Covid 19 decisions
There is something I’ve been reading about that I feel compelled to share. There is so much information available about the pandemic and after a while, I get tired of reading! But this is important to think about. This is not meant to be medical advice and is for educational purposes only. It is also not meant to create fear. The large majority of people who become infected with Covid 19 have mild to moderate symptoms that do not require hospitalization.
The information I have read about how rapidly Covid can progress in people who become acutely ill, makes me realize how important it is to make sure your loved ones know what treatment you would want or not want if you suddenly became critically ill. Most likely you would be in the ER or ICU alone since family are not allowed to be with you. Having your advance directive with you or on file in the hospital records will save the medical professionals and your family a lot of time and confusion.
Remember, from my previous blog, an advance directive designates someone as your decision maker if you are unable to communicate for yourself. In that document you spell out in as much detail as possible, how aggressive you would want the medical interventions to be. I will share several possible scenarios below.
But first, I want to share information from a very helpful webinar I listened to last week. It was hosted by the Wild Health Podcast doctors and included multiple speakers. The recordings are available on their podcast.
The doctor I was particularly interested in was Dr Scott Weingart. (podcast #104) He is chief of the Division Emergency Critical Care at Stony Brook Hospital in New York. He shared that death rates are higher in those patients who wait to come in until their symptoms are more serious and also in older age groups especially those with other chronic illnesses. Those with heart disease, hypertension, diabetes and obesity are all at higher risk. But there are also younger patients without any apparent health issues who have bad outcomes and the reasons for this are not clear. Maybe there is a genetic predisposition? Maybe they had health conditions they weren’t aware of? I have not seen answers yet.
Doctors have been observing that patient outcomes may be better if intubation (which means putting someone on a ventilator) is delayed and instead use techniques such as prone ventilation or cpap or higher flow oxygen. The issue may be that hemoglobin can’t carry oxygen to the tissues because the Covid virus has blocked oxygen’s ability to attach to the hemoglobin molecule in our red blood cells. The lungs of a Covid patient are sometimes not as stiff as the lungs of someone with acute respiratory distress syndrome (ARDS). So the protocols used for ARDS are not always working for Covid. All this is still just observation, not proven physiology.
Dr. Weingart has described 4 categories of patients he has observed:
Mild symptoms, some fatigue, cough, fever but minimal shortness of breath and these people generally do fine at home with supportive treatment like rest and fluids
The happy hypoxic patients come into the ER and are found on testing with an oximeter to have low oxygen saturation. Normally the saturation on a pulse oximeter, the device they put on your finger to check pulse and oxygen levels, is around 97-98% if you have healthy lungs. This group has oxygen saturations less than 90% and sometimes in the 70’s or 80’s which would typically result in respiratory distress and urgent intubation. But for some reason this group is not as uncomfortable as expected. They respond to oxygen by nasal cannula but do not generally need a ventilator.
Indolent presentation- they may look ok at first but then explode with cytokine storm and have to be intubated rapidly or they die, and even after intubation they still may not be able to come off the ventilator and may die after two weeks of intensive effort
Hyperacute- a very rapid course that may only last 4 hours from admission to sepsis and death. Even young patients can present this way.
I am not aware of anyone who has figured out who presents with each of these patterns. There are some lab tests that are potential indicators of who is deteriorating, and that can be predictive later in the course.
So getting back to the advance directive discussion. Say you are a pretty healthy person, maybe in your 50’s for example, and you start getting sick with a fever and cough. You get tested (hopefully tests are available), and you test positive for Covid. You stay home and rest and drink fluids like you are told but then you get worse and go to the ER. Your family cannot go with you because of the quarantine and you do not have an advance directive. You kept meaning to have that conversation and prepare the papers but just hadn’t gotten around to it. Your family doesn’t know if you would want to go on a ventilator or not since you didn’t talk about it. Now you are in respiratory distress, you can’t breathe, you can’t talk, the doctors don’t have time to call family because they have multiple people needing emergency care. So now you are on a ventilator with a tube down your trachea and probably sedated so you don’t fight the machine.
Did you want to be on a ventilator?
What if after 2 weeks you are no better, will you want a tracheostomy? That is a direct hole in your trachea to continue to allow the ventilator to breathe for you.
Will your family be able to make the decision to stop the ventilator if there is no hope of improvement?
Do you want CPR to be performed if your heart stops?
This can be so confusing and upsetting for all involved! At this point in the pandemic, the data that I have seen is that once people are intubated and on a ventilator, the chance of surviving, coming off the ventilator and having restored lung function is not very good. In some age groups the rate of death is greater than 90%! Obviously younger, healthier groups have better statistics. And also remember that the large majority of Covid infections are mild. I am only talking about the patients with severe symptoms and those who experience the cytokine storm where the body over reacts with a massive inflammatory response.
I read an NY Times article today about the 44 year old physician who was critically ill in Washington state and survived after experiencing near death, thanks to aggressive and experimental treatments. He had his age and health on his side. And he still has a long recovery ahead of him but he is out of the hospital! Encouraging news!
If you knew ahead of time that you would not want to be on a ventilator, then you can have your advance directive with you and be able to communicate your wishes more clearly. This should mean that you can then be treated by a palliative care team and kept comfortable, rather than being put on a ventilator when your chance of survival is so slim. To be clear, there are definitely indications for being on a ventilator! And there are definitely people who have survived Covid and successfully come off the ventilator. Some will have better function than others, depending on what their lungs were like before getting sick. But having an advance directive and having these tough discussions with your family ahead of a sudden illness is super helpful.
Advance directive decisions are different depending on the individual. If I were a healthy 30 year old, I would want more life saving measures performed than I would as a healthy 66 year old or an unhealthy 70 year old. Having a conversation about choices and having them written down will hopefully make decision making easier for all involved.
Resources:
Wild Heart Podcast #104
A Beginner’s Guide to the End by B.J. Miller, MD and Shoshone Berger includes many resources for creating a will and advance directive
https://emcrit.org/ibcc/COVID19/ A great resource for more medical information about Covid