As the first phase of the epidemic reached its peak, I wrote an explanation of how to understand what is meant by a COVID-19 death and why these numbers are sometimes confusing (20 May
). Now, as sadly the numbers of deaths are again rising, I return to the subject of mortality but from a different viewpoint, that of the doctor more than of the patient or the epidemiologist.
Many medical students become familiar with two aphorisms, once very popular among those like me who used to teach them, and apparently delivered in the guise of age-old wisdom. The first is:
Thou shalt not kill but needst not strive
officiously to keep alive…
Readers will recognise these lines as a couplet from Arthur Hugh Clough's satirical poem, The Latest Decalogue
, a parody of the Ten Commandments, and far from intended as advice to doctors. The second is a parody of the litany, but sometimes known as the doctor's prayer:
From inability to let well alone; from too much zeal for the new and contempt for what is old; from putting knowledge before wisdom, science before art, and cleverness before common sense; from treating patients as cases, and from making the cure of the disease more grievous than the endurance of the same, Good Lord deliver us.
This was indeed advice to medical students from Sir Robert Hutchison, the archetypical teaching hospital consultant physician and sometime President of the Royal College of Physicians of London. He was said in his obituaries to have been beloved by his students despite the sadistic manner he was in the habit of treating them in front of their peers. Hutchison, a brilliant diagnostician and author of a book on clinical examination which long outlived its author's 89 years, was a Scot, born (albeit in a castle) at Kirkliston. He unfortunately became a role model for some less able but equally abusive consultants of the post-war decades, satirised by Richard Gordon (Ostlere) as Sir Lancelot Spratt in Doctor in the House
There is something profound but also troubling in both these aphorisms in the context of modern medicine. They have an immediate appeal, a call to humanity. But they also raise a serious question; when should we, as patients, doctors or relatives, accept the inevitability of death and turn the switch, from striving to cure to alleviation of suffering? This decision has become progressively more difficult as medical ability to deal with previously fatal conditions has increased.
Simple mouth-to-mouth ventilation and external cardiac massage were introduced to medicine in the early 1960s, followed a decade later by electrical defibrillation. Prior to that, cardiac resuscitation depended on direct squeezing of the heart through an incision in the chest, a procedure that few doctors felt able to perform. Mechanical lung ventilation was introduced using iron lungs on a large scale in medicine in the 1952 poliomyelitis epidemic, and renal dialysis revolutionised the management of kidney failure from the 1960s. Now we have organ transplantation, and many previously fatal conditions have become remediable, though all of these apparent remedies bring with them complications and risks. All have been introduced since I became a medical student and all pose a dilemma; to apply or not to apply?
Television has moved the occasional successful resuscitation to the status of an apparently essential manoeuvre prior to almost any death. If you see someone collapse and find they have no pulse, you do not hesitate. Fast treatment of such episodes has the greatest chance of restoring many years of valued life. On the other hand, someone who is in the late stages of cancer or a chronic disabling disease may well wish to be allowed (or helped) to die peacefully and in such cases we as patients or relatives must consider not only an order not to resuscitate but also appropriate management of the process of dying. Between these clear-cut cases lies a grey area of dilemma, very much an issue with respect to COVID-19.
Now, if our intensive care specialist staff and their ventilators are to cope with the upsurge of patients contracting COVID-19, doctors must make decisions every day on whom not to treat. Often, the medical decision is not very difficult, if the patient is conscious and able to give an informed view and if the doctor is prepared to explain the pros and cons honestly. It must have been more difficult early in the current pandemic when the adverse consequences and inefficacy of intensive treatment in many cases were not fully appreciated.
As I watched COVID-19 coming across from China, I informed my son, an infectious disease consultant, that I did not wish to go into intensive care if I contracted the disease. My reason for this was that I had read of the low level of successful treatment in the elderly and the great difficulties posed by putting patients on ventilators and then stopping the treatment weeks later.
My son told me that these difficult decisions are made carefully and objectively, usually following discussion between a panel of specialists in a multidisciplinary team meeting. These discussions consider the patient's fitness prior to the illness, the response to treatment and medical complications thus far, the likelihood of survival, and finally, the likely impact on quality of life should a patient survive. This is a complex matrix of decision-making and not simply a question of offering or denying a life-saving treatment. Indeed, it is more accurate to understand that intensive care is just that – buying some time through care and support while the infection or inflammation wanes and the body heals, care rather than cure.
Among the over 80s, if we reach the stage of not responding to the current best available treatment, we will be very unlikely to survive weeks on a ventilator and all the accompanying interventions required as lungs, kidneys and heart start to fail. Happily, consultants in palliative care are in the vicinity to ease our passage, applying a different kind of intensive care. The ventilators and expertise are better used on people who have the physical ability to withstand the awful trauma of weeks or months on this treatment and the long rehabilitation required by survivors; inevitably they are younger. The decision not to care for someone 'on a ventilator' is not made on age alone; the presence of other chronic disease or disability (including disabling obesity or frailty) is what determines survival from intensive treatment.
Some who are reading this may catch COVID-19, though I hope you, like me, are all taking every measure you can to avoid it, both for your sake and for that of those who would then catch it from you. If we do get it, our response to it depends critically on our age and the presence of other chronic incapacity. Nevertheless, even among the elderly, most survive with remarkably few symptoms. If we are unfortunate enough to become breathless and our oxygen levels fall, the outlook now is much better than it was in the first phase, as treatment with oxygen, appropriate positioning of the patient and drugs (notably dexamethasone) that are now known to be beneficial are deployed early; the majority now survive without needing the support of invasive ventilation.
Dr Hutchison's advice was given before even mouth-to-mouth ventilation or external cardiac massage had been thought of, and I wonder what he would have thought of today's medicine. This is what I think of his advice. It looks sensible on first sight, but then you start to wonder. Transpose his advice and you will see why. His alternatives are not mutually exclusive. Art and science combine in the best of both vocations. The artist thinks often in terms of colour saturation, perspective, proportions. The scientist uses imagination in exploring hypotheses, and the doctor modifies treatment from understanding of the whole patient and his or her environment.
Medicine is based on old tradition but absorbs the new all the time. The wisdom and art of medicine include constant lessons from knowledge and science; being clever does not exclude the use of common sense (or rather common humanity). But sometimes the attempt to cure is indeed worse than endurance of the disease when expert palliative care is available. So those two lines from Clough with which I began are indeed apt, even when taken out of their original context.
I am certain that we will not meet a doctor in intensive care who strives with officious intent; he or she will certainly agonise over difficult decisions, weighing the pros and cons but always considering what is best for the patient. The word cure originally meant to care for and to me it still does.
Some of you will recall W H Auden, skin wrinkled by his cigarette smoking:
Give me a doctor, partridge-plump,
Short in the legs and broad in the rump
An endomorph with gentle hands
Who'll never make absurd demands
That I abandon all my vices
And pull a long face in a crisis
But with a twinkle in his eye
Will tell me that I have to die.
Well, maybe, but I hope he will take care first not to miss anything remediable.
Anthony Seaton is Emeritus Professor of Environmental and Occupational Medicine at Aberdeen University and Senior Consultant to the Edinburgh Institute of Occupational Medicine. The views expressed are his own