What If We Don’t Flatten the COVID-19 Curve?

On April 5, 2020, US Surgeon General Jerome Adams said, “The next week is going to be our Pearl Harbor moment. It’s going to be our 9/11 moment.” The same day Dr. Anthony Fauci, arguably our most trusted spokesperson during this coronavirus crisis, said, “We’ve got to get through this week that is coming up because it is going to be a bad week.” One oft-cited set of projections showed deaths from COVID-19, the illness caused by the novel coronavirus, and resource use (including ICU beds and ventilators) were expected to peak this weekend. That all of this is happening during Easter and Passover only adds to the sorrow.

For those of us in Texas, the wait to peak is a bit longer. Estimates a week ago were for peak resource use on May 6, 2020, but that prediction has now moved up to April 22, with peak in daily deaths on April 24. Texas appears to be flattening the curve. In Angelina County, we have 16 confirmed cases of COVID-19 as of April 9, but only 283 people have been tested so far. We can only hope that the wise and early decisions by our local elected officials, including the Stay Home – Stay Safe order, will have flattened our curve enough to avoid the healthcare crisis experienced in New York, New Orleans, and other cities.

But what if our hopes are unfounded? What if we get a surge of COVID-19 cases beyond what our healthcare system can handle? In New York City, some COVID-19 victims could be temporarily buried in mass graves in a park, as morgues don’t have the capacity to handle the mounting casualties.

Thankfully, doctors across the nation have been giving much thought to this grim prospect. After the 2003 SARS outbreak, North Texas physicians came together to answer that very question: What would they do if a really big pandemic hits and hospitals are overwhelmed? The result was the formation of the North Texas Mass Critical Care Council. The council established that during a time of crisis, the ethical, moral, and medical approach should be that “access to treatment would be based upon the patient’s ability to benefit from it, using objective physiologic criteria.” In other words, medical evidence – rather than insurance status, social standing, what have you – would guide decision-making about which patients are most likely to benefit from ICU interventions when there are not enough ICU beds or ventilators for every patient. The goal – as it should be in any medical crisis – is to save “as many lives as possible.”

In a similar fashion, CommonSpirit Health, the Catholic health system that is the second-largest nonprofit hospital chain in the US (and the parent of CHI St. Luke’s Health Memorial Lufkin), developed Crisis Response Guidelines for Hospital and ICU Triage Allocation. These guidelines are not based on opinion or guesswork. The many criteria used to prioritize who would benefit from ICU and ventilator support are validated in the medical literature and have been compiled to arrive at a robust sequential organ failure assessment (SOFA) score, based on the degree of dysfunction or failure of the heart, lungs, liver, kidneys, brain, and blood system. This SOFA assessment, well known to emergency and intensive care specialists, is used routinely to predict mortality in any critically ill patient.

Based on SOFA scores and other medical criteria, doctors might determine that an elderly patient with COVID-19 whose organs are functioning well is more likely to recover using a hospital ventilator than a young patient with multiple organs shutting down from the virus, but the decision would be based entirely on whether the treatment is likely to help the patient recover. Doctors are expressly prohibited from considering social status, money or other nonmedical criteria when making these decisions. The last thing doctors want to be accused of is indiscriminately playing God.

A recent Wall Street Journal opinion implied that merely considering apocalyptic scenarios would lead to legalizing euthanasia, and that not having guidelines (and thereby wasting resources on those that would not benefit) was morally superior to sound medical decision making. Texas Health and Safety Code §166.009 acknowledges that sometimes difficult choices have to be made and states that provision of life-sustaining treatment is not required if it “cannot be provided to a patient without denying the same treatment to another patient.” There is a larger problem of futile care in this country that did not start with the coronavirus pandemic and it won’t end once this virus is under control.

Crisis guidelines are not written to decide who lives and who dies; they help direct the most aggressive care to those who are most likely to benefit so that the most lives can be saved. Regardless, all patients are to be treated with dignity and receive appropriate and compassionate care. If I, as a physician and community leader, have little to no chance of survival if placed on a ventilator – based on solid medical criteria – but an illegal immigrant (for example) has a good chance of survival, guess who gets the ventilator? Not me. And that is the way it should be.

We must continue to follow the social distancing recommendations of our city, county, and health district leaders in order to minimize the impact of the coronavirus locally. We can do this – we ARE doing this. As the Lufkin/Angelina County Chamber of Commerce is encouraging us, we are #BetterTogether and #AngelinaStrong.

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.

How and Where People Die – Is it Good?

All of us, at some point, have pondered what it means to have a “good” death. A common theme is to fall asleep in one’s own bed and simply not wake up. Woody Allen famously said, “I’m not afraid of death; I just don’t want to be there when it happens.” The underlying desire is comfort, serenity, peace.

According to the Centers for Disease Control (CDC), the top ten causes of death in the United States in recent years were heart disease, cancer, accidents, lung diseases, stroke, Alzheimer’s disease, diabetes, influenza and pneumonia, kidney disease, and suicide.   These top ten account for three out of four deaths, and most are chronic diseases marked by decline over years with increasing need for medical care and hospitalization along the way. Yet all along there is this denial of illness and death.

We used to be familiar with death. Before the 1940s – prior to antibiotics, chemotherapy, heart surgery – people usually died in their homes over the course of a few days or weeks.  Sir William Osler, frequently described at the Father of Modern Medicine (d. 1919), called pneumonia – a leading cause of death in his time – the “friend of the aged” because it was an “an acute, short, not often painful illness.”  With the advent of the intensive care unit (ICU) and an ever-expanding medical-industrial complex, we now have approximately 4 million ICU admissions per year and about 500,000 ICU deaths annually.  The contrast between death at home versus in a technology-overrun ICU could not be more stark. In 2010, 28.6% of Americans died in the hospital.  Yet nine out of ten Americans say they would prefer to die at home if they were terminally ill and had 6 months or less to live. 

Unfortunately, death in the hospital is rarely pretty. Believe me; hospitals do not want patients dying in their facilities. It messes with statistics and quality ratings. It is also far more expensive.  So, if hospitals don’t want us dying there, it costs more money, and we say we would prefer to die at home, where is the disconnect?

There are several problems. Doctors don’t like talking with their patients about death and dying. Doctors don’t want to appear to be giving up hope by talking about end-of-life care, nor do they want to appear helpless, as if nothing more can be done. Patients, having watched one too many TV medical dramas, believe that technology and medicines are so good now that they can overcome any illness, even at the very end of life.

Perhaps the most egregious of these technological and communication disconnects at the end of life is with a procedure called cardiopulmonary resuscitation – the “Code Blue” you hear overhead periodically in hospitals. A code blue is an actual life-threatening emergency situation in which a patient is dying – typically their heart has stopped beating and/or breathing has ceased – and an entire medical team works to revive him/her with medications, chest compressions, intubation, electrical shocks, and more.

Cardiopulmonary resuscitation (CPR) can be life-saving in the community setting when a person suffers a heart attack or drowning, for example. According to 2014 data, nearly 45 percent of out-of-hospital cardiac arrest victims survived when bystander CPR was administered.

For hospitalized patients who suffer cardiac arrest (essentially, who die), the overall rate of survival from a “full code” procedure leading to hospital discharge is barely 10 percent. But most people, when asked in a scientific study, believe the survival rate to be more than 75 percent.  Unfortunately, the quality of life of patients who do survive resuscitation in the hospital is often not good. Rarely do the few survivors return to their previous functional status, which in hospitalized patients was probably poor to begin with. There can be brain damage from prolonged lack of oxygen, bruising and pain from broken ribs, and need for prolonged rehabilitation or nursing home placement.

But unless you – or a family member speaking for you – explicitly states otherwise, this likely will happen to you if you are coded in the hospital. And despite the resuscitation attempt, you will very probably die anyway. Is this really what you want your minutes to look like?

The good news is that we have far more control over where and how we die than one may think. First, talk with your spouse and your kids – and your doctor! – about how you wish to die and where you wish to die if you were to find out you had a terminal illness. Second, make every effort to write your wishes down. In Texas, there is a document called a Living Will available online at https://hhs.texas.gov/laws-regulations/forms/miscellaneous/form-livingwill-directive-physicians-family-or-surrogates. Both English and Spanish versions are available. This Directive to Physicians and Family or Surrogates lets you, the patient, tell your doctors and others what types of treatments you do or do not want if you are terminally ill and no longer able to make medical decisions.

In addition to this advance directive, Texas law provides for two other types of directives that can be important during a serious illness. These are the Medical Power of Attorney and the Out-of-Hospital Do-Not-Resuscitate Order. Don’t wait until a crisis to make your wishes known. It may be too late.

Finally, hospice care is available through Medicare, Medicaid, and most private insurers to help patients achieve the “good” death they say they want, not by hastening death, but by helping terminal patients to fully live the life they have left as comfortably as possible and most often at home.