The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19) | Critical Care Medicine | JAMA | JAMA Network
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March 27, 2020

The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19)

Author Affiliations
  • 1Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
  • 2Cambia Palliative Care Center of Excellence, University of Washington, Seattle
  • 3Larner College of Medicine, Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington
JAMA. 2020;323(18):1771-1772. doi:10.1001/jama.2020.4894

The novel coronavirus disease 2019 (COVID-19) pandemic is challenging health care systems worldwide and raising important ethical issues, especially regarding the potential need for rationing health care in the context of scarce resources and crisis capacity. Even if capacity to provide care is sufficient, one priority should be addressing goals of care in the setting of acute life-threatening illness, especially for patients with chronic, life-limiting disease.

Clinicians should ensure patients receive the care they want, aligning the care that is delivered with patients’ values and goals. The importance of goal-concordant care is not new or even substantially different in the context of this pandemic, but the importance of providing goal-concordant care is now heightened in several ways. Patients most likely to develop severe illness will be older and have greater burden of chronic illness—exactly those who may wish to forgo prolonged life support and who may find their quality of life unacceptable after prolonged life support.1 In addition, recent reports suggest that survival may be substantially lower when acute respiratory distress syndrome is associated with COVID-19 vs when it is associated with other etiologies.2,3

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    4 Comments for this article
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    Helpful Templates to Facilitate Discussion
    Ron Louie, MD | Clin. Prof. Peds, (Heme-Onc) Univ. WA
    Although hospital / facility admission officers usually ask about advanced directives at the front door, there may be logistical issues having the document available when it's needed. If no document exists, the decision-making process usually takes time, so it may be practical to delegate the introduction of concepts to another member of the team, with followup with clinicians later.

    Social work and palliative care / hospice units undoubtedly have their own paperwork to facilitate the discussion, but independent non-profits like End of Life Washington have nicely made documents available through their website (not affiliated).
    CONFLICT OF INTEREST: None Reported
    Advance Care Planning a Gift to Ourselves, Families and Healthcare Providers
    Bob Parke | Bioethicist UHN Toronto
    I appreciate this article which also encourages us to remind patients that if advance care plans (ACPs) have been done they should inform family members (decision makers) where the plans are as well as any related power of attorney documents if completed.

    An ACP is a gift a person first gives themselves to best ensure they receive the treatment they want or not. Secondly, it is a gift provided to their family members or decision makers if they must make treatment decisions on their behalf. A gift with the benefit of peace of mind, less guilt and greater
    assurance that loved ones of the patient have made decisions the person wanted. Thirdly, at this time of the COVID-19 pandemic, completing an ACP and having it available is a gift given to treating staff including the front-line doctors. With likely shortages of ventilators, ICU beds and when doing CPR may put staff at risk, an ACP with the focus on comfort care is a gift that will lift some of the burden placed on an MD who has to propose treatments in the context of limited resources.

    In response to Ron Louie MD's concern in the comments about the logistical problem of having documents available when needed, this is a real concern and why patients if they have done ACPs should inform their decision makers where those documents are. I would like to add that ACPs can be provided in ways other than paper documents. One modality that I am coming to appreciate is the work done by Dr. Ferdinando Mirarchi to embed video recordings of ACPs within a QR code on a fob or card. The card can be in a wallet or on a bracelet that can be easily read by current smart phones. Dr. Mirarchi has abbreviated this method MIDEO (My Informed Decision on VidEO) (1). At a time when family members can't be with their loved ones it is another way for the person to quickly give voice to their wishes.

    REFERENCE

    1. https://mideocard.com/
    CONFLICT OF INTEREST: None Reported
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    Critical Ill patient and informed consent in a pandemic situation
    Giuliano Ramadori, Professor of Medicine | University Clinic,Internal Medicine,Göttingen,Germany
    The authors address an important issue for doctors involved in the treatment of critically ill COVID-19-positive patients: how to inform not only the patient but and even more importantly how to inform family members and how to involve them before the important decision of mechanical ventilation is taken.

    They mention two reports which gave some indications that survival after this treatment can be very low; mortality after mechanical ventilation was 65.7% and 20.9% of the patients were discharged from the hospital in the first report from China (1). In the second report (2) mortality in mechanically ventilated patients
    was 67% and 9.5% were released from the ICU. In the first report 20.9% of the patients remained hospitalized (1) while in the second report (2) 24% of the patients remained critically ill at the time of publication. It is reasonable to believe that about 80% of the patients who required mechanical ventilation probably died in the ICU. It would be interesting to learn, however, the fate of those patients who remained critically ill. Furthermore it would be important to know the clinical characteristics of those patients who could be released from the ICU and/or from the hospital.

    This information could help facilitate real informed consent from patients and family members and could also reduce the risk of criminal and civil liability (3)

    REFERENCES

    1.Wu C, Chen X, Cai Y, et al Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China. JAMA Intern Med. 2020; doi:10.1001/jamainternmed.2020.0994

    2.Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020. doi:10.1001/jama.2020.4326

    3.Cohen G,Crespo AM,White DBPotential legal liability for withdrawing or withholding ventilators during COVID-19.Assessing the risk and identifying needed reforrms.JAMA.2020 Apri 1.
    CONFLICT OF INTEREST: None Reported
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    Surprise Billing, Surprise Decisions
    Leslie Kelly Hall | Engaging Patient Strategy
    Today there are 30,000 surprise bills to patients every day. Advance Directives set the stage for direction for care. When this is ignored, the patient's family get the surprise. My voice. My care. My risk. My cost. Listen to me.
    CONFLICT OF INTEREST: None Reported
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