As doctors, we know how this disease progresses. We know the prognosis for patients who need to be on a ventilator. We know that if we have a cardiac arrest during the course of COVID infection, our prognosis gets much grimmer. Faced with this knowledge, how do you decide how far you are willing to go to try and survive?
If you had to be intubated on a ventilator, would you want CPR performed? Would you want intubated at all for that matter? From studies I read out of China, patients with a need for CPR during COVID hospitalization had a mortality rate of 86 percent. That’s bleak. You take that, and add in the fact that in the U.S. we have drastic shortages of personal protective equipment. This means the people we ask to perform CPR on us have a much higher risk of getting infected themselves. Seen in this life, CPR becomes a measure that seems selfish, even reckless. I’d say it even is immoral to ask for CPR under these circumstances.
On the other hand, if you couldn’t wean off the ventilator after let’s say 3 to 4 weeks, but were neurologically intact, without other severe organ failure, would you get a tracheostomy and percutaneous endoscopic gastrostomy? Without even taking COVID into consideration, we’ve all seen our share of tragic patients who’ve been trached and pegged. Not to mention, again, that this also exposes your health care team to more risks. The surgical procedures themselves, and the care of the trach thereafter, mean more people would be at risk for contracting COVID.
I find myself struggling with this decision. I’m a hospitalist doctor, age 38 and obese, but otherwise healthy. Since this is an acute infection, as opposed to a chronic terminal illness, that factors heavily into my decision making. I think that if I had a chance to recover, I’d be willing to take that chance, and I would undergo the trach and peg.
Obviously, this assumes that we have enough vents and resources to treat everyone. That will vary significantly based on where you reside, and the prevalence of COVID in your local community. Take New York City right now: We know they lack many resources. The severe absence of PPE there is going to play into clinical decisions. Without adequate PPE, how can we ask health care workers to perform CPR? They would be much more likely to acquire the infection themselves by doing so. Not only that, but ventilators are becoming more scarce by the day. Isn’t it morally wrong to continue ventilator treatment if someone isn’t improving as you have more and more new acute cases piling up every day? Many hospitals are developing protocols to help doctors make these difficult decisions.
How much do our belief systems play into these complex choices? I am an atheist myself, and that weighs heavily on me as I contemplate life and death. In my belief system, dead is dead, and for me, that means that I find myself willing to endure more suffering if there is a chance I could survive. But at what cost? If survival means chronic vent dependency, then count me out. If it means chronic debility and inability to continue to practice medicine, then hell no. How much are we willing to sacrifice for a chance at continued life?
I think in general, if I were to be one of the unlucky physicians in need of ICU care, I would put my trust into my fellow doctors. I would ask my husband to defer to their judgment. If they feel a certain measure would be futile, then I would want my husband to follow their recommendations. We need to place our faith in each other as medical professionals and human beings.
Jenny Hartsock is a hospitalist who blogs at Doctor of a Certain Size.
Image credit: Shutterstock.com
