DMEJ
Duke Medical Ethics Journal
The Post-Covid Catch Up- Delayed Healthcare and Terminal Illness
By: Rhiannon Eplett
Over the past year, We’ve all heard the horrifying stories of car crashes and heart attacks brought to the doors of hospitals and being turned away because their emergency rooms and ICUs are overflowing with Covid patients. When victims of life or death trauma find that care is inaccessible to them, it creates a certain bone-chilling awareness of the gravity of the pandemic. With covid, your care is a matter of prolonged management. With trauma, you get care or you die right then. Being forced to prioritize one emergency over another is one of the principal struggles of medical care. This phenomenon is very apparent when it comes to treatment that simply cannot be postponed, but what is easier to miss, and what will become more significant as we attempt to move forward out of the pandemic is the issue of all the procedures and diagnoses that were delayed due to Covid-19.
.png)
Over the last year and a half, would-be patients encountered new obstacles to healthcare such as doctor’s offices refusing to see them, “canceling their appointments” or individuals simply not feeling safe in a medical environment (Hui, 2021). Think of all the biopsies that were postponed, and the concerns that were pushed to the backburner during the Covid crisis. Our personal issues do not seem as important in the middle of a global pandemic when a hospital or doctor’s office is one of the most threatening locations to frequent, but that does not mean that a patient’s individual emergency is less deserving of care when, “among those who said they received delayed care, 57% experienced negative health consequences” (Hui, 2021). For many, staying out of the way of the pandemic probably meant pushing a cancer or other serious diagnosis dangerously into the future, and now the medical community should feel some pressure to correct this life or death imbalance.
Oncology is a medical specialty where timely treatment is essential to outcomes, so any sort of delayed healthcare is going to have an impact. One U.K. based study found that delays in diagnosis or treatment due to pandemic avoidance of healthcare are projected to “increase in deaths due to cancer up to 5 years after diagnosis from 4.8% for lung cancer to 16.6% for colorectal cancer” (Maringe et al., 2020, p.1023). What's more, there is an entire library of possible serious health conditions that were impacted by pandemic delays. In some of these scenarios, the consequences have already been felt including in the realm of pediatric care where, “the fear from COVID-19 pandemic resulted in delayed diagnosis and higher complication rates in common paediatric medical conditions,” particularly drawing attention to appendicitis (Snapiri et al., 2020, p. 1672). Furthermore, “because the COVID-19 pandemic led to a global surge in critically ill patients, hospitals were forced to reallocate resources, potentially resulting in reduced health care access for patients requiring essential care” as in the case of “untreated hip fractures” which are “associated with a high mortality rate, and even slight delays (>72 hours) have been shown to increase morbidity and mortality” (Egol et al., 2020, p. 400). Covid-19 reduced diagnostic referrals across the board, so other life altering health consequences could be observed in the future like in the area of rheumatology where “the consequences of delayed diagnosis can be particularly evident in giant cell arteritis, leading to the most dreaded complication of the disease: irreversible visual loss” (Monti et al., 2020, p. 1658).
“If treating one emergency effectively means sacrificing the lives of patients with other concerns, it is evident that our healthcare system requires some restructuring, or better yet, more infrastructure to begin with.”
Herein lies the issue: we can already feel a push to resume normal life, but normal life in this case will also mean playing catch up. We can expect a crush of people clamoring to get access to normal healthcare. We can expect to be swamped with new diagnoses, terminal illnesses, and surgeries. We can also expect a faction of people used to delaying their needs who could potentially be in very seriously require access to healthcare such as “unpaid caregivers for adults, respondents with two or more underlying medical conditions, and persons with disabilities” where “avoidance of both urgent and routine medical care because of COVID-19 concerns was highly prevalent” (Czeisler et al., 2020). We must consider how we manage equitable access to care when care is in high demand and how we also encourage those who are reluctant to seek out care to come forward when they might be the ones who need medical attention the most. Covid-19 has demanded better systems from healthcare providers so that the next time there is a public health emergency, delayed healthcare does not manifest as a roster of chronic or dangerous illnesses that were allowed to go ignored.
The healthcare system has been unbelievably stressed during the pandemic, and now that we are hopefully in the home stretch, the stressors are not entirely going away. They are merely changing. With people coming back to the doctor's office in need of treatment, more decisions are going to need to be made over who gets seen first because, right now, the people who want well visits and check ups are going to be in competition with those with chronic or semi-emergent health issues that need to be addressed. Check ups are still important. This is the area of medicine where we often sniff out the issues that could become more serious. If we push those aside to make room for the patients with known conditions then we continue the problems the pandemic created where people who needed preventative medical care were deprioritized to deal with the obvious emergency. If we continue with a first come first serve lineup for all of the same providers, then the people who want check-ups may actually be more proactive than those with chronic issues which then, in effect, creates a system that is discriminatory to people who absolutely must have care.
On top of this, as much as we would like to act as if Covid is over, we have really just switched to playing the long game of dealing with new variants and surges as they come up, so a portion of medical resources will be directed towards Covid-19 for the foreseeable future. More than ever, the pandemic has brought to light the dilemma of what to do when supply does not match demand and we must decide between preventative and reactive medicine.
The issue at hand is that in a perfect world we would not have to decide at all. What we are missing in the struggle to achieve this perfect world is simply more: more access, more care, more providers.
One option to address this issue is the increasing incorporation of non-physician healthcare providers into our healthcare systems. Providers like Physician Assistants (recently re-named to Physician Associates), nurse practitioners, and others have been developing an ever larger role in medicine. In areas where there is an obvious demand for healthcare providers, many hospitals and doctors’ offices, nationally, are turning to providers without MDs to meet the need. These practitioners are especially influential at the primary care level, and in these current conditions, they could be essential to providing increased opportunities to make up for all of the healthcare needs that were delayed during the height of the pandemic. With more primary care providers comes more access to care put off by the pandemic which then allows us to catch up on diagnoses and treatment in those cases that would lead to serious or terminal illness.
Photo credit to Storyblocks
Increased non-physician practitioners can also help address the problem of improving outcomes in the future the next time we have to deal with a national health crisis. Simply having the increased resource of more providers could make it easier to ensure that those who really need care or who really need a diagnosis do not feel the need to delay their care because the healthcare system as a whole would be less stressed.
Even without the pandemic, we may have seen a shift towards non-physician providers in the near future with one study finding, “that from 2008 to 2016, the share of specialty practices that employ either nurse practitioners (NPs) or physician assistants grew from 23 percent to 28 percent while the share of primary care practices that do so increased from 28 percent to 35 percent” (Svorny & Cannon, 2020). Medical institutions are inevitably turning to these providers because non-physicians are the affordable option for the healthcare industry. On one hand, it is possible that the increased ease of access to providers and these providers being more affordable for healthcare institutions could also pass these discounts along to the consumer. However, even if increasing the number of providers by recruiting non-doctors seems like a grand solution, it will always be a point of concern to make sure that other issues do not arise where patient outcomes suffer because hospitals and medical practices went exclusively affordable with regards to providers. Proper licensing and qualifications must still be strictly scrutinized. Non-physician providers are an undeniable asset in the race to meet the demand for both current and potentially future pandemic delayed healthcare, but it must be ensured that the primary motivation is always to improve patient care and outcomes and not purely to cut costs.
Covid-19 will not be the last medical emergency to impact our country and society. It is so easy in medicine to direct focus and energy to the most obvious glaring problems and emergencies, but this does not mean that those afflicted by more subtle silent killers do not deserve care. This does not mean that they can afford to wait for care, and if treating one emergency effectively means sacrificing the lives of patients with other concerns, it is evident that our healthcare system requires some restructuring, or better yet, more infrastructure to begin with. Yes, emergencies have to come first, but in the case of terminal illnesses and cancer diagnoses, these situations are emergencies that happen to transpire more slowly. In the case of medicine and healthcare, it is ethically imperative that we find a way to do it all. It is a shared hope of many that the world will be better prepared for the next global health crisis, and in the interlude there must also be preparation for how to continue to provide non-pandemic health care in the midst of said pandemic. The visible, prominent emergencies are always going to be foremost in our minds, but even in these times of high systematic strain, invisible emergencies do not deserve our neglect.
Review Editor: Sajan Singh
Design Editor: Heiley Tai
References
Czeisler, M. (2020, September 10). Delay or avoidance of medical care because of
COVID-19–related concerns - United States, June 2020. Centers for Disease Control and
Prevention. Retrieved November 5, 2021, from
https://www.cdc.gov/mmwr/volumes/69/wr/mm6936a4.htm.
Egol, K. A., Konda, S. R., Bird, M. L., Dedhia, N., Landes, E. K., Ranson, R. A., Solasz, S. J.,
Aggarwal, V. K., Bosco, J. A., Furgiuele, D. L., Ganta, A., Gould, J., Lyon, T. R.,
McLaurin, T. M., Tejwani, N. C., Zuckerman, J. D., & Leucht, P. (2020). Increased
mortality and major complications in hip fracture care during the COVID-19 pandemic:
A New York City Perspective. Journal of Orthopaedic Trauma, 34(8), 395–402.
https://doi.org/10.1097/bot.0000000000001845
Hui, K. (2021, January 6). 1 in 5 adults delayed medical care due to covid-19, study finds.
Verywell Health. Retrieved November 5, 2021, from https://www.verywellhealth.com
/covid-19-pandemic-delays-medical-care-5093910#citation-1.
Maringe, C., Spicer, J., Morris, M., Purushotham, A., Nolte, E., Sullivan, R., Rachet, B., &
Aggarwal, A. (2020). The impact of the COVID-19 pandemic on cancer deaths due to
delays in diagnosis in England, UK: A national, population-based, modelling study. The
Lancet Oncology, 21(8), 1023–1034. https://doi.org/10.1016/s1470-2045(20)30388-0
Monti, S., Delvino, P., Bellis, E., Milanesi, A., Brandolino, F., & Montecucco, C. (2020). Impact
of delayed diagnoses at the time of COVID-19: Increased rate of preventable bilateral
blindness in Giant Cell Arteritis. Annals of the Rheumatic Diseases, 79(12), 1658–1659.
https://doi.org/10.1136/annrheumdis-2020-217915
Snapiri, O., Rosenberg Danziger, C., Krause, I., Kravarusic, D., Yulevich, A., Balla, U., &
Bilavsky, E. (2020). Delayed diagnosis of paediatric appendicitis during the Covid‐19
pandemic. Acta Paediatrica, 109(8), 1672–1676. https://doi.org/10.1111/apa.15376
Svorny, S., & Cannon, M. F. (2020, August 16). Health Care Workforce Reform: COVID-19
spotlights need for changes to clinician licensing. SSRN. Retrieved November 5, 2021,
from https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3674104.