Andrea, the nurse at the care home, sounded calm and competent. She had done a full set of observations on 80-year-old Neville before contacting the out-of-hours service: pulse racing, breathing fast, high temperature and oxygen saturations down at 85 per cent. Most worrying of all, while his eyes had flickered when she’d inflated the blood pressure cuff round his arm, he was otherwise unresponsive. The deterioration had occurred over the space of a few hours, and it had happened in spite of the antibiotics Neville’s GP had prescribed three days before, when he had first developed fever and cough.
“Have you got coronavirus there?” I asked.
“Five confirmed.”
“Is there a TEP in place?”
“He’s not for resuscitation.”
“What about admission?”
“I don’t know. Hang on.”
She disappeared to fetch Neville’s file. A treatment escalation plan (TEP) is the modern equivalent of a “living will”, allowing an individual to set out their wishes in the event of serious illness. TEPs are not legally binding, but they do allow professionals to take account of a patient’s views, especially when the situation requires urgent decision-making, or if the person themself is no longer able to communicate.
Andrea came back on the line. “It doesn’t actually say about admission, but it’s a yes for intravenous fluids and antibiotics, so I guess that means he’d want to go in.”
Having no previous knowledge of Neville, I sought rapidly to get a sense of his story. He had only been at the nursing home for ten days, having been discharged there following a month in hospital with aspiration pneumonia. This is where, often as a result of the breakdown of the complex coordination of normal swallowing, fluid or food goes down into the lungs, with bacterial infection developing on top. “His swallow really is very poor,” Andrea confirmed.
This muddied the waters. While it was probable that Neville was the home’s sixth Covid-19 case, he could conceivably be suffering from another aspiration pneumonia. He was highly unlikely to survive severe Covid whatever anyone did. But hospital care might – just might – bring him back from a bacterial infection, as it had done six weeks before.
I took further details. Prior to that last hospital admission, Neville had spent a couple of months in a different care home, where he’d been placed urgently because he was no longer coping at home with a package of care. The picture is all too familiar in an era where modern medicine is so effective at keeping people alive: it is the march of frailty. As ageing bodies progressively weaken, the level of dependency increases and the likelihood of recovering from acute illness declines. Frailty is assessed by a one to nine score on something called the Rockwood scale, one being fit and active, nine being terminally ill. Neville, I estimated, had scored five or six a few months ago. On arrival at his current nursing home he was in the seven to eight range.
“Have you got a number for his next of kin?”
I spent a careful quarter of an hour talking things through with his daughter, Helen. Notwithstanding his TEP, I explained,
I wanted to make the decision that would be in his best interests. If this was coronavirus, then admission would be tantamount to sending him to die in a bewildering clinical environment. If it were an aspiration pneumonia, he was already gravely ill and unlikely to make it. But even if he did, what would we be achieving for him? His frailty suggested he was in his final months of life. We would simply be returning him to nursing home care, in even poorer condition, to await the next overwhelming infection. The added cruel twist was that, even were he Covid-negative now, admission would send him into an environment with a potentially higher risk of contracting the virus.
These are some of the most exquisitely sensitive conversations to have in medicine: I was a total stranger, calling Helen on the phone to discuss the life or death of her dad. At one point, quite reasonably, she asked more about who I was. I told her where I practise and about the decades of experience I have as a GP. I think that helped; some of the fear went from her voice. She said she simply couldn’t make this kind of decision, it was one for professionals. I assured her it was me that would take it: I just wanted to take account of her views. She said she’d understood everything I’d told her, and asked me to do what I thought best.
I checked back with Andrea; she had the same view as me. I arranged for a GP to visit to equip her with palliative drugs to ensure Neville would be kept comfortable. Andrea and her colleagues nursed him in the calm surroundings of his final home. He died in the early hours the next morning.
I don’t know whether Neville’s GP cited Covid-19 on his death certificate; whether he will be counted among the thousands of UK citizens who have succumbed to the disease. I do know that the way the care home sector has been treated during the pandemic must be examined in a future inquiry.
The clamant need to empty hospital beds ahead of the peak has meant that asymptomatic inpatients have been discharged to nursing homes without testing; many will have taken coronavirus with them. Covid-positive patients have also been sent to care homes, supposedly to be barrier-nursed in strict isolation, but the appalling failure to supply PPE to the care home sector has rendered this perilous proposition virtually impossible to achieve. Numerous institutions housing some of our most vulnerable people have been ravaged by coronavirus. In many cases, it will have been the panicked and ill-prepared system that sent the infection in.
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This article appears in the 22 Apr 2020 issue of the New Statesman, The coronavirus timebomb