In the weeks ahead, physicians may be asked to make decisions that they have never before had to face, and for which many of them will not be prepared. Though some people may denounce triage committees as “death panels,” in fact they would be just the opposite — their goal would be to save the most lives possible in a time of unprecedented crisis. Creation and use of triage committees, informed by experience in the current pandemic can help mitigate the enormous emotional, spiritual, and existential burden to which caregivers may be exposed.
Anticipating the need to allocate ventilators to the patients who are most likely to benefit, clinicians should proactively engage in discussions with patients and families regarding do-not-intubate orders for high-risk subgroups of patients before their health deteriorates. Once patients have already been placed on mechanical ventilation, decisions to withdraw it are especially fraught. Less than 50 years ago, physicians argued that withdrawing a ventilator was an act of killing, prohibited by both law and ethics. Today, withdrawal of ventilatory support is the most common proximate cause of death in ICU patients, and withdrawal of this support at the request of a patient or surrogate is considered an ethical and legal obligation. Withdrawal of a ventilator against the wishes of the patient or surrogate, however, is primarily done only in states and hospitals that permit physicians to unilaterally withdraw life support when treatment is determined to be futile.
Decisions to withdraw ventilators during a pandemic in order to make the resource available to another patient cannot be justified in either of these ways: it is not being done at the request of the patient or surrogate, nor can it be claimed that the treatment is futile. Even though the chances of survival may be low, in the absence of the pandemic the treatment would be continued. Whereas this type of rationing may not be unusual in countries that tragically have a chronic shortage of essential ICU care, it is unprecedented for most physicians who practice in well-resourced countries. Reports from Italy and US describe physicians “weeping in the hospital hallways because of the choices they were going to have to make.
From the Center for Bioethics (R.D.T., C.M.), the Department of Global Health and Social Medicine (R.D.T., C.M.), the Office of the Dean of the Faculty of Medicine (G.Q.D.), Harvard Medical School, and the Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital (R.D.T.) — both in Boston.
The physicians, nurses, or respiratory therapists who are caring for the patient should not be required to carry out the process of withdrawing mechanical ventilation; they should be supported by a team that is willing to serve in this role and that has skills and expertise in palliative care and emotional support of patients and families. Pain and suffering at the end of life can be controlled, and these patients deserve the best that palliative care can provide.
The decision about initiating or terminating mechanical ventilation is often truly a life-or-death choice.
Zeljko Serdar, CCRES
References (5)
It's likely that there were individual cases of coronavirus in Sweden as early as November 2019, according to the Public Health Agency, but the country is not currently working to trace the earliest cases. The news follows a report from France that a man was infected with the coronavirus on December 27th, several days before the first cases were reported in China. The patient was diagnosed with pneumonia but a sample taken at the time has now tested positive for the coronavirus. That man has fully recovered since his illness, but reportedly has no idea how he caught the virus.
ReplyDeleteNow state epidemiologist Anders Tegnell has said there were likely infected individuals in Sweden at this time too.
"There wasn't any spread [of infection] outside Wuhan until we saw it in Europe later. But I think that you could find individual cases among Wuhan travellers who were there in November to December last year. That doesn't sound at all strange, but rather very natural," said Tegnell.
Currently the first confirmed case of the virus in Sweden was a woman in Jönköping who tested positive on January 31st after a recent trip to China. She has since recovered from the illness.