Ethical Dilemma, Triage Problems And The Allocation Of Resources In Light Of Covid-19: Implications For Nigeria -By Etudaiye Isah Abdul

“Let’s say a patient is on a ventilator but isn’t improving and this patient might do better if they were allowed to stay on the ventilator longer but there are people waiting for that ventilator.

Do you withdraw the ventilator earlier than you might normally do? So its not just who gets the vent, its also who stays on it .

– Nancy Berlinger, Research Scholar.

The opening statements above should send shivers down the spine in the face of what we have before us at this critical times in our national and global lives . COVID-19 has taken root in our world, altering our lives and having the potential to take more of the living.

Global cities and ancient landmarks becoming empty of the hustle and bustle, the disease is sending humans to sleep early, some eternally in death.

Hospitals are bursting at the seams, health workers overwhelmed, mortality figures still rising. At the time of writing this, over 23,000 lives have been lost globally.

As Nations battle to upstage the virus from their landscape, taking measures that stretches and tests the limits of the medical community, another problem arises, How do Nations battling with this scourge allocate resources to save lives?  Who receives care? In what order?

In Italy, Doctors are making difficult decisions about who should receive care This is due to the rapid spread of the disease across her population. Already, the rate of mortality has since outnumbered that of China who had a higher confirmed positive case of the virus.

Such spike in cases have equally put a strain on the healthcare facilities and the number of personnel with the loss of 29 doctors and the breakdown of Nurses as a result of exhaustion. bringing the need for that unsavory dilemma : who should live ?   Who should die? Who to treat? Who to abandon to their fate?

Evidence is the daily high rate of death coming from Italy in recent days and the dead are mostly the elderly because the Italian Medical Association issued guidelines that doctors may have to give priority to younger COVID-19 patients over the older ones. “It may be necessary to place an age limit” on access to intensive care, the guideline advised.

In a related  scenario ,doctors in the US are also at the point of making their own decisions regarding attention to patients due to depleting resources  Which patient gets treated and which patient do not.?.  Which patients should be revived and who should be left to die?

In doing this, the goal is often to save as many lives as possible but that in itself is a challenge on conscience and morality

.Factors often used for the triage issues  are a combination of age , life expectancy ,severity of illness ,whether treatment will help and whether patients has underlying illnesses that could shorten the person’s life span e.g  cancer ,heart diseases ,diabetes ,kidney or liver disorder etc . Each of these are then given weights or scores that forms the basis for prioritizing care .Other factors used could be status of patients in the society for example a doctor might be giving priority care because it is hoped that if he recovers he can go on to save more lives The loss of 29 doctors in Italy put this factor into relevance.

How then will all these pan out in Nigeria in the face of scarce healthcare resources and the increasing number of COVID19 cases?

It is a critical question that should get everyone worried.

The indicators are there for all to see and the goal of this piece is to present issues that may arise and to alert the reader to these issues in order to arouse   everyone to the urgency of adhering to medical advisories and to prepare all hospital medical advisory committees to start updating their guidelines.

To not digress much, It will bore the reader to discuss the obvious failings of government in this country since her independence in the area of investment and capacity building in the health sector. Every Politician in Nigeria have always had reasons to travel out to seek medical aid even for massaging of potbellies. Their failings in that regard have come to haunt every one of them at this very moment and sadly the citizens too. As we lay our bed…

So in view of the scarcity of resources both human and material in the health sector ,our greater challenge in the fight against CoronaVirus will be the  optimal  utilization and allocation of scarce resources and the ethical challenges when it comes to prioritizing care .

The dearth of human resources in the health sector in the face of this deadly pandemic is about to be exposed.

The current doctor to patient ratio in Nigeria stands at 1 to 3500 according to available statistics. This is a far cry from the World Health Organization recommended ratio of 1:600. In the context of Nigeria’s population, She needs about 300,000 doctors in order to achieve the W.H.O standards..

What now happens in the event of increasing number of COVID -19 infections? What will be the criteria for assigning doctor to patients?

Who would have access to the doctors? How would they cope in a worst case scenario? These are questions that begins to unsettle the minds when one considers the impossibility of travelling out to seek medical aid, especially for the rich, aged politicians who normally choose this option that is often called medical tourism.

Then there is the problem of brain drain. Out of the about 40,000 medical doctors we have, some of them have left the country in search of career fulfillment and greener pastures. That is a massive leaching of the system and right now it’s going to bite us big time.

Hospitals should be making plans on how to build capacities to make up for the numbers of doctors and medical personnel that may be needed. One Solution will be to engage the services of final year medical students in all the universities to be attached to lesser number of qualified doctors per pool, say 5 to 1. While this may not be optimal, it would surely go a long way at this time.

Yet another solution will be to contact medical personnel and consultants who may have retired. The only challenge to this solution is the lack of effective database that can aid in contacting these category of personnel.

Then, when the issue of human resources have been sorted, the next problem is about how to allocate the very limited medical supplies and equipment.

I have earlier x-rayed the problem of acute shortage of ventilators, a critical resource in the fight against COVID -19. There are already unverified reports of a ventilator been moved from one of the Teaching hospitals to an unknown destination for the use of an unknown patient?  If this were to be true, then more of such incidences are bound to happen.

What now happens to patients that will require ventilators when there seems to be virtually inadequate number of these machines? How would care givers solve this problem? Surely it’s a psychological problem for a doctor to watch a patient die when such death could have been preventable or it’s as a result of no equipment that could have assisted the patient to full recovery. This is the biggest challenge facing the world right now. To ration ventilators does not look feasible at all. Ordering for them is nearly an impossible task as the orders might not even arrive in 3 months.

Making them locally is also not possible due to the scarcity of experts and industry for that. We are at a crossroad here.

Also when a patient comes earlier with a lesser problem and the next patient cones with a severe case. Would doctors ditch the traditional First Come First serve model or they attend to the critical patient?

What if a patient on ventilator goes into cardiac arrest, it normally requires many care givers attempting to do a resuscitation, in light of scarce resources both human and material, will they attempt a CPR while other patients in critical conditions are abandoned or the CPR is abandoned and the patient allowed to die?

Would younger patients have priority of care over much older patients with underlying terminal cases? What happen to outpatient care for other unrelated health challenges?

These are issues that will confront the medical advisory committees of each hospital as regards Covid-19 and it will be better to have strategies and plans in place and hope we do not get to such situations than to ignore and then throw in the towel to this disease.

No matter how odd the chance against us ,we must have a plan to defeat this pandemic but the challenge before the country will be those of   Ethics, triage   and he utilization of scarce human and material resources.