In Britain's triage system, he fears 'terrible decisions' may be made


LONDON – Denying vital care to conserve public resources is nothing new to Britain's National Health Service.

For costly treatments for cancer and other diseases, the health service officially limits what it will spend to postpone a death: £ 30,000, or about $ 37,000, for each full "quality,quot; year of life provided to a patient.

In the event of a pandemic, public guidance from health officials for more than a decade has been that physicians must prepare to retain the scarce resources of the weakest patients in order to save the strongest, especially with use of life support fans. .

However, now that a pandemic has finally arrived, health authorities this week refused to explain exactly how to make those dying decisions, evidently for fear of a public uproar.

British health officials said on Friday that the number of hospital deaths in the past 24 hours had reached a new high of 684, bringing the total to 3,605. The full extent of the infection remained impossible to quantify, in part because the test materials were so scarce.

British authorities began issuing a vague pandemic guidance more than a decade ago, telling health care providers to give preference to those who are most likely to benefit from access to limited resources such as ventilators.

"Everyone matters equally, but this does not mean that everyone is treated in the same way," the ethics health department stated. guideline formulated after the 2009 H1N1 flu, or swine flu, pandemic.

"Even if the existing capacity of critical care beds can be maximized, during the peak of a pandemic, there may be 10 times more patients requiring mechanical ventilation than the number of beds available," the health department estimated at the Pandemic Flu Guide first issued in 2009.

"Additional safety measures,quot; may be needed, the same document warned, to protect doctors making classification decisions from the anger of people whose friends or family were denied respiratory support to sustain life.

But that general orientation failed to address many of the trickiest questions, including how to decide which patients have the best chance of survival.

Advocates for the elderly warn that older but physically healthy patients may suffer unfairly if doctors use age as a substitute for resilience, and that decision-making may vary from hospital to hospital. Diabetes, heart disease, obesity, or other health risks may be counted differently.

"This has been the most alarming concern for people with disabilities worldwide," said Catalina Devandas, United Nations Special Rapporteur on the rights of people with disabilities. "The highlight of this drama is that it appears to be the default reasoning of society at large: the lives of people with disabilities are not considered as valuable."

In the absence of guidance from Britain's top health officials, the same body that applies the £ 30,000 limit to new treatments, the Official National Institute for Health, Care and Excellence, generally referred to by the acronym NICE. – He sought to intervene. Last week N.I.C.E. He advised physicians to prioritize ventilator access in part by consulting a numerical score known as the Clinical Fragility Classification.

But the frailty rating is a measure of physical activity and overall self-sufficiency designed to assess only older people, not the general population. Lawyers representing people with autism and other disabilities quickly complained, and N.I.C.E. It modified its guideline to specifically rule out any application to people who are younger or with learning disabilities or long-term disabilities, although patient advocates argued that the changes were insufficient.

Then this week, the British Medical Association, the leading medical trade group, issued its own general guidelines, arguing that its members and other health care providers should be given special priority. That way they could return to caring for others, the association reasoned.

"Decisions about which groups will have to resort to scarce resources first may also take into account the need to maintain essential services," the medical association said. That should include, he said, "those people involved in addressing the immediate health and social aspects of the pandemic, and particularly those with poor and irreplaceable skills."


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