Is life so precious that any number of painful, lonely, frightened deaths is acceptable to preserve one life?
As a child, I competed with my siblings to see who could hold their breath the longest. I remember the increasingly desperate need to draw a breath as time slowed in proportion to discomfort. The idea that units of time are constant is made absurd when you need to breathe and can’t. It is almost painful. Then there is the sweet, instant relief as you give up. The spent air is forced out, and a lungful of fresh air is gulped in. The whole thing is followed by raucous laughter and calls for another round.
Wouldn’t it be grand if people dying from COVID could just laugh it off as they draw the next sweet breath of air? Immediate salvation from death by hypoxia. Families around the world prayed for those easy breaths as they bundle loved ones into cars, tuk-tuks, and rickshaws in a desperate search for air — and care. On arrival at a hospital, staff had to make a quick decision. With limited resources, they had to choose who would be left to die.
I was told of one hospital where the “not to be treated” were seated in a circle with a single oxygen mask to share between them. They handed the mask from one to the other until, like the ten green bottles, one by one, they dropped out of the round. A colleague’s mother gasped her last breath seated in that circle. In other hospitals, the COVID patients died supine and alone on cots and floors tucked away from the urgent task of saving lives.
I have spent two nights of my adult life taking one careful breath at a time. Asthma. I very rarely have it, and when I do, it is environmentally triggered. On the last occasion, it was 11pm. We were six weeks into the pandemic, and I was alone in my flat in Dhaka. Breathing had become work. Tiring work. I remember skipping breaths because it was restful. Although I was worried, arriving with breathing difficulties at the A&E of a panic-stricken hospital seemed a bad idea. With judicious and relatively frequent use of a salbutamol inhaler , the worst of it only lasted a handful of hours before I settled into modest discomfort and sleep.
It is a poor analogy, and I cannot really imagine the feeling of dying from COVID. It did get me thinking, however. What tradeoffs should be made to provide decent palliative care for those COVID patients who are dying?
The standard triage arrangement in hospitals prioritises patients according to the severity of the condition and treats the most severe cases first. If you are waiting to treated for a broken arm and someone is rushed in with myocardial infarction (MI). The MI wins, at least in terms of the immediate allocation of resources. And this will be true, even if the MI patient is highly unlikely to survive. No one dies because of the choice to treat the worst-off first. This is in sharp contrast to battlefield triage (or triage in humanitarian emergencies), where resources are severely limited. The choice to treat the most severe cases will condemn others, who have greater chances of survival, to a needless death. Battlefield triage will put some critical patients beyond care, focusing resources on lives that can be saved.
For many doctors, the COVID pandemic was their first experience of battlefield triage. At its worst, the situation meant there was not enough oxygen, ventilators, personal protective equipment, or staff.
Given two patients who will die without treatment and only enough resources to treat one patient, who should be treated? One patient is over 80 and has multiple co-morbidities; the other patient is under 30 and has no co-morbidities. The patient under 30 would win that lottery for (potentially) live-saving care.
But what of our over-80 patient (Sarah)? Does she warrant any resources? Does she deserve any clinical management and care even though her death is inevitable? Without any healthcare resources, she will die alone, distressed and in discomfort over the next 24 hours. If the situation is particularly dire — as it was during periods of the pandemic when patient waves crashed against the hospitals’ doors — even giving staff time to Sarah will endanger other lives that could be saved.
I am setting up a tradeoff. Tradeoffs have been used extensively to identify people’s preferences for different health states. The classic tradeoff is the time tradeoff (TTO). It is used in clinical research (and patient management) to identify preferences between the length of life and quality of life. The TTO might look something like this.
Imagine you have 10 years of life left with chronic obstructive pulmonary disease (COPD). You could trade those 10 years of life with COPD for fewer years of life in perfect health. How many years of life in perfect health would be equivalent to 10 years with COPD?
If you would not give up any years of life with COPD to live in perfect health, you are saying that you have no preference for a life with COPD over a life in perfect health. They are equivalent with respect to time. The example I give here is bare-bones. Numerous variations of the TTO have been developed to estimate preferences for different health states. Another tradeoff, the person tradeoff (PTO), was created to evaluate the severity of various disease states. The flavour of the PTO is given in the following, and I will stick with COPD for consistency.
Imagine you could choose (A) to extend the lives of 1,000 healthy people by one year, or you could choose (B) to extend the lives of N people with COPD by one year. How many lives of people with COPD would you need to extend for one year to choose B over A?
Suppose you would not tradeoff any lives (that is, 1,000 healthy people living for an extra year is equivalent to 1,000 people with COPD living for an additional year). In that case, you are saying (at least within the calculus of the PTO) that you have no preference for a life with COPD over life in perfect health.
These tradeoffs are all focused on the valuation of years of life. In the TTO it is explicit because you are changing the amount of time that a single life is lived. In the PTO, it is implicit. You are not asked to vary the time of a single life. You are nonetheless trading years of life: 1,000 person-years in perfect health is equivalent to how many person-years with COPD?
The tradeoff I am proposing for palliative care (explicitly terminal care) is somewhat different. In the TTO and the PTO, you are trading things of an equivalent nature — time or person-years. In the scenario of palliative care, you are trading things of different kinds (apples and oranges) — life against a comfortable death.
How many comfortable deaths need to be achieved to forsake a single life? The reality is that a comfortable death need not take a lot of resources away from saving lives, but it will need some. If reallocating resources results in one extra person dying, how many painful, lonely, frightened deaths would need to be made comfortable deaths to make that tradeoff acceptable? I would be prepared to lose lives that could otherwise be saved if it meant that many people whose lives could not be saved were given comfortable deaths. This view is not reflected in many government policies and I suspect that until the tradeoff is made explicit and data gathered, there will be no progress in fair resources for palliative care. It would also be good if voices from the global south were reflected in such considerations