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DEAR DR. ROACH: At what point in COVID-19 does the order not to resuscitate a person become a problem? When does treatment become an “exceptional or extraordinary” effort? It would appear that organ transplants, otherwise coma / prolonged mechanical ventilation would be eligible. I have never seen anything on this issue. – RS
REPLY: An order not to resuscitate is not uniform. Ideally, a person thinks carefully about what they want and, with the help of an expert, writes a document (called a “living will”) to explain how it relates to various circumstances.
Since it is impossible to consider every possible situation, it is also wise to discuss your feelings with a designated person who becomes a patient’s health care proxy by means of a document called an enduring power of attorney for care. health “. This person can then help the team of doctors and other people taking care of the patient in situations not specifically addressed by the living will. A living will can also state that a person would like everything to be done from a medical point of view, except when they have been diagnosed with a serious or terminal illness.
In the case of COVID-19, many people who have contracted the infection have pre-existing health conditions that have made them vulnerable and have a living will that says they don’t want “exceptional or extraordinary” care. Many other terms are used, such as ‘heroic’, but again, it is best to identify specific interventions that a person would or would not want. For some people, this can even include tube feeding, antibiotics, and intravenous fluids.
However, many people infected with COVID-19 are healthy young people. In these cases, we usually try absolutely everything we can, as some people, even the sickest, will get away with it. This includes putting on a breathing tube (intubating an endotracheal tube) and using a ventilator (also called a respirator). Very sick people are put on their stomachs (this is called a lying position) because it helps the lungs and survival is better.
One of the very last remedies available to us is extracorporeal membrane oxygenation (ECMO), which is a machine that essentially takes care of the work of oxygenating the blood through the lungs. People placed on ECMO for severe COVID-19 infection still have a 50% risk of death in hospital, but that is much better than the odds without this treatment. Another treatment of last resort is lung transplantation: this also saves lives, but it is a precious resource that many will not be entitled to and will not have an organ available when they need it. .
A person infected with COVID-19 and a typical do not resuscitate order would still be treated with the best medication and support we have, but would generally be allowed to die rather than be placed on a ventilator, and certainly would not get not the real heroic such as ECMO or lung transplant.
A colleague of mine recently wrote that many of the patients she has cared for just before intubation ask for the vaccine. It is too late then. Hospitalization for COVID-19 infection, with its risk of intubation and death, can be avoided in more than 90% of cases by vaccination when a person is still well. If you have not been vaccinated, please make an appointment to do so today. Doctors, nurses, respiratory therapists and all members of the intensive care hospital team would prefer not to see you there.
Dr Roach regrets not being able to respond to individual letters, but will fit them into the column whenever possible. Readers can send questions to [email protected] or send mail to 628 Virginia Dr., Orlando, FL 32803.
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