The purpose of board committees (as opposed to management) is to help the board obtain assurance. Similarly to other committees (such as the quality committee which may be the closest comparator), a board ethics committee should check that: the organisation has policies in place that are adequate to the task, there are systems and processes in place to implement those policies, the systems are processes are understood by those who need to use them and are used and they produce the required results. This task will of course be shaped at the current time by the context of the coronavirus pandemic.
Clinical ethics committees in trusts will need to consider and identify the principles of an ethical approach to prioritising treatment in a worst case scenario where overwhelming demand means access to intensive care and ventilators is limited. Trust leaders have shared some of these principles with us, to help inform and guide their peers. More support is available from the national body UKCEN: Clinical Ethics Network. Considerations vary according to the different stages of the outbreak, but include:
- Distributive justice: The benefits, risks and costs of healthcare should be distributed fairly, with regard to the prognosis and likely outcome. Understanding the needs (and communication needs of vulnerable groups including people with learning disabilities, autism and some mental health needs) becomes paramount at this time.
- Consistency: All patients with a similar prognosis should be treated in a similar way. The approach to admission of patients with COVID-19/non-COVID-19 illness to intensive care should follow the same principles and basic thresholds.
- Available resources: Healthcare resources in every country are always constrained and prioritised. As in normal times, decision-making around the allocation of resources must be ethically sensitive, accountable and transparent.
- Respect for autonomy and best interests: As in normal times, while demand for services can be managed, the primary ethical consideration for ICU admission remains the patient’s best interests. However, if demand escalates to a point where it exceeds capacity, the ethical basis for decisions to restrict ICU admission may be made on the basis of distributive justice, prognosis and outcome.
- Non-maleficence: It is important that patient harm is avoided or mitigated wherever possible.
In addition to these ethical principals, trusts are also implementing the ‘three wise people’ approach whereby three options are sought, typically from senior consultants, to inform challenging decisions on individual cases. For every ethical decision of this type, additional support from the ethics committee should be available at pace and at all times. Several trusts are ensuring NED involvement in forums to support decision-making or involving wider representatives from the public, the education sector and civil society
Operational considerations to support an ethical approach
Trusts across the mental health, community, acute and ambulance sector have in place, or are developing, a range of:
- Ethical panels and committees, often including representatives from civil society, academia, and non-executive director (NED) engagement (sometimes a NED with a clinical background). These committees and panels will inform the trust’s approach overall within the boundaries of national policy.
- Trust are also commonly implementing the 'three wise people' approach whereby three options are sought, typically from senior consultants, to inform challenging decisions on individual cases. Several trusts are ensuring NED involvement in forums to support decision-making or involving wider representatives from the public, the education sector and civil society.
In addition to establishing an ethical decision-making process, trusts are also taking steps to:
- provide patients and their families with information on admission to intensive care, learning from existing pathways such as cancer
- support ICU staff with their duty of care, as well as wider clinical teams who will need to make decisions about resuscitation and referrals to ICU
- explicitly show support for clinicians operating under extreme pressure and provide reassurance that no staff member will be put in the position where they have to made a challenging clinical decision alone
- review decision-making processes relating to ICU admission and ventilated support regularly as the COVID-19 outbreak evolves and demand changes
- develop decision-making support for ICU triage which draws on senior clinicians’ expertise at pace and at all times.
We are collating examples of the terms of reference for trust ethics committees where trusts are able to share these. To share good practice or find out more about how others are approaching the governance of these issues, please contact Miriam.firstname.lastname@example.org or email@example.com
We are also compiling resources and professional guidance to support trusts in ethical decision making here.