There he sat, bolt upright, struggling for every breath, a 65-year-old male with diabetes and heart disease who had every symptom of COVID-19. He needed a ventilator, and there was only one left in the hospital. We quickly got him intubated and sighed relief when we saw he was able to breathe again. But then terror returned: Will this man ever make it off the ventilator to return home or speak to his family again? What were we going to do when another patient needed a ventilator? We didn’t have another one to offer.
Explore This IssueACEP Now: Vol 39 – No 05 – May 2020
The looming possibility of rationing supplies and interventions, such as personal protective equipment and ventilators, haunts us all on the front lines. Statistics surrounding the case fatality rate of COVID-19 are particularly grim for our elderly patients. In China, the virus killed 8 percent and 15 percent of patients in the 70–79 and 80+ age ranges, respectively.1,2 Half of those who became critically ill (49 percent) died from this disease. Data from the first month of the pandemic in the United States indicate higher ICU admissions than China, with a similar overall case fatality rate of 2 to 3 percent.
Stated plainly, those who become critically ill with this virus have a high mortality rate whether they have a ventilator or not.
There is no more critical time than now to have the kind of conversation that you never wanted to have—the one about setting goals and plans regarding medical care and treatments known as advance care planning. Any physician can have an advance care planning conversation with a patient during a primary care visit or even in the emergency department. Fred Rogers of Mr. Rogers’ Neighborhood said it best: “Anything human is mentionable, and anything mentionable can be manageable.” Being able to talk about death and bad outcomes makes this whole COVID-19 conversation manageable.
This article provides a simple approach to difficult conversations focusing on end-of-life preferences.
Step 1: Ask the patient or family member to identify their health care proxy—ie, the person or persons who will be the patient’s representative when they can no longer speak for themselves. Health care proxies can be spouses, adult children, siblings, or any other designated person. Ensure everyone involved in the patient’s care is involved in the discussion to allow re-negotiation whenever circumstances change.3
Step 2: To answer thorny questions, we must know what we value. Take a moment to ask what is most important to the patient. What gives them purpose and meaning in your life? We have had patients tell us being at family gatherings with everyone they love is most important. Others have said their independence is essential. One gentleman most valued working on his antique cars. The responses are varied and very individual. What is important to me might not be so important to you.