Washington State has benefited from an early response to COVID-19; organized and isolated, the curve seems to have flattened. Within our hospitals, we continue to prepare for the worst. This includes addressing the reality of limited resources and an insurmountable number of patients, a “crisis” standard-of-care.
For many health care workers, fatigue and fear of exposure pale compared to the emotional toll of countless COVID-19 tragedies. At the forefront of our minds are the reports from Italy, highlighting the impossible choices physicians were forced to make. As the news put it, doctors “choosing who lives and dies,” categorically rationing medical care to unilaterally pursue a “comfort measures only” approach. This is already becoming necessary for our sisters and brothers in New York.
That is our nightmare: medicine without humanity. It is true, in the face of death and disease, health care workers often have no control. We educate our patients to lead them to the acceptance of their clinical course. Then, together, we decide how to face death, with peaceful calm, furious strength, or any approach between. The outcome is the same, but the recompense comes from navigating the choice with our patients.
When I joined the COVID-19 intensive care unit (ICU) staff, I saw tense health care providers in a “crisis” state-of-mind with a modest census of patients. True to expectation, the majority of my service was spent reviewing goals-of-care with COVID-19 patients who had worsening clinical status. While I was fresh to the ICU, many of my peers were tired from weeks of working under the threat of a surge. Everyone faced unique existential pressures which emphasized anxieties and promoted a sense of urgency—this biased staff’s expectations regarding the clinical course, goals-of-care, and outcomes. So, while I was pleasantly surprised to have the luxury of time to have long discussions with my dying patients, it was met with skepticism from my colleagues.
I was asked to evaluate an 80-year-old Vietnamese woman, admitted to the acute care service with her husband with COVID-19 and, endearingly, boarded together in the same room. I ended up spending most of the night with a sleepy woman, her husband, and a telephone-based Vietnamese interpreter.
The woman was becoming progressively hypoxemic, with findings of acute respiratory distress syndrome. She was confused and sleepy, so I mostly talked to her husband. He preferred to defer to the judgment of “the hospital and doctors.” That may be the only choice in the future, I thought, but tonight we get to take our time to help you understand.
I laid out the scenarios: intubation versus no intubation, resuscitation versus no resuscitation, transfer to the ICU versus remaining on the acute care service. Yes, she could continue care in the same room as her husband, though the hypoxemia would worsen and lead to death. Alternatively, she could be transferred to the ICU, a different room, unconscious, and intubated. I expressed my doubt that she would be extubated or see her husband again.
I was eventually able to pose the question in a way to best elicit his preference. He finally told me, if he were forced to choose, he would rather his wife stay in the same room as him. His wife woke up to hear that statement.
The circularity of my discussion ceased; the tone became straightforward, pointed. She looked at me, suddenly her eyes bright with clarity. I asked her if she wanted a breathing tube to treat her illness; she nodded no. I asked if she wanted to stay with her husband, she nodded yes. She asked me if she could see her son. I told her I was not sure if it was allowed, I apologized. She thanked me anyways. The recompense was in navigating the decision.
I documented my conversation, “DNR/DNI, no ICU transfer,” and the acute care and ICU teams wholeheartedly agreed. Conversely, there were patients who were younger, healthy, who chose to be full code. To my surprise, not everyone in the ICU agreed. I was asked several times why I spent so much time in the room with patients discussing intubation and resuscitation. “CPR in a COVID-19 patient would endanger staff and be unsuccessful,” I was informed. More than once was there mention of the scenario in Italy or the institutional guidance we have received regarding code status during “crisis.” I thought to myself, we are not in Italy, and we are not yet in crisis.
I gained insight into the collective ethos of the COVID ICU. I came to two conclusions; we need validation and perspective. First, all health care providers need our fears heard and validated. We must listen to each other, and our institutions must listen to us. Just as importantly, though, in the coming months, we must frequently reassess our perspective on the situation as a whole. This requires structured institutional responsiveness and transparency.
There can be no ambiguity in these questions: Are we in crisis mode? Does institutional need necessitate disregarding an individual’s goals-of-care? If the answer to these questions is “no,” then our approach must be an unequivocal routine standard-of-care. Our anxieties in the face of an existential threat should not color our approach to our patients, so long as resources are available. Fear cannot overshadow medical facts, curtailing our commitment to understanding our patients, and providing care suitably targeting their goals.
A time may come where we all will be required to abandon our humanistic approach to eliciting our patient’s goals-of-care in exchange for a cold, but necessary, algorithm. Let Italy serve as an example, and possibly New York. At that time, I have faith that our leaders will provide us with protocols that will make these impossible decisions for us. We will have to enact these decisions, but we will do so compassionately, though with heavy hearts. We will do so together, as a professional community, joined together by our desire to serve. Until then, we must hold on to humanity while we still can.
Jay Brahmbhatt is an internal medicine resident.
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