BMA doctors set out ways care may have to be rationed as UK braces for sharp rise in deaths

Stable coronavirus patients could be taken off ventilators in favour of those more likely to survive, it emerged on Wednesday, as another sharp rise in deaths left the UK braced for the outbreak to reach up to 1,000 deaths a day by the end of the week.

In a stark new document issued by the British Medical Association, doctors set out guidelines to ration care if the NHS becomes overwhelmed with new cases as the outbreak moves towards its peak.

A rise in the death toll of 563 brought the overall total to 2,352, an increase of 31% on Tuesday’s figure. If the total continues to grow in line with increases over the last week, it is on course to go past 1,000 new deaths recorded each day within three to four days.

Under the proposals, designed to provide doctors with ethical guidance on how to decide who should get life-saving care when resources are overstretched, hospitals would have to impose severe limits on who is put on a ventilator. Large numbers of patients could be denied care, with those facing a poor prognosis losing the potentially life-saving equipment even if their condition is improving.

The BMA suggested that younger, healthier people could be given priority over older people and that those with an underlying illness may not get treatment that could save them, with healthier patients given priority instead.

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The document explained that the guidance has been drawn up because when the outbreak peaks, “it is possible that serious health needs may outstrip availability and difficult decisions will be required about how to distribute scarce life-saving resources”.

The BMA published its proposals amid concern over limits to NHS resources, with officials admitting on Wednesday that only 30 of the 30,000 new ventilators needed as the outbreak escalates will be available by next week.

The proposals came out as:

• A retired hospital medical director, Alfa Saadu, became the latest doctor to die of the virus after volunteering at a Hertfordshire hospital at the age of 68.

• New applications for universal credit approached 1m within two weeks, a rise of more than 500% that dwarves the increases seen during the financial crisis.

• The Ministry of Defence called up 3,000 military reservists to provide medical and logistical support to the NHS.

• Italy extended its lockdown to 13 April but recorded its lowest death toll in more than a week, sparking hopes that the outbreak there could be reaching a plateau.

• The UN secretary general, Antonio Guterres, described the global pandemic as “the most challenging crisis we have faced since the second world war”.

The Department of Health and Social Care said as of 9am on 1 April, a total of 152,979 people had been tested, of whom 29,474 were diagnosed as positive – an increase of 4,324 on the previous day.

London continues to report the highest number of deaths proportionally, accounting for more than a third of England’s total. NHS trusts in the capital have now registered 728 deaths from coronavirus.

But the figures do not provide a precise picture of the deaths within 24 hours, as a number of deaths announced in Wednesday’s figures occurred earlier in March.

The BMA paper, which is intended to help the UK’s 240,000 doctors manage the difficult decisions the pandemic could throw up, explores a range of circumstances that could pose them with severe ethical dilemmas. It also suggests that patients who work in vital services and industries including the NHS, utilities and telecoms may be deemed a priority for an ICU bed.

In another suggestion that could prove controversial, the document said that ICU patients who do not improve or worsen after admission may have their treatment withdrawn under a new “capacity to benefit quickly” approach.

The document said the NHS’s limited supply of intensive care beds will inevitably mean that doctors will have to refuse access to some people, especially those with one or more underlying health conditions and those who are older, though it does not specify an age threshold.

It does not list the illnesses but they are likely to include heart problems, kidney disease, diabetes or a pre-existing lung condition such as COPD. One in four Britons have at least one such chronic illness.

“To maximise benefit from admission to intensive care, it will be necessary to adopt a threshold for admission to intensive care or use of scarce intensive treatments such as mechanical ventilation or extracorporeal membrane oxygenation,” it says.

“Relevant factors predicting survival include severity of acute illness, presence and severity of co-morbidity and, where clinically relevant, patient age. Those patients whose probability of dying, or requiring a prolonged duration of intensive support, exceeds a threshold level would not be considered for intensive treatment, though of course they should still receive other forms of medical care.”

Rationing could become even tighter as the pandemic progresses, the document states. “Depending upon the nature of the pandemic, there may be a need during its progress to shift from one level of service rationing to a more or less severe one,” it says.

Public Health England has finalised an updated document setting out what protective kit should be worn in different medical settings, which it hopes will dispel the confusion, alarm and fear among frontline NHS staff.

Sources involved said that the document, due out on Thursday, represents a partial revision of the guidance that led to PHE facing a barrage of criticism from groups representing doctors, nurses, midwives and other NHS staff.

They accused PHE of downgrading advice issued by the World Health Organization about which situations need full PPE – double gloves, surgical gown, FFP3 extractor mask and a visor or goggles – and which others require just a surgical mask, apron and single pair of gloves.

Sources said that PHE’s revised, final guidance, developed after discussions with about 1,000 doctors and medical groups, will increase the number of settings in hospitals where full PPE should be worn because of the risk of contracting the coronavirus and also the type of dealings with patients when both GPs and ambulance crews should wear either full PPE or the more limited form.

• The image on this article was changed on 2 April 2020 to replace one of a continuous positive airway pressure (Cpap) breathing aid, with one of ventilators.