{"id":6263,"date":"2020-09-30T07:29:40","date_gmt":"2020-09-30T11:29:40","guid":{"rendered":"http:\/\/www.silvercentury.org\/?p=6263"},"modified":"2020-09-30T07:29:40","modified_gmt":"2020-09-30T11:29:40","slug":"should-you-change-your-living-will-because-of-the-pandemic","status":"publish","type":"post","link":"http:\/\/78.142.243.82\/~silvercentury\/2020\/09\/should-you-change-your-living-will-because-of-the-pandemic\/","title":{"rendered":"Should You Change Your Living Will Because of the Pandemic?"},"content":{"rendered":"

What kind of hospital care would you want if you had COVID-19 and were desperately ill? In this article, journalist Judith Graham pulls together the facts about treatments, especially with ventilators, along with expert advice on what to do and how to decide. Her article was posted on the KHN<\/a> website on May 12, 2020, and also ran on the Washington Post.<\/em><\/p>\n

DENVER \u2015 Last month, Minna Buck revised a document specifying her wishes should she become critically ill.<\/p>\n

\u201cNo intubation,\u201d she wrote in large letters on the form, making sure to include the date and her initials.<\/p>\n

Buck, 91, had been following the news about COVID-19. She knew her chances of surviving a serious bout of the illness were slim. And she wanted to make sure she wouldn\u2019t be put on a ventilator under any circumstances.<\/p>\n

\u201cI don\u2019t want to put everybody through the anguish,\u201d said Buck, who lives in a continuing care retirement community in Denver.<\/p>\n

For older adults contemplating what might happen to them during this pandemic, ventilators are a fraught symbol, representing a terrifying lack of personal control as well as the fearsome power of technology.<\/p>\n

Used for people with respiratory failure, a signature consequence of severe COVID-19, these machines pump oxygen into a patient\u2019s body while he or she lies in bed, typically sedated, with a breathing tube snaked down the windpipe (known as \u201cintubation\u201d).<\/p>\n

For some seniors, this is their greatest fear: being hooked to a machine, helpless, with the end of life looming. For others, there is hope that the machine might pull them back from the brink, giving them another shot at life.<\/p>\n

\u201cI\u2019m a very vital person: I\u2019m very active and busy,\u201d said Cecile Cohan, 85, who has no diagnosed medical conditions and lives independently in a house in Denver. If she became critically ill with COVID-19 but had the chance of recovering and being active again, she said, \u201cyes, I would try a ventilator.\u201d<\/p>\n

Out of all those who become infected with COVID-19, frail older adults are the least likely to survive treatment with a ventilator.<\/strong><\/p><\/blockquote>\n

What\u2019s known about people\u2019s chances?<\/p>\n

Although several reports have come out of China, Italy and, most recently, the area around New York City, \u201cthe data is really scanty,\u201d said Carolyn Calfee, a professor of anesthesia at the University of California-San Francisco [UCSF].<\/p>\n

Initial reports suggested that the survival rate for patients on respirators ranged from 14 percent (Wuhan, China) to 34 percent (early data from the United Kingdom). A report from the New York City Area<\/a> appeared more discouraging, with survival listed at only 11.9 percent.<\/p>\n

But the New York data incorporated only patients who died or were discharged from hospitals\u2014a minority of a larger sample. Most ventilator patients were still in the hospital, receiving treatment, making it impossible for researchers to draw reliable conclusions.<\/p>\n

Calfee worries that data from these early studies may not apply to US patients treated in hospitals with considerable resources.<\/p>\n

\u201cThe information we have is largely from settings with tremendous resource gaps and from hospitals that are overwhelmed, where patients may not be treated with optimal ventilator support,\u201d she said. \u201cI would be very worried if people used that data to make decisions about whether they wanted mechanical ventilation.\u201d<\/p>\n

Still, a sobering reality emerges from studies published to date: older adults, especially those with underlying medical conditions such as heart, kidney or lung disease, are least likely to survive critical illness caused by the coronavirus or treatment with a ventilator.<\/p>\n

\u201cTheir prognosis is not great,\u201d said Douglas White, MD, a professor of critical care medicine at the University of Pittsburgh. He cautioned, however, that frail older adults shouldn\u2019t be lumped together with healthy, robust older adults, whose prospects may be somewhat better.<\/p>\n

The choice isn\u2019t as black-and-white as go on a ventilator or die.<\/strong><\/p><\/blockquote>\n

Like other clinicians, White has observed that older COVID patients are spending considerably longer on ventilators\u2014two weeks or more\u2014than is the case with other critical illnesses. If they survive, they\u2019re likely to be extremely weak, deconditioned, suffering from delirium and in need of months of ongoing care and physical rehabilitation.<\/p>\n

\u201cIt\u2019s a very long, uphill battle to recovery,\u201d and many older patients may never regain full functioning, said Negin Hajizadeh, MD, an associate professor of critical care medicine at the School of Medicine at Hofstra\/Northwell on New York\u2019s Long Island. \u201cMy concern is, who\u2019s going to take care of these patients after a prolonged ventilator course\u2014and where?\u201d<\/p>\n

In St. Paul, MN, Joyce Edwards, 61, who is unmarried and lives on her own, has been wondering the same thing.<\/p>\n

In late April, Edwards revised her advance directive to specify that \u201cfor COVID-19, I do not want to be placed on a ventilator.\u201d Previously, she had indicated that she was willing to try a ventilator for a few days but wanted it withdrawn if the treatment was needed for a longer period.<\/p>\n

\u201cI have to think about what the quality of my life is going to be,\u201d Edwards said. \u201cCould I live independently and take care of myself\u2014the things I value the most? There\u2019s no spouse to take care of me or adult children. Who would step into the breach and look after me while I\u2019m in recovery?\u201d<\/p>\n

People who\u2019ve said \u201cgive a ventilator a try but discontinue it if improvement isn\u2019t occurring\u201d need to realize that they almost surely won\u2019t have time to interact with loved ones if treatment is withdrawn, said Christopher Cox, MD, an associate professor of medicine at Duke University.<\/p>\n

\u201cYou may not be able to live for more than a few minutes,\u201d he noted.<\/p>\n

But the choice isn\u2019t as black-and-white as go on a ventilator or die.<\/p>\n

\u201cWe can give you high-flow oxygen and antibiotics,\u201d Cox said. \u201cYou can use BiPAP or CPAP machines [which also deliver oxygen] and see how those work. And if things go poorly, we\u2019re excellent at keeping you comfortable and trying to make it possible for you to interact with family and friends instead of being knocked out in a coma.\u201d<\/p>\n

People are thinking about what could happen to them and they want to talk about it. It\u2019s opened up a lot of conversations.<\/strong>
\n\u2014 Rebecca Sudore, MD<\/strong><\/p><\/blockquote>\n

Heather McCrone of Bellevue, WA, realized she\u2019d had an \u201call-or-nothing\u201d view of ventilation when her 70-year-old husband developed sepsis\u2014a systemic infection\u2014last year after problems related to foot surgery.<\/p>\n

Over nine hours, McCrone sat in the intensive care unit as her husband was stabilized on a ventilator by nurses and respiratory therapists. \u201cThey were absolutely fantastic,\u201d McCrone said. After a four-day stay in the hospital, her husband returned home.<\/p>\n

\u201cBefore that experience, my feeling about ventilators was, \u2018You\u2019re a goner and there\u2019s no coming back,\u2019\u201d McCrone said. \u201cNow, I know that\u2019s not necessarily the case.\u201d<\/p>\n

She and her husband both have advance directives stating that they want \u201clifesaving measures taken unless we\u2019re in a vegetative state with no possibility of recovery.\u201d McCrone said they still need to discuss their wishes with their daughters, including their preference for getting treatment with a ventilator.<\/p>\n

These discussions<\/a> are more important than ever\u2015and perhaps easier than in the past, experts said.<\/p>\n

\u201cPeople are thinking about what could happen to them and they want to talk about it,\u201d said Rebecca Sudore, MD, a professor of medicine at the UCSF. \u201cIt\u2019s opened up a lot of conversations.\u201d<\/p>\n

Rather than focusing on whether to be treated with a ventilator, she advises older adults to discuss what\u2019s most important to them\u2014independence? time with family? walking? living as long as possible?\u2014and what they consider a good quality of life. This will provide essential context for decisions about ventilation.<\/p>\n

\u201cSome people may say, my life is always worth living no matter what type of serious illness or disability I have,\u201d she said. \u201cOn the other end of the spectrum, some people may feel there are health situations or experiences that would be so hard that life would not be worth living.\u201d<\/p>\n

Sudore helped create Prepare for Your Care<\/a>, a website and a set of tools to guide people through these kinds of conversations. Recently it was updated to include a section on COVID-19, as have sites sponsored by Compassion & Choices<\/a> and The Conversation Project<\/a>. And the Colorado Program for Patient Centered Decisions has published a decision aid<\/a> for COVID patients considering life support, also available in Spanish.<\/p>\n

Some older adults have another worry: What if there aren\u2019t enough ventilators for all the COVID patients who need them?<\/p>\n

In that situation, \u201cI would like to say \u2018no\u2019 because other people need that intervention more than I do and would benefit, in all probability, more than I would,\u201d said Larry Churchill, 74, an emeritus professor of medical ethics at Vanderbilt.<\/p>\n

\u201cIn a non-scarcity situation, I\u2019m not sure what I\u2019d do. I\u2019m in pretty good health, but people my age don\u2019t survive as well from any major problem,\u201d Churchill said. \u201cMost of us don\u2019t want a long, lingering death in a custodial facility where the chances of recovery are small and the quality of life may be one we\u2019re not willing to tolerate.\u201d<\/p>\n","protected":false},"excerpt":{"rendered":"

Last month, Minna Buck revised a document specifying her wishes should she become critically ill.<\/p>\n

\u201cNo intubation,\u201d she wrote in large letters on the form, making sure to include the date and her initials.<\/p>\n

Read more Should You Change Your Living Will Because of the Pandemic?<\/span> ›<\/span><\/a><\/div>\n

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