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Doctor's Office Apologizes After Asking High-Risk Patients to Sign COVID-19 Do Not Resuscitate Form

A Welsh doctor’s office apologized this week after sending a letter to some of its more vulnerable patients, asking them to sign do not resuscitate forms amid the COVID-19 crisis so limited resources could be allocated “to the young and fit who have a greater chance.”

Health care systems around the world are facing difficult decisions about how to ration care as COVID-19, a new-to-humans coronavirus that causes a respiratory infection and other symptoms, stretches hospitals to breaking point. As doctors in countries like Italy face gut-wrenching decisions on how to deliver care in overwhelmed hospitals, other countries are also working out how to proceed.

Though some hospitals in the United States are weighing blanket do not resuscitate orders for COVID-19 patients in a worst-case scenario, one doctor’s office in Wales took matters into its own hands. Llynfi Surgery in Maesteg, Wales, sent a letter to a small number of patients with “significant life-limiting illnesses,” including those with cancer, pulmonary fibrosis and neurological conditions like amyotrophic lateral sclerosis (ALS).

WalesOnline was sent a copy of the letter from an anonymous patient, and the letter has been circulating on social media. In the letter, Llynfi Surgery asks these high-risk patients to sign a do not attempt cardiopulmonary resuscitation (DNACPR) form in the event they fall seriously ill with COVID-19.

“People with these conditions are also unlikely to be offered hospital admission should they become unwell and certainly will not be offered a ventilator bed,” Llynfi Surgery’s letter reads, continuing:

We would therefore like to complete a DNACPR form for you which we can share … which will mean that in the event of a sudden deterioration in your condition because [of] Covid infection or disease progression the emergency services will not be called and resuscitation attempts to restart your heart or breathing will not be attempted.

Llynfi Surgery then outlined the benefits of these patients signing a DNACPR form, which included their loved ones and doctor knowing not to call emergency services in the event of serious illness. Another benefit suggested “scarce ambulance resources can be targeted to the young and fit who have a greater chance.” It concluded, “We will not abandon you but we need to be frank and realistic about what the next few months holds for all of us.”

In response to the letter, the patient who anonymously sent it to WalesOnline said the letter made her feel worthless and didn’t account for the quality of her life even with a chronic condition.

“It not only greatly upset me but my family and close friends,” the patient said. “It was like having my death warrant being sent by the grim reaper. It made me feel worthless. I’ve lived with cancer for eight years and I want to live another couple of years. I’m not digging my grave yet.”

Other advocates expressed outrage as the letter circulated on social media.

“The letter sent to vulnerable patients … and I’m shocked that it was even written, let alone sent out,” Heléna Herklots, CBE, older people’s commissioner for Wales, said in a statement, adding:

Many of those who will have received the letter will no doubt have been left feeling worthless, that their lives do not matter and will have felt significant pressure to sign a DNACPR form. This is shameful and unacceptable. Whilst difficult and painful decisions will need to be made in the weeks ahead, these must be taken on a case-by-case basis, through honest discussions between patients, doctors and their families that consider risks and benefits, as well as people’s own wishes.

The letter also highlights a trend that worries disability and chronic illness advocates. Karin Willison, a senior editor at The Mighty, explained that patients with disabilities and chronic illnesses are at high-risk, not just from COVID-19, but ableism in the medical system and the resulting rationing policies.

“These rationing policies are a symptom of the deep ableism ingrained in the medical profession,” Willison wrote. “People with disabilities are often seen as less worthy of care, less valuable as human beings.”

A Los Angeles patient was informed via letter that her health care provider would not be filling her hydroxychloroquine (brand name Plaquenil) prescription for the time being, a medication she relies on to treat her lupus. That letter thanked the patient for her “sacrifice,” indicating this could “actually save lives.” Mighty contributor Jae Cobb, who lives with lupus, explained why health care systems need to consider this issue differently.

“We should be able to treat all COVID-19 patients without ‘sacrificing’ anybody,” Cobb wrote, adding:

We talk about sacrificing our health so those with an acute illness can survive, but what about the continual sacrifices those of us with chronic illness are already making financially, physically and mentally? We are now in the ‘who has it worse?’ competition and it should not be that way.

In response to outrage about the letter, the Welsh health board investigated the letter, and assured people it was not a standard policy issued by Public Health Wales. According to the health board, Llynfi Surgery was reaching out to patients who received its letter to discuss and apologize.

“A letter was recently sent out from Llynfi Surgery to a small number of patients,” a spokesperson for Cwm Taf Morgannwg University Health Board told WalesOnline, adding:

We have been made aware that the letter has caused upset to some of the patients who received it. This was not the intent and the surgery apologise for any distress caused. Staff at the surgery are speaking to those patients who received the letter to apologise directly and answer any concerns they may have.

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