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.
Step 3: Knowing your patient’s values, you can move on to the most difficult question you never wanted to ask:
“If you are so sick that you are unlikely to recover and would require artificial life support during the time you have left, would you prefer to continue on artificial life support, or would you prefer to allow a natural death?”
Everyone may have a different answer. Some may say, “I prefer nature to take its course. I want to die naturally.” Others may say, “Keep me alive at all costs, no matter what. I can’t bear the thought of dying.” What is most important is that the decision is based on the patient’s values, not what their family or even you as the provider prefers.
Step 4: Offer a recommendation. Language is everything. Studies indicate that what listeners understand often differs from what physicians intend. Certain phrases can lead families to feel abandoned and forced to choose between aggressive curative care and giving up.4 As emergency physicians, we should propose realistic goals. Here are two examples, and more are listed in Table 1:
- “Given that you said you most value being at home and hugging your children, I suggest home hospice.”
- “I recommend we accept that he will not live much longer and allow him to die peacefully.”
Planning for end of life is not a new phenomenon, but the presence of COVID-19 has made all of us a little more aware of our own mortality. None of us want to contract the virus and potentially die from it. However, that may be a reality for many people in this country. We are all hoping for the best outcome—that is, very few people falling ill and dying—but we must be practical and prepare for the worst.
Table 1: End-of-Life Conversation Suggestions
|Instead of Saying…||Try Using This Language|
|“Do you want us to do everything possible?”||“Would you like us to initiate artificial life support, or would you prefer to allow a natural death?”
“This virus is so deadly that no matter what we do given her age and comorbidities it is not clear she’d survive.”
“What do I need to know in order to do a better job taking care of you?”
|“We’ll refrain from extraordinary measures.”
“I’m going to make it so he won’t suffer.”
|“Your comfort and dignity are my top priority.”
“Can we agree not to escalate care, which will prolong the dying process?”
|“It’s time we talk about pulling back.”
“Will you agree to discontinue care?”
“I think we should stop aggressive therapy.”
|“I want to help you live meaningfully in the time you have left.”
“What can I do to help fulfill your wish to be at home with your family?”
“Let’s concentrate on improving your quality of life.”
- The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19)—China, 2020. China CDC Weekly. 2020;2(8):113-122.
- Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72,314 cases from the Chinese Center for Disease Control and Prevention. JAMA. 2020;323(13):1239-1242.
- Emanuel LL, Ferris FD, von Gunten CF. EPEC. Education for physicians on end-of-life care. Am J Hosp Palliat Care. 2002;19(1):17-18.
- Angus DC, Barnato AE, Linde-Zwirble WT, et al. Use of intensive care at the end of life in the United States: an epidemiologic study. Crit Care Med. 2004;32(3):638-643.
Dr. Manfredi is immediate past chair of the ACEP Well-Being Committee and associate clinical professor of emergency medicine at the George Washington University School of Medicine & Health Sciences in Washington, D.C. Dr. Jacobs is assistant clinical professor of emergency medicine at the George Washington University.