with best evidence and within their competence.9

Redefining comfort zones: reducing risk

Comfort zones are characterised by a sense of security due to familiarity. Normal comfort zones have been erased as healthcare systems have been rapidly re-organised over recent weeks. HCWs are asked to be flexible, and to work in non-standard clinical areas for the benefit of patients.5 Prior to the pandemic, understaffing was a concern. A recent survey found that many doctors are now working on rotas with 20% of staff absent.10 Concern for the safety of staff, patients and families places the provision of adequate personal protective equipment (PPE) at the forefront of any discussion. Italy has recorded deaths of over 100 doctors, with HCW deaths in the UK rising steadily at the time of writing.11 Personal experiences of morbidity and mortality combined with new clinical roles are not within normal comfort zones for most HCWs.

HCWs always aim to provide the best patient care possible with the resources available including ‘in the highly challenging but time-bound circumstances of the peak of an epidemic’.5 In the context of PPE shortages, tension arises between reducing risk (to self and to patients) through use of adequate PPE and remaining within personal comfort zones which, as the tale of Dr Gillies illustrates, have been constructed to put patients first.

British Medical Association (BMA) guidance recognises the right of a doctor to refuse to work if PPE is inadequate when they are at a high risk of infection and there is no other way of delivering care.12 Recent changes to guidance for PPE (due to shortages), have been criticised by the Royal College of Surgeons for ‘risking confusion’ and for being ‘wholly inadequate for an operating theatre environment’.13,14 There is further confusion about the correct level of PPE to wear due to inconsistency regarding whether cardiopulmonary resuscitation (CPR) is an aerosol generating procedure (AGP); Public Health England guidance states CPR is not an AGP, whereas the Resuscitation Council (UK) guidance states that it is.15,16 Conflicting definitions have led to concern that guidance is based upon the availability of PPE rather than the best available evidence for practice. This has led to organisations such as the Doctors' Association UK (DAUK) to campaign for improved PPE availability and bring to light the issue of workplace bullying attempting to silence frontline doctors on this issue.17 Limits of sacrifice must be defined; HCWs should not be placed at higher personal risk than necessary by their employer.

Ethics in a pandemic

The published ethical framework for responding to pandemic influenza recognises the potential conflict between the needs of the individual and that of the population.18 Understanding ethical responsibility within this context requires a layered approach. Government and employers are responsible for systems that ensure provision of adequate equipment and staff. Assessment of risk at an organisational, team and individual level requires professional judgement from HCWs, both clinical and non-clinical. The mutual goal is to ensure that patients receive safe care, consistent with accepted standards, and based on robust evidence. Variation in clinical practice may be necessary, and decisions about treatment pathways demand clear communication between clinical staff. Ethical concerns are particularly fraught with regard to resource allocation in the intensive treatment unit setting. BMA guidance supports the approach that it is both lawful and ethical to withhold or withdraw treatment on the basis of evidence-based resource allocation to optimise outcomes.19 However, in practice, withdrawal will ‘feel different’. Removing ventilation and not providing it in the first place may not be regarded by the courts as legally equivalent. There needs to be an open and transparent national debate that results in a nationally applied approach to withdrawal that ideally has public support. This is especially important in the likelihood of further peaks and future pandemics.20 The issue of whether immunity from civil liability should apply for any injury or death alleged to have been sustained because of any acts or omissions undertaken in ‘good faith’ during the COVID-19 crisis by HCWs has also been raised.21

Conclusions

Medical practice has always had the potential to take clinicians out of their comfort zone. This is universally evident amid the significant challenges presented by the COVID-19 pandemic, and there are many examples of courage and sacrifice. These values are not new to HCWs. We urge governments to learn and implement rapidly the improvements necessary to reduce the risk of deaths, both for the population and for staff with direct workplace exposure. As a profession, we must continue to act with courage in our patients' best interests, but in the process not neglect our own personal safety nor that of our colleagues.

  • © Royal College of Physicians 2020. All rights reserved.

References

  1. ↵
    1. Withall M
    . The Easdale Doctor: The Life and Times of Patrick H. Gillies. Origin, 2018.
  2. ↵
    1. Hegarty S
    . The Chinese doctor who tried to warn others about coronavirus. BBC News, 2020. www.bbc.co.uk/news/world-asia-china-51364382 [Accessed 09 April 2020].
  3. ↵
    1. General Medical Council
    . Early provisional registration for final year medical students. London: GMC, 2020. www.gmc-uk.org/news/news-archive/early-provisional-registration-for-final-year-medical-students [Accessed 09 April 2020].
  4. ↵
    1. Philpotts E
    . GMC asks 5,000 unlicensed GPs to return to work in coronavirus crisis. Pulse Today, 2020. www.pulsetoday.co.uk/clinical/clinical-specialties/respiratory-/gmc-asks-5000-unlicensed-gps-to-return-to-work-in-coronavirus-crisis/20040394.article [Accessed 09 April 2020].
  5. ↵
    1. General Medical Council
    . Supporting doctors in the event of a Covid19 epidemic in the UK. London: GMC, 2020. www.gmc-uk.org/news/news-archive/supporting-doctors-in-the-event-of-a-covid19-epidemic-in-the-uk [Accessed 09 April 2020].
  6. ↵
    1. Hendry R
    . Coronavirus: GPs' medico-legal questions answered. GP Online, 2020. www.gponline.com/coronavirus-gps-medico-legal-questions-answered/article/1676857 [Accessed 09 April 2020].
  7. ↵
    1. Royal College of Physicians
    . Ethical dimensions of COVID-19 for frontline staff: 2 April 2020. London: RCP, 2020. www.rcplondon.ac.uk/file/20551/download [Accessed 12 April 2020].
  8. ↵
    1. Vaughan J
    . The long road to justice for Hadiza Bawa-Garba. London: BMJ, 2018. https://blogs.bmj.com/bmj/2018/08/14/jenny-vaughan-the-long-road-to-justice-for-hadiza-bawa-garba [Accessed 24 April 2020].
  9. ↵
    1. General Medical Council
    . How we will continue to regulate in light of novel coronavirus. London: GMC, 2020. www.gmc-uk.org/news/news-archive/how-we-will-continue-to-regulate-in-light-of-novel-coronavirus [Accessed 09 April 2020].
  10. ↵
    1. Royal College of Physicians
    . COVID-19 and its impact on NHS workforce. London: RCP, 2020. www.rcplondon.ac.uk/news/covid-19-and-its-impact-nhs-workforce [Accessed 09 April 2020].
  11. ↵
    1. Federazione Nazionale degli Ordini dei Medici Chirurghi e degli Odontoiatri
    . [List of doctors who died during the Covid-19 epidemic]. FNOMCeO, 2020. https://portale.fnomceo.it/elenco-dei-medici-caduti-nel-corso-dellepidemia-di-covid-19/?fbclid=IwAR3b5IF1gLQzIL_0phFhjMyC94mGjvMn9omgXzGimUZE3BfYXtZdT6hZLbY [Accessed 09 April 2020].
  12. ↵
    1. British Medical Association
    . COVID-19 refusing to treat where PPE in inadequate. London: BMA, 2020. www.bma.org.uk/advice-and-support/covid-19/your-health-and-wellbeing/covid-19-refusing-to-treat-where-ppe-is-inadequate [Accessed 19 April 2020].
  13. ↵
    1. Public Health England
    . Considerations for acute personal protective equipment (PPE) shortages. London: PHE, 2020. www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/managing-shortages-in-personal-protective-equipment-ppe [Accessed 19 April 2020].
  14. ↵
    1. Royal College of Surgeons
    . RCS statement on latest Public Health England PPE guidance. London: RCS, 2020. www.rcseng.ac.uk/news-and-events/media-centre/press-releases/rcs-statement-on-latest-public-health-england-ppe-guidance [Accessed 19 April 2020].
  15. ↵
    1. Public Health England
    . Guidance COVID-19 personal protective equipment (PPE). London: PHE, 2020. www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe [Accessed 24 April 2020].
  16. ↵
    1. Resuscitation Council (UK)
    . Resuscitation Council UK statement on COVID-19 in relation to CPR and resuscitation in acute hospital settings. London: Resuscitation Council (UK), 2020.
  17. ↵
    1. Dyer C
    . Covid-19: doctors are warned not to go public about PPE shortages. BMJ 2020;369:m1592.
    OpenUrlFREE Full Text
  18. ↵
    1. Department of Health and Social Care
    . Responding to pandemic influenza. The ethical framework for policy and planning. London: DHSC, 2007.
  19. ↵
    1. British Medical Association
    . COVID-19 ethical issues. A guidance note. London: BMA, 2020. www.bma.org.uk/media/2226/bma-covid-19-ethics-guidance.pdf [Accessed 23 April 2020].
  20. ↵
    1. Thomas G
    , Gollop K, Roper S. COVID-19: Allocation and withdrawal of ventilation - the urgent need for a national policy. UK Medical Decision Law Blog, 2020. http://ukmedicaldecisionlawblog.co.uk/rss-feed/119-covid-19-allocation-and-withdrawal-of-ventilation-the-urgent-need-for-a-national-policy [Accessed 08 May 2020].
  21. ↵
    1. The Medical Defence Union
    . MDU calls for national debate over protecting NHS from COVID-19 clinical negligence claims. London: MDU, 2020. www.themdu.com/press-centre/press-releases/mdu-calls-for-national-debate-over-protecting-nhs-from-covid-19-clinical-negligence-claims [Accessed 24 April 2020].
View Abstract
Back to top
Previous articleNext article

Article Tools

Download PDF
Article Alerts
Sign In to Email Alerts with your Email Address
Citation Tools
Sacrifice and risk in the time of COVID-19
Julia Simons, Jenny Vaughan
Future Healthc J Jun 2020, 7 (2) 158-160; DOI: 10.7861/fhj.2020-0035

Citation Manager Formats

  • BibTeX
  • Bookends
  • EasyBib
  • EndNote (tagged)
  • EndNote 8 (xml)
  • Medlars
  • Mendeley
  • Papers
  • RefWorks Tagged
  • Ref Manager
  • RIS
  • Zotero
Share
Sacrifice and risk in the time of COVID-19
Julia Simons, Jenny Vaughan
Future Healthc J Jun 2020, 7 (2) 158-160; DOI: 10.7861/fhj.2020-0035
del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
  • Tweet Widget
  • Facebook Like
  • Google Plus One

Jump to section

  • Article
    • ABSTRACT
    • Introduction
    • Sacrifice in medicine
    • COVID-19 is changing roles
    • Principles of practice
    • Redefining comfort zones: reducing risk
    • Ethics in a pandemic
    • Conclusions
    • References
  • Figures & Data
  • Info & Metrics

Related Articles

  • No related articles found.
  • Google Scholar

Cited By...

  • No citing articles found.
  • Google Scholar

More in this TOC Section

  • Autonomic dysfunction in ‘long COVID’: rationale, physiology and management strategies
  • Preventing vitamin D deficiency during the COVID-19 pandemic: UK definitions of vitamin D sufficiency and recommended supplement dose are set too low
  • Requests from primary care for chest X-ray and CA125 measurements during the COVID-19 emergency: An observational study
Show more COVID-19 rapid report

Similar Articles

Navigate this Journal

  • Journal Home
  • Current Issue
  • Ahead of Print
  • Archive

Related Links

  • ClinMed - Home
  • FHJ - Home

Other Services

  • Advertising
futurehosp Footer Logo
  • Home
  • Journals
  • Contact us
  • Advertise
HighWire Press, Inc.

Follow Us:

  • Follow HighWire Origins on Twitter
  • Visit HighWire Origins on Facebook

Copyright © 2020 by the Royal College of Physicians