Palliative care and ethical framework

Tutorial presented by Dr Idris Baker, Consultant in palliative care.

Patients with severe COVID-19 infection in the community can occasionally develop severe, distressing symptoms that can develop quickly. For patients requiring palliation, there are three fundamental approaches:

Urgency
Doing the basics right
The importance of individualisation

Some patients may get better, but this should not alter the approach to providing rapid symptom control where necessary. Evidence suggests that if patients are to get better, rapid symptom control will not adversely affect their recovery.

The pharmacological approach to palliative care in COVID-19 in the community can be found linked in the resources below.

Ethical framework summary statement

Some people benefit from rapid escalation to intensive care and ventilation. In some patients this will not work. Some can be identified early. We should use treatments that work, without disproportionate harm, subject to consent or best interest judgments, and provided they can be offered within the resources available. We should not use treatments that do not pass these tests. A treatment, however widely used and well known and however much the patient &/or those close to them think they would want it, should not be used if it stands no real chance of working in a particular patient or if it would cause disproportionate harm. Whatever treatments are being used, each patient should be given the best care available, helping them to survive if that can be achieved, and in all circumstances helping them to be comfortable, to live with dignity, and to be in the place of their choice if that is important to them. Guidance is offered to support decisions about which treatments will help, which will not, and how to maintain comfort. For some patients, there is nothing to gain by being in hospital. The question of what treatment is to be used may therefore help decide where the patient should be. If all the treatment being used can be done at home, and if some care is available, home (including a care home if that is the person’s home) is usually the best place and often the place they would prefer.

The best that is available may be less good than we would want to provide. We should be as flexible as possible to get the patient as comfortable as possible within the limitations we face. There may not be enough capacity to offer every patient every treatment. Decisions not to use a treatment are likely to be needed much more often during a pandemic crisis. Making sure that patients are not given treatments that are not right for them helps them. It also helps the other patients who may then have a greater chance to have treatments that would work. This should be the basis of decisions and is the fairest way to decide when there is not enough to go around.