NHS ‘score’ tool to decide which patients receive critical care

Doctors will use three metrics: age, frailty and underlying conditions write Peter Foster, Bethan Staton and Naomi Rovnick in The FT

Doctors coping with the coming peak of the coronavirus outbreak will have to “score” thousands of patients to decide who is suitable for intensive care treatment using a Covid-19 decision tool developed by the National Health Service.

With about 5,000 coronavirus cases presenting every day and some intensive care wards already approaching capacity, doctors will score patients on three metrics — their age, frailty and underlying conditions — according to a chart circulated to clinicians.

Patients with a combined score of more than eight points across the three categories should probably not be admitted to intensive care, according to the Covid-19 Decision Support Tool, although clinical discretion could override that decision.

The UK is set to exceed 80,000 coronavirus cases on Sunday and 10,000 deaths in hospital with government models showing the peak of the outbreak is now expected to be reached over the next two weeks, leaving the healthcare system facing arguably its toughest challenge since its inception. 

The scale of the pandemic and the speed at which Covid-19 can affect patients, has forced community care workers, GPs and palliative carers to accelerate difficult conversations about death and end-of-life planning among vulnerable groups.

The NHS scoring system reveals that any patient over 70 years old will be a borderline candidate for intensive care treatment, with a patient aged 71-75 automatically scoring four points for their age and a likely three on the “frailty index”, taking their total base score to seven points.

Any additional “comorbidity”, such as dementia, or recent heart or lung disease, or high blood pressure will add one or two points to the score, tipping them into the category suitable for “ward-based care”, rather than intensive care, and a trial of non-invasive ventilation.

Although doctors and care workers stress that no patient is simply a number, the chart nonetheless codifies the process for the life-and-death choices that thousands of NHS doctors will make in the coming weeks.

A frontline NHS consultant triaging Covid-19 patients said the “game-changer” for assessment of patients with coronavirus was that there is no available treatment, meaning doctors can only provide organ support and hope the patient recovers.

“If this was a bacterial pneumonia or a bad asthma attack, then that is treatable and you might send that older patient to intensive care,” the consultant said, adding that decisions on patients were “art not science” and there would be exceptions for patients who were fit enough.

“The scoring system is just a guide; we make the judgment taking into account a lot of information about the current ‘nick’ of the patient — oxygenation, kidney function, heart rate, blood pressure — which all adds into the decision making,” he said.

But it is not just hospital doctors who must make tough decisions. GPs, hospice workers and families with vulnerable members are also involved.

Last week NHS England wrote to all GPs asking them to contact vulnerable patients to ensure that care plans and prescriptions were in place for end of life decisions, leading to many difficult conversations. These have been made harder by the need to conduct them on the phone or via Skype to observe social distancing rules. 

Ruthe Isden, head of health and care at Age UK, the charity, said the need for haste had unsettled many elderly patients, who have felt under pressure to sign “Do Not Resuscitate”, or DNR, forms. 

"Clinicians are trying to do the right thing and these are very important conversations to have, but there’s no justification in doing them in a blanket way,” she said. “It is such a personal conversation and it’s being approached in a very impersonal way.” 

The subject of DNR notices is particularly unsettling for individuals and families who want the best care for their loved ones, but often feel the choices have not been fully explained.

The data clearly show that resuscitation often does not work for elderly patients and can often cause more suffering — including broken ribs and brain damage — while extending life only by a matter of days.

Vaginas may be weird and hairy, but they certainly don’t need steaming

We’ve moved on from stripping our most sensitive regions of their natural hair, and have
apparently started paying for vagina beauty treatments. Olivia Goldhill rounds up some of
the most absurd products imaginable, including the vajacial. Some women do this, but on their vaginas.  

By Olivia Goldhill
3:45PM GMT 05 Dec 2013

In the good old days, all you needed to be ready for sex is two willing participants and a healthy dose of sexual chemistry. Then pubic hair went out of fashion, and women suddenly had to start plucking, shaving, waxing,trimming away their natural state before copulation.
Now, it seems that vajacials are a thing. As in, facials, but for your vagina.

Apparently, these started off as a relatively simple affair in 2010, with a papaya enzyme mask, deep cleanse and tweezer hair extractions. They’ve moved on though. Impossibly, beauticians have moved on from convincing women that a papaya-scented nether region is a necessary aspect of good sex, and have introduced a whole new
range of vagina-themed beauty products.

Some women, before a big date or perhaps a romantic mini-break, actually book themselves in for a treatment of vaginal steaming. Presumably, they sit back, spread their legs and allow steam to gently (I hope) cleanse their vagina. But what temperature is the steam, where (exactly) does it go, and how on earth is steam any better at cleaning than plain water?
The treatments are usually done a day or two after the woman's period ends, and "heals any
imbalances" in the vagina. Which suggests I've been walking around with an unbalanced vagina for years.

Vaginoplasty is another trend, where you can shape your vagina into the desired shape. But what is this desired shape and who has a vagina that needs to be cosmetically re-modelled before sex? Poetry aside, vaginas are weird-looking things - they’re so un-pretty, I’m unsure what a “beautiful” vagina is supposed to look like. Perhaps we’ve been going overboard with the flower metaphors and some women actually want their vaginas to look like a rose.
Symmetry and neatness are listed as the longed-for traits, but this raises a whole new set of questions - is everyone else measuring their vaginas for perfect symmetry?

Now London’s getting in on America’s vaginal fashion trends, with salons offering "vaginal
rejuvenation" for hundreds of pounds. Bad news for students then (and most other people), who will undoubtedly struggle to afford an appropriately-preened vagina. Maybe it can be a special treat that a couple saves up for once a year, when they can enjoy annual sex day with properly presented sexual organs.

The vagina is apparently rejuvenated by a costly serum, which was originally created to treat wounds, but has moved on to a new life sprucing up female genitals. Magically, this serum can improve "vaginal function" and "tighten and firm the vaginal walls".

I’m not surprised that these treatments exist, but I’m a little scared that women—even one, solitary woman—is paying for them. There are women out there who are so anxious about what their partner will think about their vaginas, that they spend hundreds of pounds making them look “nice”.

But they need to stop this. They really do. No one envies the sex life of a woman complimented on her jojoba and rosemary scents. No one envies the sex life of a woman whose partner notices her jojoba and rosemary scents.

Vaginas are weird and they are hairy and that’s how they’re supposed to be. We need to stop worrying out what our poor vaginas look like during sex. It’s how they feel that really counts. OK?

Cancer medication as low as Rs 1,000/month on way

Malathy Iyer, TNN

MUMBAI: It's widely known that a month's dose of cancer drugs can cost lakhs, but what isn't common knowledge is that Tata Memorial Hospital's doctors are working on alternatives that could cost less than Rs 1,000 a month.

Dubbed the metronomic treatment protocol, it comprises daily consumption of a combination of low-dose medicines that are cheap because they have been around for decades. "There is no need to worry about patents or recovery of billions spent on research,'' said Dr Shripad Banavali, head of the medical oncology department of Tata Memorial Hospital, Parel, who has been working on the low-dose-low-cost therapies.

His colleague, Dr Surendra Shastri sums up the mood well: "The metronomics experiment is path-breaking in terms of providing good quality and affordable cancer care for a majority of the over 10 lakh cancer cases diagnosed in India each year.'' These findings could revolutionize cancer care in most developing countries, he said.

The catch is, however, that this branch is still in research stage. The conventional cancer treatment comprising chemotherapy is given at "maximum tolerated doses" which are tested and have reams of research to back it. As against this, in metronomic therapies, the drugs are given at very low doses. "But side-effects are fewer and patients have a good quality of life,'' said Dr Banavali.

The word metronomics is borrowed from music; musicians use the metronome to mark time and hence rhythm. Patients are asked to take these medicines for a period of 21 days or more before taking a break of a week; such a cycle continues for months.

Dr Banavali's work has been published in the May issue of the medical journal Lancet Oncology. Thousands of patients have been on metronomic treatment in Tata Memorial Hospital as well as its rural centre, with a sizeable number managing to control the growth of cancer. "In India, the main challenge in cancer is not just finding cures, but to develop affordable treatments'' he said.

In fact, the metronomic work arose out of such cost concerns over a decade back. The Tata doctors found that many patients were lost to treatment because they were overwhelmed by the cost of medicines. "Moreover, many patients came so late for treatment that we had to turn them away without any medicines,'' said Dr Banavali. Instead of turning away such patients, the Tata team decided to adopt the metronomic treatment as palliative treatment that was being tested out in various parts of the world. "We gave them drugs that would help in pain or at least ensure that their case doesn't worsen," he adds.

But the results surprised them. In a large group of children with blood cancers called acute myeloid leukemia (AML), they found that metronomic maintenance treatment had helped increased survival rate to 67%. The group then started its own innovation, going ahead of the rest of the world. "The West used the same set of medicines for all forms of cancer, but we introduced personalised medicines for various types of cancers,'' said Dr Banavali.

The Lancet paper, titled 'Has the time come for metronomics in low-income and middle-income countries', mentions combination of drugs used for four cancers (see box). The Tata doctors feel that these drugs may work as well for newly developed tumours. "While the developed world is going after 'drug discoveries', that is discovering new drugs which are very costly for our patients, we are going after 'drug repositioning', that is using time-tested drugs for the treatment of cancer," said Dr Banavali. For example they are using drugs likemetformin (an anti-diabetic drug), sodium valproate (an anti-seizure drug) and propranolol (an anti-hypertensive drug) in the treatment of cancer.

The Lancet paper said, "The combination of metronomic chemotherapy and drug repositioning might provide a way to overcome some of the major constraints associated with cancer treatment in developing countries and might represent a promising alternative strategy for patients with cancer living in low- and middle-income countries.''

Metronomics chemotherapy works at three levels. It attacks tumours while working on the "micro-environment", like the blood vessels, around the tumour. Thirdly, it works on the immuno-modulating system of the body. "Unless the metronomic dose works on all these three fields, it may not work,'' said the doctor.

Survivor of twin blows, counselor for others

On the occasion of Cancer Survivors Day on June 2, members of Ugam, an NGO, will put up a skit at Tata Memorial Hospital to underline the problems of parents whose children suffer from cancer. Comprising childhood cancer survivors, Ugam members counsel cancer patients undergoing treatment at Tata Memorial Hospital. One of its founder members, Shalaka Mane (29), who lost her right eye to cancer, will be there too. She feels people discriminate against cancer patients. "I feel there is a need to increase awareness about the treatment of cancer in society and the government, and enable these families to get financial help," she says. Diagnosed with blood cancer when she was eight years old, she barely got back to being at the top of her class when she was found to have brain cancer. "I was in Class XII and planning to take up medicine, but it wasn't to be,'' she says. The second cancer was so virulent that she lost her eye. But she emerged victorious a second time and completed her masters. She now teaches at Kalvidhai Mission High School, Andheri, which she attended as a student. "My principal and teachers never discriminated against me because of my illness. I enjoy my job," she adds.

'Cancer can't affect my future'

Artist Sachin Chandorkar is a poster boy of sorts at the Tata Memorial Hospital, Parel. At 28, he has won several awards (one from chief minister Prithviraj Chavan last month) for his murals and sculptures. But the Tata connection comes from his victory over cancer when he was five years of age. He was suffering from Hodgkin's Lymphoma. "I remember feeling irritated due to the itch on my head. When I would stratch my head, tufts of hair would come into my hands. I would then start crying," says Chandorkar, who studied at the JJ School of Arts. He usually doesn't talk about his battle with the Big C. "When my mother and sisters sometimes talk about it, I ask them to stop. I have decided that cancer is a part of my past and cannot affect my future,'' he adds.