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#15,155
As the number of severe COVID-19 cases increases - our nation, and the world - faces an unprecedented ventilator (and critical care bed) shortage. Over the past week, in Contemplating A Different `Standard of Care and HHS ASPR-TRACIE: COVID-19 Crisis Standards of Care Resources we've looked at this growing dilemma.
While it is highly probable that any COVID-19 ARDS (acute respiratory distress syndrome) patient who is ill enough to require these sorts of interventions will die without them, being admitted to the ICU or being put on a ventilator is far from a panacea.In Characteristics and Outcomes of 21 Critically Ill Patients With COVID-19 in Washington State by Matt Arentz, MD1; Eric Yim, MD2; Lindy Klaff, MD2; et al, published by JAMA, of 21 cases included in the study (mean age, 70 years [range, 43-92 years]; 52% male), 71% required mechanical ventilation, 67% had died, 24% remained in the ICU, and only 9.5% had been discharged from the ICU at the time of publication.
Putting a COVID-19 patient on a ventilator - particularly someone who is elderly, and who has significant comorbidities - is a heroic, last ditch, but often futile attempt to buy some time for the body to heal itself. Being put on a vent is an invasive, traumatic, and difficult course of treatment, which can lead to other life threatening complications including Ventilator-associated pneumonia (VAP).
Like CPR, is isn't nearly as successful in real life as it is in the movies.Even when they are not faced with a shortage of ventilators or ICU beds, doctors must decide on which interventions are most appropriate based on how likely a patient is to benefit from them. Decisions to withhold care are made every day.
But during a pandemic, with limited resources, doctors can have more potentially salvageable patients than critical care beds or ventilators, and they need an ethical framework for deciding who gets access to scarce resources.
First a link to an editorial published in JAMA last week on the rationing of scarce resources. Follow the link to read it in its entirety. When you return, I'll have a postscript.
Viewpoint
March 27, 2020
A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic
Douglas B. White, MD, MAS1; Bernard Lo, MD2,3
Author Affiliations Article InformationJAMA. Published online March 27, 2020. doi:10.1001/jama.2020.5046
As the coronavirus disease 2019 (COVID-19) pandemic intensifies, shortages of ventilators have occurred in Italy and are likely imminent in parts of the US. In ordinary clinical circumstances, all patients in need of mechanical ventilation because of potentially-reversible conditions receive it, unless they or their surrogates decline. However, there are mounting concerns in many countries that this will not be possible and that patients who otherwise would likely survive if they received ventilator support will die because no ventilator is available.
In this type of public health emergency, the ethical obligation of physicians to prioritize the well-being of individual patients may be overridden by public health policies that prioritize doing the greatest good for the greatest number of patients.1 These circumstances raise a critical question: when demand for ventilators and other intensive treatments far outstrips the supply, what criteria should guide these rationing decisions?
(Continue . . . )
While it is true that the more ventilators we can put into service during a severe pandemic, the more lives we can probably save, the reality is many - perhaps even most - patients who need and receive this level of care will still succumb.
Although most people who get COVID-19 will experience only mild illness, and only a small percentage will become ill enough to require critical care treatment, it is worth considering now what your wishes would be should you find yourself in need of heroic medical interventions (for COVID-19 or any other severe illness).Having a Living Will that specifies what types of medical treatment you would desire should you become incapacitated, and a legally binding Health Care Proxy that designates someone who can make medical decisions for you if you are unable to do so, makes sense, regardless of whether we are facing a pandemic.
Nearly every Thanksgiving I write about this - and the importance of keeping an updated medical history on every family member (see Reminder: Thanksgiving Is National Family History Day) - and I show ways to prepare and keep this vital information handy.
Elderly family members with chronic health problems, or those with terminal illnesses, may even desire a home DNR (Do Not Resuscitate) Order. Without legal documentation, verbal instructions by family members – even if the patient is in the last stages of an incurable illness – are likely to be ignored by emergency personnel.Nine years ago, in On Having `The Conversation’, I described a close call for my elderly (then 86 y.o.) father, and his decision to make `end of life' plans. A little over a year later, in His Bags Are Packed, He’s Ready To Go, I told of his last few days in home hospice care, where he passed away peacefully in his sleep.
These are never pleasant things to think about, or discuss.But perhaps more than ever, this is the right time to sit down with family and friends and make sure your wishes are known and respected.
