A controversial ‘scoring system’ used by the NHS to decide who receives critical care has been slammed over fears disabled people will be denied life-saving treatment.
The so-called ‘Clinical Frailty Scale’ (CFS) ranks patients’ frailty from one to nine and is designed to prioritise those most likely to recover from the killer virus.
It has been implemented as NHS hospitals desperately scramble to free up beds and ventilators, which Britain is desperately short of, to fight the COVID-19 crisis.
But it discriminates against people with learning disabilities who may need round-the-clock care, according University of London professor Irene Tuffrey-Wijne.
Lynn Murray, from the learning disabilities charity Don’t Screen Us Out, said the scoring system treated disabled people as a ‘sub-class of the population’.
NICE recommends NHS clinicians use the controversial Clinical Frailty Scale when considering patients for intensive care. It ranks patients’ frailty from one to nine and is designed to prioritise those most likely to recover from the killer virus.
But it discriminates against people with learning disabilities who may need round-the-clock care, according University of London professor Irene Tuffrey-Wijne (pictured)
Under the guidance, coronavirus patients are ranked out of nine based on their age, frailty and underlying conditions.
People are deemed ‘severely frail’ if they are ‘completely dependent for personal care’, the guidance says.
That would put them at a total of seven points before underlying health conditions are even considered.
Those with a combined score of more than five are said to have uncertainty around the benefits of critical care, according to the system.
Professor Tuffrey-Wijne, a leading learning disability and palliative care expert, said the system left too much room for interpretation and could see disabled people incorrectly categorised as ‘approaching end of life’.
She said people who are ‘completely dependent for personal care, because of both physical and cognitive disabilities’ may be classed as frail despite being otherwise healthy.
Professor Tuffrey-Wijne, writing on her blog, said: ‘There is no reason to think that [they] won’t live into a ripe old age, but the CSF has her firmly in the category of decline, one step away from approaching the end of life, and two steps away from dying.
‘It is completely obvious, therefore, that the Clinical Frailty Scale is not suitable for use with people who have learning disabilities (nor, indeed, for people with any other kind disabilities or conditions that affect their ability to do things independently).
‘My concern is that many NHS staff, working under pressure and having to make impossibly difficult decisions for and with patients, will turn to the guidance without full knowledge, consideration or understanding of the need for making reasonable adjustments.’
NHS regulator, the National Institute for Health and Care Excellence (NICE), has clarified that its scoring system should not be used to assess disabled patients.
But it has yet to remove the incorrect documents from its website.
Lynn Murray, from Don’t Screen Us Out, added: ‘Discrimination towards people with disabilities that starts before birth continues throughout their lives and sadly now it looks like some medical professionals are treating people with learning disabilities as a sub-class of the population to be denied treatment during the current crisis.
‘The guidance issues that have occurred around people with learning disabilities being assessed for treatment and possibly denied treatment does not align with the equality guidance that the United Kingdom has signed up to.
‘It’s at times like these that negative perceptions of life with learning disabilities such as Down’s syndrome come keenly to the fore.
‘We are calling for the Department of Health and Social Care to issue urgent guidance making it clear that this practice is unethical, discriminatory and must not happen, to ensure that any discrimination ceases. COVID 19 must not lead to people with learning being screened out and denied treatment.
Peter Todd partner at Hodge, Jones and Allen solicitors, wrote to NICE last month demanding the guidance was withdrawn.
He told The Independent: ‘The guidance is still published on the NICE website and says that clinicians should comply with it. It would be better if they took it down and amended it before it was published again.
‘You could be totally forgiven as a doctor for thinking this was still a valid policy, but they have already accepted they have made a major blunder.’
A spokesman for NICE said: ‘In its COVID-19 rapid clinical guideline on critical care for adults, NICE recommends the use of the Clinical Frailty Score in some people in whom it has been validated as part of a holistic assessment – as it was before COVID-19.
‘The guideline makes it clear that it should not be used in isolation to direct clinical decision making and that clinicians should take any decisions about care in conjunction with patients and their carers where possible.
‘The guideline also states that the tool should not be used in certain groups, including those with learning disabilities or with stable long-term disabilities such as cerebral palsy.’
Are doctors HARMING coronavirus patients by putting them on ventilators too early? Doctors warn the gadgets may be overused and could even damage the lungs of the infected
The nationwide shortage of ventilators and Britain’s rush to build them has been one of the biggest stories of the coronavirus pandemic
But now doctors have warned putting patients on the machines too early could cause more harm than good.
Figures show two-thirds of COVID-19 sufferers who are hooked up to the potentially life-saving machines in the UK do not survive.
Reports in China, Italy and the US have found that less than half of patients who are intubated recover. Experts are unsure why the death rates are so high.
In New York City, at least 80 per cent of coronavirus patients in New York City who have been put on a ventilator have died.
As health officials around the world push to get more ventilators to treat patients, some doctors are moving away from using the breathing machines when they can.
The reason: Some hospitals have reported unusually high death rates for coronavirus patients on ventilators, and some doctors worry that the machines could be harming certain patients.
Mechanical ventilators push oxygen into patients whose lungs are failing. Using the machines involves sedating a patient and sticking a tube into the throat.
Deaths in such sick patients are common, no matter the reason they need the breathing help.
Generally speaking, 40 percent to 50 percent of patients with severe respiratory distress die while on ventilators, experts say.
Ventilators pump oxygen under pressure directly into the lungs via a tube inserted down the throat
Two-thirds of coronavirus patients in the UK who need to be hooked up to a ventilator will die from the illness, official NHS data suggests. Graph also shows the likelihood of critically ill COVID-19 patients surviving based on their age, BMI and whether they have health woes
Higher-than-normal death rates – like those in New York City – also have been reported elsewhere in the US, said Dr Albert Rizzo, the American Lung Association’s chief medical officer.
Similar reports have emerged from China and the United Kingdom.
One UK report put the figure at 66 percent. A very small study in Wuhan, the Chinese city where the disease first emerged, said 86 percent died.
The reason is not clear. It may have to do with what kind of shape the patients were in before they were infected.
Or it could be related to how sick they had become by the time they were put on the machines, some experts said.
But some health professionals have wondered whether ventilators might actually make matters worse in certain patients, perhaps by igniting or worsening a harmful immune system reaction.
That’s speculation. But experts do say ventilators can be damaging to a patient over time, as high-pressure oxygen is forced into the tiny air sacs in a patient’s lungs
Some say it is simply a result of patients being extremely ill when they are put on the machines, which pump oxygen directly into the lungs via a tube down the throat.
But others suggest the ventilators – which can make inflammation in the lungs worse – are being implemented too soon and harming coronavirus patients.
In the most life-threatening cases, COVID-19 can permeate deep into the lungs and cause severe inflammation, making it hard to breathe.
Pumping pressurised oxygen into the lungs can irritate the organs and damage them further.
Dr Paul Marik, chief of pulmonary and critical care medicine at Eastern Virginia Medical School, said this was a ‘vicious cycle’ for coronavirus patients.
Scott Weingart, a critical care physician in New York, told Stat News coronavirus patients get worse ‘as a direct result of intubation’.
He added: ‘High levels of force and oxygen levels, both in quest of restoring oxygen saturation levels to normal, can injure the lungs. I would do everything in my power to avoid intubating patients.’
Dr Paul Marik, chief of pulmonary and critical care medicine at Eastern Virginia Medical School, said putting coronavirus patients on ventilators was a ‘vicious cycle’ because it actually makes them worse
For most people, COVID-19 causes mild or moderate symptoms which clear up in a few weeks.
But roughly 20 per cent, mainly the elderly or those with underlying conditions, fall seriously ill and have trouble breathing.
The killer infection can burrow its way deep into the lungs, causing them to become severely inflamed.
The inflammation causes fluid from nearby blood vessels to leak into the tiny air sacs in the lungs, making breathing harder and cutting the supply of oxygen to the organs.
Intensive care doctors turn to mechanical ventilators as a last resort when patients’ oxygen levels plummet and they can’t be boosted with drugs or non-invasive techniques.
Ventilators pump oxygen under pressure directly into the lungs via a tube inserted down the throat.
Patients are heavily sedated so they can’t fight the sensation of being unable to breathe on their own.
But doctors are panicking and intubating COVID-19 patients sooner because the new virus is causing their blood-oxygen to fall to critically low levels, Stat News reports.
‘Data from China suggested that early intubation would keep 19 patients’ heart, liver, and kidneys from failing due to hypoxia (oxygen deprivation),’ a veteran emergency medicine physician told the website.
‘This has been the whole thing driving decisions about breathing support: Knock them out and put them on a ventilator.’
There are widespread reports that coronavirus sufferers are being ventilated for far longer than other types of patients.
Patients with non-coronavirus related pneumonia are usually intubated for a day or two, compared to coronavirus patients who have can need a ventilator for up to two weeks.
Pushing pressurised oxygen into the organs can cause them to become extremely inflamed and worsen the condition. Very high levels of oxygen can also be harmful.
Dr Paul Marik, chief of pulmonary and critical care medicine at Eastern Virginia Medical School, said this was a ‘vicious cycle’.
It is thought at least 30,000 ventilators will be needed to cope during the peak of the pandemic, as manufacturing companies race to build more (pictured, medical equipment labelled and prepared for use by NHS staff at the ExCeL centre in London)
He told Yahoo News: ‘The ventilator is causing lung injury, which causes them to stay on the ventilator longer, and basically is depleting the supply of ventilators for people who need them. It’s becoming a vicious cycle.’
Dr Eddy Fan, an expert on respiratory treatment at Toronto General Hospital, added: ‘We know that mechanical ventilation is not benign.
‘One of the most important findings in the last few decades is that medical ventilation can worsen lung injury – so we have to be careful how we use it.’
Dr Marik has called on other clinicians to implement a gentler approach than the high-pressure ventilators.
He said anti-inflammatory drugs, as well as breathing masks used in sleep apnoea, should be used for as long as possible before switching to a ventilator.
Not only would it potentially save more lives, he claims, it would also would help relieve a shortage of the machines.
The UK is projected to need 30,000 ventilators at the peak of the outbreak in the next week. It is thought to be thousands short of this number.
It comes after MailOnline revealed two-thirds of coronavirus patients in the UK who need to be hooked up to a ventilator die from the illness.
A report from the Intensive Care National Audit and Research Center (ICNARC) found ventilated patients succumb to the virus 66.3 per cent of the time.
A ventilator is a machine that helps people breathe. It puts oxygen directly into patients’ lungs and removes carbon dioxide from them
That is double the mortality rate of non-virus patients who were put on breathing support between 2017 and 2019, before the outbreak.
The NHS is still 22,000 ventilators short of the estimated 30,000 it will need during the peak of this crisis, which has infected almost 34,000 Britons.
The high death rate has led some doctors to question whether some critically ill COVID-19 patients are being put on ventilation ‘for the sake of it’, when the machine could be spared for a healthy person with a higher chance of survival.
The ICNARC report looked at the first 775 patients who had fallen critically ill with COVID-19 across 285 intensive care units.
Of the 98 patients who needed advanced respiratory support when their lungs started to fail, just 33 patients lived (34 per cent).
Patients in this age range die 73 per cent of the time if they fall seriously ill after contracting the disease.
For critically ill patients aged between 50 and 69, the mortality rate is just over 40 per cent. And a quarter of over-16s succumb to the disease, the figures show.
There are several reasons why older people have trouble fighting off the virus.
The likelihood of having chronic conditions increases markedly as people age, with four out of five over-65s living with at least one underlying health condition.
Elderly people also have weaker immune systems, a natural side-effect of the body ageing. This makes them more vulnerable to serious infections of all types.
The ICNARC report showed obese people are at a heightened risk of dying from coronavirus.
Among patients who needed intensive care after catching the infection, people with a BMI over 30 died 61 per cent of the time.
There was little discrepancy between overweight patients and those with a health body weight.
Those with a BMI under 25 – the ideal range is between 18.5 to 24.9 – the mortality rate was 42.1 per cent. For overweight patients , it was 41.7 per cent.
People with pre-existing health conditions are thought to be at greater risk of developing severe symptoms because of their weakened immune systems.
But the ICNARC report found people with severe underlying health woes were just 10 per cent more likely to die if they fell seriously ill with COVID-19 than otherwise healthy people.
The document also found that most coronavirus patients in intensive care were male, 71 per cent of all cases.
Only 18 patients (9 per cent) had ‘severe co-morbidities’, such as underlying heart conditions or lung disease; while two patients had been pregnant within the last six weeks.
The mortality rate was 58.8 per cent for people with pre-existing conditions and 47.6 per cent for those without.