End-of-Life Implications of the Coronavirus Pandemic

We are early in this coronavirus game of social distancing and hand washing. We haven’t quite become weary of it. We joke about it. And yet, I am starting to see – among my friends – some very real concern about our elder parents and grandparents. But we don’t allow ourselves to linger on those thoughts much. We should.

The United States has been accused of being late to respond to the coronavirus pandemic, late to test our US population compared to other countries (South Korea, for example), and “doomed” in our response. Even so, we are just beginning the initial rise of the now well-known bell curve of the Coronavirus Disease 2019 (COVID-19) pandemic. Known cases are doubling every day, it seems. Deaths are increasing as well.

As a cancer physician with additional hospice and palliative medicine (end-of-life care) certification, I view the coronavirus pandemic with increasingly darkened lenses. Coronavirus is a new and immediate threat to life, and we are not ready for what that means. If we don’t succeed in slowing the spread of coronavirus and suppressing new cases – now widely known as flattening the curve – 2.2 million people in the US could die. We are not talking openly – publicly –about how we are going to handle this massive number of deaths with COVID-19.

If the coronavirus epidemic is as bad as some predict it will be, discussions about end-of-life care with this disease will soon become front and center. There may not be enough ventilators for everyone who “needs” ventilator support. Italy has been forced to triage sick coronavirus patients based on age, given that the death rate among the elderly is so high. Italian doctors have admitted that there were simply too many patients for each one of them to receive adequate care. They describe a “tsunami” of patients and a more than 7% death rate (though researchers have lowered the calculated death rate in Wuhan, where the pandemic started, to 1.4%). Preliminary outcomes of patients with COVID-19 in the US show death is highest in persons aged ≥85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years.

The Italian society of anesthesiologists issued fifteen recommendations of ethical and medical criteria to consider if ICU beds are exhausted, saying doctors may have to adopt more wartime triage criteria of gauging who has the best chance of survival versus “first come, first served.” Those who are chronically ill with pre-existing lung disease, even if they survive a serious coronavirus infection, are likely to be left with even further reduced lung function and poorer quality of life.

Unlike a localized disaster – most memorably Hurricane Katrina, in New Orleans in 2005, where healthcare decision-making received intense scrutiny and prompted legal action – we are experiencing a global, acute healthcare emergency that may require historic moral and ethical decisions that impact who lives and who dies. We will be rationing healthcare on the fly. Are we ready for that? As family members? As a community? As a nation? Are our hospices ready for the number of patients needing immediate, short-duration, and contagion-related end-of-life care?
Perhaps the most terrifying aspect of the coronavirus epidemic in countries where death has become frighteningly common is the loneliness of the death. Hospitals in the US are already limiting or even forbidding visitors. In Italy, seriously ill coronavirus patients are isolated from family and often die alone. Families are not allowed to have a proper burial, and not just due to restrictions on gathering – morgues have an enormous backlog to work through. That is certainly not what we would call a “good death” and not what those of us in the hospice care field want for any patient.

Trump has labeled himself a wartime president, declaring we are at war with an invisible enemy. "Now it's our time. We must sacrifice together, because we are all in this together, and we will come through together," he said. What is not stated – and what I am afraid will happen – is the wartime sacrifice analogy will extend to real lives lost. In an ironic twist of fate, it very well may be that the remnants of the Greatest Generation are once again on the front lines. Even down to the Baby Boomers, our nation’s elders will bear the brunt of the coronavirus disease, certainly, but likely the financial catastrophe surrounding the pandemic as well. (I wonder if the economic collapse will kill as many or more people than coronavirus does.)

The time is now to have discussions with our older/elderly parents and grandparents about the very real risk of serious illness and death from COVID-19. Wills need to be written and advance directives and durable powers of attorney completed now – before our loved ones hit the hospitals. This is not morbid; it is both pragmatic and necessary. If we emerge from this battle relatively unscathed, we are no worse off for having had the discussions and done the planning. Patients and families should be driving end-of-life care decisions. We owe it to our hospitals and healthcare workers not to overburden the system with trying to care for those who neither want nor would benefit from aggressive measures.

DETCOG, Broadband and Health

Can you hear me now? That phrase, made popular by Verizon Wireless in the early 2000s, epitomizes the frustration of rural America over lack of reliable cell phone coverage. To this day – despite what cell phone carriers like AT&T, Sprint, and Verizon advertise – coverage in many areas (including at my house inside the Lufkin, Texas city limits) is suboptimal. AT&T’s answer? Just use WiFi calling! That may work for me; I have adequate internet access. But what about the majority of deep East Texans? More than just being an inconvenience, poor cell phone coverage and inadequate broadband access are harming our health.

Broadband is the infrastructure and information technology network that delivers high speed connectivity to the internet. Think of broadband as a pipeline of information. As with any pipeline, the rate of flow (water, gas, data, etc.) can depend on the number of users, time of day, and reliability of service. But you have to be able to connect to the pipeline.

In the early days, the internet was accessed through slow, often expensive dial-up connections. Today, high speed or broadband internet access is via DSL (or Digital Subscriber Line), fiber-optic, wireless, cable, and satellite services, often bundled with phone and TV subscriptions.

Broadband access is about more than faster access to Facebook and Instagram. Increasingly, reliable and high-speed internet access is important for community health. The Federal Communications Commission (FCC), which is responsible for regulating the radio, television and phone industries, established a Connect2HealthFCC Task Force to raise consumer awareness about the value of broadband in the health and care sectors. You may know about heart-healthy diet and recipe apps and wearable fitness trackers, but did you know that we now have medical devices like pacemakers, defibrillators, glucose monitors, insulin pumps, and neuro-monitoring systems that can utilize wireless technology to control or program a medical device remotely and monitor and transmit patient data from the medical device to the healthcare team? Those without internet access can get delayed and inadequate care.

Maps showing lack of broadband coverage look just like maps of poor, rural America where healthcare is also lacking. In Kentucky, for example, the same areas where higher rates of lung cancer are seen are those with limited broadband access. These county-by-county maps are similar to what we see in deep East Texas with cancer deaths and health outcomes. This does not mean that lack of broadband access causes lung cancer, obviously! But the social determinants of health (such as education level and income) that are associated with smoking, lung cancer, heart disease, obesity, and overall health outcomes, are more pronounced in areas with limited broadband access.

So how could access to broadband increase the health of a community? The FCC believes that “broadband-enabled technology solutions can help us meet the health and care challenges of today and tomorrow by connection people to the people, services and information they need to get well and stay healthy.” Possible solutions that are especially important in deep East Texas include telehealth and telemedicine for improved access to physicians and specialists (including mental health services), health information technology and access, fall detectors, pharmacy connectivity, personal health data upload capability, and connectivity to hospitals and emergency rooms. With a growing and aging population compounded by a shortage of primary care physicians nationwide estimated in the tens of thousands –especially pronounced in rural areas – remote connectivity options for healthcare become even more important.

The Deep East Texas Council of Governments (DETCOG), under the leadership of Executive Director Lonnie Hunt, recently received a report titled Deep East Texas Broadband Growth Strategy, which detailed the potential economic growth (10,300 new jobs and $1.4 billion in GDP growth over 10 years) and growth in median household income associated with near complete broadband access, a loft goal. In IT, education, and telehealth alone, investments have the potential to impact the region with 2,500 jobs and $300 million in GDP over the next ten years.

DETCOG’s goal is to support development of a regional fiber optic-based broadband network throughout its twelve-county region. They hope to do this through creation of a non-profit or other entity that would manage the project, bring the necessary partners together to accomplish the goals, and oversee planning, financing, and implementation of the regional broadband network. Full implementation realistically will cost hundreds of millions of dollars. But it doesn’t have to all come at once.

In February, with support from the TLL Temple Foundation, DETCOG started the process to contract with a major law firm with offices in Washington, DC, to create an entity to manage broadband in East Texas. Funding such an entity and project will not be easy. Other COGs have tapped into grants like the FCC’s Rural Health Care Program, which provides funding to eligible health care providers for telecommunications and broadband services necessary for the provision of health care. Electric and telephone cooperatives, public utilities, internet providers, local, state, and federal entities, and foundations can and should play a role.

Do you hear me now? We must support DETCOG’s vision for a fiber optic network for all of deep East Texas. This will be a long term project requiring many players, both public and private, to accomplish. We need – we must have – high-speed broadband access in our entire region for jobs, for the economy, and for our health.