COVID-19: Will We Finally Start to Talk About Advanced Directives?

Joel Rowe writes in The Atlantic:

I am a resident emergency physician in New York City, and I’ve lost count of the number of times I’ve had to pick up the phone to inform the family of a patient with the coronavirus that their loved one was close to death. Recently, when an elderly woman arrived with what my colleagues and I identified as severe COVID-19, her prognosis was grave. I went to the ambulance bay, away from the cacophony of the emergency department, to call her relatives to tell them that even our most advanced interventions would not help her. The news was understandably difficult to absorb. The family reflexively asked us to “do everything,” rather than heeding the gentle recommendation that we focus on preserving her comfort.

We placed a tube in her throat to connect her to a ventilator, inserted catheters in her veins to administer medications that would sustain her heart, and performed chest compressions to temporarily supply blood to her vital organs. Our team tried for 45 minutes to resuscitate the patient as her lungs and heart gave out.

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[M]y patients and their families are facing the sudden decline that can occur in people with COVID-19, and many are not prepared. Before the pandemic, my colleagues and I conducted end-of-life conversations or delivered bad news over the phone only in very rare circumstances. I would take a patient’s family to a quiet room, sit face-to-face with them, and offer a hand to hold. Now the comfort I can offer the family, in some cases living mere blocks away, is limited, since relatives are rarely allowed in the hospital during coronavirus surges. Such restrictions exist for everyone’s safety, but they can make end-of-life decisions that much more difficult. When family members see the physical condition of their loved one, that’s often when the gravity of an acute situation truly sinks in. Without witnessing this reality, disbelief is common. “You can’t be talking about my dad,” one family member said to me over the phone. “There’s no way you have the right person. Please tell me this is a mistake.” No one should be making decisions about end-of-life care under such stressful circumstances.

 

In the absence of an advance directive, physicians always “do everything” to save someone’s life; it is our ethical and legal mandate. But in the final days or hours of an illness, when the body is permanently failing, disrupting the dying process without an advance directive in place can feel especially troubling. CPR is not like it is in the movies. Effective chest compressions, for instance, regularly break ribs. Invasive measures are justified when a patient has decided that they want them—and many patients choose that route. But they aren’t what everyone might wish for as they lie dying. When I know a patient’s wishes, I can work with a family to achieve them, even over the phone. In the end, I want my patients to die with dignity, whatever that means to them.

The Pandemic Should Change the Way We Talk About Dying