Advance care plans/ decisions to help people and their families discuss their preferences if they become severely unwell or their long term conditions progress and they are at risk of dying are a *good* thing that we should be doing more of and help people achieve a better death

It is right and proper, Coronavirus or not that we do our best to support people to remain in their own homes or return home sooner or be supported by community teams or community facilities outside the acute hospital when acute hospital is not the best or safest place for them

we should never deny people acute hospital treatment that they might benefit from and in fact if you look at which patients are in hospital beds right now, mid pandemic first wave, they are largely mid life or older people with (often multiple) underlying conditions/frailty etc

if hospital is the best or only place they can receive treatment including high Fi02 Oxygen, Non Invasive Ventilation, Intravenous fluids and antibiotics, frequent observation and access to regular senior review, outreach teams, imaging, daily bloods etc then hospital it is

but this is not a , binary game "hosptial safe/good, home unsafe/bad"
If they come in they won't see their families or have their usual social interaction, they will be exposed to higher Covid-19 risk if they don't yet have it and hospital admission can be distressing/alienating

although hospital is clearly the right and best option some of the time it has always carried other risks e.g. Delirium, increasing dependence, infection risk, psychological distress, loss of agency etc. Keeping people at home or getting them back home is a good aim not a scandal

with regard to nursing and residential homes there were deep seated problems in the sector, despite some wonderful caring staff in wonderful caring homes. Underfunded, cuts, squeezed financially, staffing gaps (made worse by immigration policy), patchy access to NHS in reach

clearly the problems in care homes are now in the spotlight due to lack of personal protective equipment for staff, an upsurge in admissions to them, more people leaving hospital sooner to return to them, more acute treatment on site, more isolation, more palliative care in situ

But.....before the pandemic, it was always the case that care home residents were frail, with multiple life limiting long term conditions, physical dependence, and cognitiive impairment/dementia and generally in the last phase of their lives

and it was always the case that they would have very low survival rates from CPR and that conveyance to an acute hospital would often be profoundly distressing, often add little value to their care in 1/3 cases lead to their death on an unfamiliar ward not a familiar place

So in principle, advance care plans and DNACPR and "do not convey" to hospital and better support from healthcare teams and palliative care within the home were always a good thing and the right thing to do. It just happens that the pandemic has overwhelmed capacity completely

meanwhile when people *do* come to hospital (from any residence) if they do *not* have advance care plan/decision to refuse treatment/DNACPR or a person centred shared care plan it is *good* that hospital staff *do* discuss resus and limits and goals of treatment there and then

the alternative is that it is *not* discussed either with the person or their family and then when they have a cardiac arrest or rapid deterioration decisions to intervene (or not) have to be made on the hoof and often not in that person's interest or in line with their wishes

"DNACPR" which some people would prefer to be called "allow natural death" applies only to when your heart stops beating. (And is especially important when your heart is the last, not the first, organ to fail) it does not mean "do not treat" or "do not admit" or "don't try"

other more nuanced appproaches like the ReSPECT process and documentation (a universal treatment planning process) go beyond "Yes/No" to CPR and more to person's own goals and trade offs and priorities so that degree of treatment escalation or limitation can be openly planned

all of this is *GOOD* practice which we were already doing and should have been doing more of and yet is now somehow being labelled as bad and wrong due to misunderstandings. Now on to ICU admission decisions..

Although the UK started this pandemic with among the lowest number of ICU beds in OECD nations, hospitals have doubled or trebled their capacity and could go higher still. Despite some overwhelm in some london units earlier in the pandemic and a big scary workload ICU is coping

ICU medics, critical care outreach teams and ward teams considering calling or referring have *always* before the pandemic, had to make careful decisions on which patients had a decent chance of benefitting from ICU including ventilation or pre-ICU interventions like CPAP

these are not neutral procedures, they can be distressing, short and long term outcomes can be poor, not everyone (including doctors ourselves) would want this for us or our families if the chance of a good outcome was low. This has always been the case - not "ICU for all"

I do not believe that, in general, the NHS having significantly expanded ICU (and HMU, NIV) capacity is turning away lots of people with Covid-19 from ICU or ventilation for whom risk/benefit made it worth a go nor that the threshold for admission has changed that much

making well informed decisions based on that person's likelihood of benefit and with a wealth of outcome data from big databases/audits like ICNARC and well validated prognostic scores like APACHE is not "writing people off because they are old or disabled". It is good practice

it is absolutely the case that if units are swamped, in extreme circumstances there may be hard decisions to be made between two individuals who might ordinarily have been admitted to ICU - although i don't think we are there yet in most places in UK from many people i speak to

if those decisions *do* have to be made, i do not believe any doctor i know is doing so on "value to society" or "quality of life" judgements which we are not qualified to make, or openly disablist or ageist attitudes labelling people. ICUs *do* take pretty old or disabled pts

however, they *do* take into account that person's physiological reserve ability to cope with/benefit from treatment or the distress treatment might cause. This will sometimes mean that an older or disabled person is not admitted but that is differentiation *not* discrimination

yes it is true that scoring systems like Clinical Frailty Score (or APACHE or NEWS) are used to help clinicians identify people who might benefit (or not) from treatment escalation and that these are explicitly part of NICE and some local guidelines. but...

but...the use of such scores is not capricious or discriminatory - it is based on solid empirical evidence for poor outcomes including death. I do not believe anyone is just calculating a crude score, with no individualised assessment of that patient and deciding to give up

So basically we find ourselves combatting misunderstandings, misinformation (much of it based on understandable fear and anxiety and reinforced by unhelpful media reporting which then shapes views) and fighting straw men

when in reality most of what i am describing is *good* practice with sound underpinnings which we should be doing more of and should have been doing more of before the pandemic. It is being almost wilfully mispresented and sensationalised

then we come to palliative care whether in hospital, in care homes, in hospices in person's own home. Palliative care aims to give someone a person centred, dignified, death and attempts to minimise distressing symptoms and also ease the burden on families, before and after death

often it is far better to recognise and explain that someone is dying, discuss it openly with them and their family and then try to make the death as good as possible rather than subjecting a dying person to an over-medicalised death with too many interventions and false hope

speak to Drs having seen so much overmedicalisation of death (including CPR) about what they would want for themselves and their parents or spouse and it is less heroic, life prolonging but futile intervention and more focus on palliation. Again it is a GOOD thing not a failing

I think has been an awful lot of good stuff *among* clinical professionals to improve communication and practice skills around death, dying, advance care planning, limits of treatment but with notable exceptions like @drkathrynmannix and @Atul_Gawande we need to go more public

if we had done more to explain dnd demystify these issues we would not find ourselves in a situation where mainstream media outlets and social media accounts and campaigning groups are turning what is essentially good practice (even if not always done or communicated well)

So post-pandemic, l, i would like a big coalition of interested medical organisations, health charities, patient groups alongside mainstream media do high end plain english mythbusting big public conversations People are scared enough without untruths scaring them more
ENDS