A precious ventilator.
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Consider the nightmare scenario you’ve heard many times by now: Twelve patients with COVID-19 arrive in the ICU needing emergency mechanical ventilation. Only six ventilators are available. Which patients should the doctors place on ventilators? Which patients should be left to die?
This is a nightmare in two parts: One is the overflowing hospital, the vision of sick patients waiting for the medical care or equipment that they might not get in time. The other is the decision-making, in which doctors must choose who lives and who dies.
The U.S. is now closer to this scenario than we have ever been in the history of modern medicine. But there might be a way to avoid it, or at least substantially mitigate it—a strategy that has nothing to do with testing, treating, or containing the coronavirus. It is a strategy that is cheap, and fast, and not actually that radical: Make sure every American has an advance directive.
An advance directive (sometimes called a living will) is a document that details a patient’s wishes in the event that he or she becomes critically ill. They can vary quite a bit, but a standard advance directive always addresses the question of whether or not the person desires life support—i.e. medicines and machines to keep the person alive when organ systems are failing.
The most critical component of life support in many cases, and certainly in the case of COVID-19, is mechanical ventilation.
How would you respond if you were asked the following question: In the next 12 months, in the event that you develop a life-threatening respiratory illness requiring mechanical ventilation (whether from COVID-19 or another illness), would you prefer:
A) Mechanical ventilation and intensive care , with the goal of sustaining life by all medically effective means
B) A time-limited trial of mechanical ventilation, then transition to other, less burdensome treatments
C) No mechanical ventilation or burdensome treatments of any kind—just focus on comfort?
This question may seem hard or complicated to answer, and for most people it is. Multiple factors will likely influence your choice, including your age, how much longer you expect to live, your religious or spiritual beliefs, your family and other relationships. In light of this difficulty, and the rapid escalation of the COVID-19 crisis, experts are rightfully urging us to bring up the subject with our families and loved ones. But to have a real impact—both for individuals and the wider population—this conversation can’t just be between family members. We have to go one step further, and make sure everyone is having this discussion with a healthcare provider. Now.
A doctor—or in some cases a nurse practitioner or physician’s assistant—can usually answer important questions that family members can’t. For example, what it’s like to be on a mechanical ventilator, what complications and risks are involved with ventilation, and how likely it is that you (with your particular combination of risks and health conditions) would survive a severe respiratory illness. A doctor should also screen for untreated depression and suicidality. Most importantly, a doctor or healthcare provider must document the decision for other doctors, so that those doctors can be certain the decision is well-informed and that they should make every effort to honor it.
Such conversations could start happening right now over the phone. Emergency and ICU physicians may be inundated with patients, but there are many physicians whose clinics have been effectively shuttered by the COVID crisis: ophthalmologists, surgeons, perhaps even your own primary care provider. Many of these MDs were trained in medical school to have end-of-life discussions, even if they no longer do it on a regular basis. It’s not a perfect scenario, but it’s a whole lot better than forcing doctors to make life-or-death decisions without knowing patients’ wishes, or without giving patients adequate time to consider those wishes.
State governments, who certainly have an interest in keeping their hospitals and ICUs from overflowing, should take the lead on this. State departments of public health could start by sending a postcard to every registered address, as well as stocking postcards for pickup at grocery stores and doctors offices. The card would include a multiple-choice question like the one above, a space for your name and signature, and a space to fill in the name of the doctor with whom you discussed your decision. (Something similar to this postcard already exists in most states. although it is intended only for people at high risk for a life-threatening event. In my state of California, it’s called a POLST, and it’s printed on bright pink paper.)
State departments of public health could then create online registries where healthcare providers could sign up to participate and document their phone calls. Individual doctors’ offices could also take the initiative to call their established patients, then document them on the central registry. After all, the ideal advance directive conversation always takes place with a doctor whom you already know and trust. But because we know that ideal won’t be possible for everyone, we can instead aim to make the broadest, fastest impact on a population level.
Even in this current setting of vast uncertainty, an advance directive gives us time to consider our options thoroughly, before the urgency and fear of critical illness have taken over our ability to think clearly about our values, goals, and plans for the future—both life and death. It’s important to emphasize that everyone has the right to choose Option A—whether it will be available to everyone is a different matter. But if we all take some time to reflect, talk, and ask questions, I suspect many of us will choose something else.
Imagine if every patient across the country who fell ill with COVID-19 started showing up in the emergency room with their advance directive in hand. Done on a massive scale, this effort could drastically reduce the burden of this disease on our nation’s hospitals, particularly ICUs. It would help triage patients in the emergency room and direct ongoing bed assignments in the hospital. Patients who want and require immediate ventilation can be transferred to the ICU (Option A). Those who want comfort care only (Option C), or those who have been in the ICU and are clearly not getting better (Option B), could be transferred to standard hospital beds, or even to a non-hospital setting (perhaps even to their homes) for hospice care.
You may not think the COVID crisis will impact you or your family, and depending on where you live and how lucky (not just careful, but lucky) you are, you may be right. But these questions aren’t going to go away. Talk to any healthcare worker who’s spent time in an ICU, and most of them will tell you how important it is to have an advance directive, whether it’s for the current crisis or another future—but inevitable—cause of death.
The bottom line is this: Doctors will need to make these tough decisions. But we would vastly prefer to make them with our patients’ help—now more than ever—to ensure that everyone gets the care they not only need, but want.
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