Ventilator treatment for COVID-19 leads to questions of end-of-life

Now is the time to talk to your friends and family about your prospects of survival should you become deathly ill. But if you’re like me, you’d rather not start the conversation.

image: The Conversation

If you are unfortunate enough to catch the new coronavirus and are placed on a ventilator, the odds are two-to-one that you will die. And if you survive, your quality of life could be seriously compromised.

The numbers are still coming in, but they don’t look good. One review conducted in China said that 86 percent of COVID-19 patients put on ventilators eventually died. In the UK, about two-thirds of ventilated patients died.

From an optimistic perspective, you have a chance of living so why not take it?

In the most serious cases, COVID-19 takes over the respiratory system and leads to pneumonia. Your lungs fill with fluid and you can no longer capture oxygen; you begin to suffocate and are left literally gasping for air.

A ventilator seems like the obvious choice but it’s extremely invasive. You are sedated and muscle-paralyzing drugs are given -the procedure is so aggressive that you would not tolerate it otherwise. A 10-inch tube is inserted into your lungs with the hope is that the oxygen will prevent you from suffocating to death before the body’s immune system is able to rally, overwhelm the virus and return you to health. That’s the hope.

Kathryn Dreger, an internist and professor of medicine at Georgetown University, describes a common result:

“The amount of sedation needed for Covid-19 patients can cause profound complications, damaging muscles and nerves, making it hard for those who survive to walk, move or even think as well as they did before they became ill. Many spend most of their recovery time in a rehabilitation center, and older patients often never go home. They live out their days bed bound, at higher risk of recurrent infections, bed sores and trips back to the hospital.”

Given that prospect, you will have to make the agonizing decision to ventilate or not. And you will have to decide at a time when you are least able to do so, when you are very sick and perhaps not thinking clearly.

Your doctor can help you decide but it’s not a purely medical decision. These are highly personal decisions affecting your future quality of life.

As difficult as it may be, you should give advance directions regarding invasive treatments.

As I watched my wife die of breast cancer seven years ago, the need for such directions became painfully clear. She had signed a “do not resuscitate (DNR)” order. It instructs health care providers not to do cardiopulmonary resuscitation (CPR) if her breathing stopped or her heart stopped beating. She died without any of those interventions.

When I talked to my doctor shortly after her death about a DNR order for me, he was concerned; worried about my apparent preoccupation with imminent death when I seemed perfectly healthy.

The best chance that a DNR will be honoured is if you have talked to your doctor and family. But kids have trouble dealing with their own mortality, let alone yours.

In our culture where talk of death ends a conversation, it’s easier not to start the conversation.

I would not consider a life hooked up to tubes, or bed-ridden with recurrent infections, worth living but I procrastinate in getting a DNR order.

One day when I’m least capable making the decision, I’ll probably regret my procrastination.

 

SARS reaction out of whack, but it does serve as a warning

“It’s bioterrorism without bioterrorists,” says Michael Bliss, professor of history at the University of Toronto.  He was referring to the recent SARS scare in Canada.  Reminiscent of September 11, 2001, North America was terrorized by an external force – – this time a deadly foreign microbial agent.

sars

The disease with the redundant name, Severe Acute Respiratory Syndrome, resulted in terror beyond reason.  Although it killed 23 Canadians, other respiratory infections kill far more. What was it about SARS that had the ability to generate such fear?

Other biological attacks since September 11 have been home-grown.  The Anthrax scare, for example, originated through letters sent in the U.S. mail.

Like the Anthrax scare in the U.S., a relatively small outbreak in Canada created national panic. Of the 11 Americans infected by Anthrax inhalation, 5 died.  Most of the Canadian SARS victims were already weakened by underlying medical conditions.  SARS may be as common as the common cold and Anthrax is not contagious. But that didn’t diminish the terror.

Other severe respiratory infections kill more.  Why weren’t we more concerned that 8400 Canadians died last year from pneumonia,  760 from  influenza and 125 from tuberculosis?  The SARS scare cost our economy millions, threw thousands out of work in restaurants, hotels and the airline industry.  The reputation Canada’s biggest city – – Toronto the Good – – was sullied.

That’s the nature of terror.  Terror creates unreasonable fear.  Fear strips away the veneer of civilization and we revert back to primal reflexes.  We hide in fear.  We blame foreigners for our misfortune.  We superstitiously cling to misconceptions.

The front line of public health protection barely held.  The cuts to funding for health care that were initiated by former federal finance minister Paul Martin in the early 1990s almost did us in.  By the time that SARS was under control, public health was breaking down.  Nurses were burnt out and resigning.  If the SARS infection had a slightly stronger foothold, we would have lost the war.

Health care has been cut to the bone.  There is no surplus capacity for the unexpected.  We have been seduced by politicians into thinking we can reduce deficits by cutting health care.

It’s a similar naiveté that befell North America prior to September 11, 2001.  Terrorism, like infectious disease in the majority world,  is supposed to happen elsewhere.  One million children die world-wide each year from a preventable infectious disease, measles, according to the international agency Doctors Without Borders.  Do we care?

It’s not supposed to happen here.  So, when a few dozen Canadians die from a mysterious disease, all hell breaks loose.  The deaths of thousands that resulted from the attacks on New York and Washington were tragic but the frenzied reaction was out of proportion.  Thousands of Afghanis were collateral damage in the U.S. cleansing of the Taliban.  But the deaths of thousands of foreigners was met with a shrug.

Our public health care workers heroically gave their lives in fighting the SARS.  They demonstrated the same spirit of public dedication as the firefighters who climbed the stairs of the doomed World Trade towers on September 11.  As those rescuers climbed up, office workers ran down to safety.

As our doctors and nurses treated the sick and dying they became infected by those they tried to cure.  Some died of the disease given to them by patients.  Unlike New York Mayor Rudolph Guilliani, no politician stepped forward to give a voice to public heroism and Toronto’s sick and dying.

There were no grand funerals for Canada’s fallen health care heroes.  No politicians stood in line to eulogize doctors and nurses. No monuments have built to their dedication.

While the threat to public health and safety brought out the best in health care workers, it brought out the worst in others.  Some Canadians shunned fellow citizens because they looked Asian.  Some infected Canadians selfishly refused to quarantine themselves and spread their misery to others.

North Americans better get used to biological and political terrorism made easy by globalization.  Capital moves at the speed of light down an optical fiber, and bio-terrorism and terrorists move at jet speed.

SARS should serve as a wakeup call to those politicians who would cut health care funding further.  Next time,  our first line of public health defense might not hold.