COVID-19 Moral and Ethical Advisory Group Wales: 14 May 2020

The Chair made introductions and noted apologies.

Minutes agreed and actions considered.

Dr Ben Thomas – Asst Medical Director from Betsi Cadwaladr UHB joined to discuss consent and ethics. Welsh legal services provided advice regarding resuming routine treatment and the principle of informed consent, which was discussed by the group.

Medical assessments and legal assessments can be difficult to align. This advice could overcomplicate risk assessment and try to quantify something that is very difficult to quantify. Do not want to confuse healthcare professionals and clinical practice is looking for more simplicity.

There is a difficult between balancing the interest of the person and the public health interest. Individual’s behaviours may endanger others whilst not endangering themselves.

As an example, Emergency departments have high risk of nosocomial infection due to numbers of people admitted.

Comments on the document were wide ranging. There is a concern regarding the risk of litigation. It was also concerning there is no mention of recording within the document. Needs to be workable in a clinical setting. Recording consent needs to be explicit. Risks are not new, clinicians make these type of decisions regularly.

No reference to choice of language. Recording language choice important and to consider lack of capacity due to lack of language choice, especially when dealing with those with particular illnesses such as dementia.

The aim is to avoid a situation where risk is unknown, that clinicians feel that they should avoid asking certain groups to come in for examination/treatment - i.e. older people, people with disabilities, long-term illnesses or who are BAME (disproportionate risk). So same principle as discussions on DNACPR - no group based blanket decisions.

Remote consultations are seen as safer, however consideration must be given to diverse language needs and whether they can be undertaken remotely.

Clinicians have difficulties obtaining all the preferred involvement to make decisions. Advanced care planning is an important in this. Best interest consultations may no longer be able to take place in person in large groups in the current climate. Capacity assessment needed.

Video recording would be the best method to capture consent. An issue this raises is half of people over 75 are not online, so digital consultation could be a concern and telephony advice needs strengthening. Those without family rely on social workers, who play an important role also.

Those shielding may consider themselves at ongoing risk and needs sensitive consideration. Easy to convince people to stay home rather to advise them it’s safe to come out. Advice indicates people have not been coming to A&E, conditions are showing late presentations for a range of conditions, and domestic violence seems to be increasing. Any emergence from lockdown needs to consider the approach to psychologically moving forward as well as physically.

DNACPR letter has been effective within the clinical community and a similar approach way work well for documentation of decision making.

What are the challenges as we move out of lockdown? The group considered issues provided by the Older People’s Commissioner and considered the UK government's recovery plan.

Older People’s Commissioner presentation

Queries raised included:

• How can this group be of most use during the transition period?
• Need and demand for health services now and when services lifted. Are values and principles being followed? A paper could be provided to the Council General.
• Poor communications have been a concern and knowledge as to where moral and ethical queries can be raised.
• Issues around discrimination for those with protected characteristics. This group could be an area to raise this and work with the Human Rights Commission.
• This group should consider its role and remit and link in with range of other bodies. Would social care also need to be considered?
• The group discussions covered the following topics:
• Post-covid morbidity a specific feature. Long term ability to cope for medical professionals a risk
• Unresolved grief manifesting in fear in children. Community groups with experience need to be considered as support for this to avoid a generation being effected.
• Whether an NHS Equality and Human Rights Group is required in Wales.
• Need to monitor how deaths are reported.
• Whether this group could (slowly) transform into a Wales Ethics Board, along the lines of those national bodies, dealing initially obviously with Covid 19 issues
• Emphasise on vulnerable needs to change to valuable. Inequality can result in vulnerability but people are not inherently vulnerable.
• Consideration of our values and what our priorities are as a country. Public messaging also very important. Proactive communications are needed.
• Collating individual cases and issues can be difficult as third sector not equipped. Advice and advocacy needs to be considered.
• A broader general need for reflection, remembrance, environmental concern and greater social justice. Communities are looking for a value based discussion about the future. Faith groups are starting to look at this.
• This group could promote inequalities and feed these perspectives into health.
• Social care currently separate. Need to explore whether these issues can be aligned.
• The group could help drive an agenda outward facing towards the public and inwards toward the health system and at government levels.
• CEOs of health boards are looking at potential harms, including Covid, NHS being overwhelmed, non-covid mortality and harm to vulnerable groups.
• An approach needed for the NHS to consider how to reset how people use the system. Faith centres, third sector, National Parks and community care will play a huge role.
• Consistency of the use of the moral and ethical guidance by the health service needs to be considered.

The group thanked the Older People’s Commissioner for the paper. It was agreed to utilise the discussion paper, edited based on the discussion in the meeting, and provide to the Counsel General who is currently collecting views on Wales’ recovery. Comments can be provided directly via this email address - ourfuturewales@gov.wales

Due to nature and speed of the work, the next meeting will take place on 21st May.

Members raised the ethical approach to the tracing app. It was agreed to be included on the agenda for the next meeting.

Concern was raised regarding visiting at care homes. All members were asked to consider and reflect back at the next meeting.