Sacrifice and risk in the time of COVID-19

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.

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