Doctors at Groote Schuur hospital are being forced to choose between which head-injury patients get expensive, specialised treatment and which do not.

If a proposed new policy is implemented, those cases which have little chance of recovery are likely to receive palliative care only.

The new rationing policy, aimed at achieving the best results for the largest possible number of patients, will entail the withdrawal of aggressive treatment from the most severe trauma patients – often young people who have been in car accidents or the victims of violent crime.

Dr Allan Taylor, a senior consultant in the Department of Neurosurgery at Groote Schuur argues that given increasing patient loads and budget cuts, the proposed policy as published in the latest South African Medical Journal makes good sense.

“By spreading our limited resources across everyone, there is a worse prognosis for all,” said Taylor.

“For those patients with at best a seven percent chance of a good recovery, the cost of one good outcome amounts to R1,4 million, given that the cost of treatment is at least R100 000 per patient.”

A recent study in KwaZulu-Natal, shows that of R9,5 million spent on head-injuries, some R6 million was spent on patients who had “bad” outcomes.

At present, unconscious and badly injured patients are usually rushed to Groote Schuur to be put on ventilators, while less serious head-injury patients are kept overnight at their local hospitals where their condition could deteriorate overnight.

By morning, those patients who were merely confused the night before, might now be beyond recovery, said Taylor.  

University of Cape Town specialist in medical ethics and law, Terry Fleischer, said an explicit, as opposed to an implicit or unspoken policy regarding the rationing of treatment for head-injury patients would be a world first.

“Even in western countries, implicit rationing is the order of the day,” said Fleischer. “The doctor just says to the family, ‘€˜it’€™s futile and hopeless’€™. We want to do things differently and open it to public debate given that this is public money we are spending.”

Taylor said while a rationing policy may be appropriate in principle, the problem is that things look different when it comes down to your family member or loved one.

“But the fact remains that families should not be able to demand ongoing treatment at the expense of other trauma patients,” said Taylor.

Proponents of the new policy know that they will be accused of “playing God”, said Taylor, “but by giving the more severely injured patients the best possible care we are denying it to those who have a much better chance of recovery”.

“First come first served is, of course, the easiest way, there are no decisions to be made, added Fleischer. “But it’€™s also short-sighted and a moral cope-out.”

If the proposed policy to rationalise resources is implemented, seven percent of head-injury patients who, in a highly resourced country, might well have recovered, will now either die or have a poor outcome. But in a resource-constrained country like South Africa, the policy will mean that more patients will have a good outcome than if the policy is not implemented at all. ‘€“ Health-e News Service

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