UW - Code Status and COVID-19 Patients
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While much remains unknown about COVID19, particularly regarding its impact in the US population, it is clear the disease is often deadly in elderly patients with co-morbid illness. Care is largely supportive, to include oxygen and respiratory, including ventilator, support. Despite full supportive efforts, many critically ill patients with COVID19 will die, generally of multiorgan failure.
All studies and reports regarding COVID19 note an increased mortality associated with both increasing age and the presence of comorbidities including hypertension, diabetes, and coronary artery disease. Respiratory failure portends a poor prognosis. A retrospective cohort study from Wuhan, China of 191 seriously ill patients with confirmed COVID19 disease reported only a single survivor among 32 patients who received mechanical ventilation. https://www.thelancet.com/pb-assets/Lancet/pdfs/S014067362305663.pdf
The survival to hospital discharge for all critically ill patients receiving CPR is very low (<15%), with already being on mechanical ventilation, older age, and co-morbidities reducing that likelihood even further. https://www.atsjournals.org/doi/full/10.1164/rccm.200910-1639OC. As such, CPR may be medically inappropriate in a significant portion of elderly, critically ill patients with COVD19 and underlying comorbidities.
The COVID19 pandemic also poses a significant public health risk. Like other infectious diseases such as MRSA or TB, providing CPR to COVID-19 patients poses risks to first responders and healthcare personnel, who must don personal protective equipment (PPE) to safely attempt resuscitation. Donning PPE may mean a delay initiating CPR in COVID19 patients, however this delay is necessary to protect the healthcare workforce, other patients in their care, and the public.
In addition, both COVID and non-COVID critically ill patients may need resources that have become scarce due to the pandemic, including healthy healthcare personnel to perform CPR. Therefore, the advice below applies to both COVID19 and non-COVID19 populations. Early goals of care discussions are strongly recommended for all patients with terminal or life-threatening illnesses.
Per UWMC and HMC DNR and Withholding & Withdrawal policies, clinicians are NOT obligated to offer or provide medically inappropriate treatment, even when requested by patients and/or designated surrogates. If treating clinicians, including more than one physician, determine that CPR is not medically appropriate, a Do Not Attempt Resuscitation Order (DNR) may be written without explicit patient or family consent. In all cases, however, the patient and/or appropriate surrogate should be informed of this decision, along with the rationale in support. Patient or family “informed assent” should be sought but is not required. For patients who are found to be alone and without an identifiable surrogate, a unilateral DNAR may be written when a patient without decisional capacity presents alone and meets the criteria outlined above, provided reasonable efforts are made to locate and discuss with family. Expert, compassionate communication with patient/family is necessary.
Potential language/points to share with family when CPR is deemed medically inappropriate:
- We are providing the best care available to help your loved one. [Talk about what you are doing for them.] We think that this coronavirus infection along with their previous medical conditions means s/he is unlikely to survive CPR. Under these circumstances we do not provide CPR, but we will continue to do x, y, z.
- We are sorry to share that we believe your loved one is dying. (when applicable) We still care about him/her and are caring for him/her. Here’s how: . . .
- Under these circumstances we do not provide CPR, but we will continue to provide treatments x, y, z We want to make sure you understand this decision and have the opportunity to ask any questions that you have.
Authors: Mark Tonelli, MD, Denise Dudzinski, PhD, James Fausto, MD, Randy Curtis, MD, James Kirkpatrick, MD
COVID-19 Code Status FAQ:
Have we changed our Do Not Attempt Resuscitation (DNR) practice/policy for COVID-19 patients?
DNR should be discussed/considered when CPR is unlikely to be beneficial based on clinical assessment and/or patient wishes, regardless of which life-threatening illness the patient has. It would be discriminatory to make a blanket DNR policy based solely on diagnosis, rather than basing decisions on CPR’s likelihood of benefit. We recognize that COVID-19 becomes a life-threatening illness quickly for some high-risk patients, and end-of-life care planning may need to occur swiftly. For those patients, we have provided the following guidance around DNR, in keeping with hospital policies.
How are we balancing patient/family requests for CPR with staff safety?
In addition to patient care, one of our highest ethical obligations is to protect our staff, both for their own sakes and for their ability to continue to care for patients. In this pandemic, each code puts our staff at risk of COVID-19 infection and requires scarce PPE resources. While other infectious diseases like TB require the same protection, this pandemic introduces a large number of infectious patients needing our care at the same time. Under normal circumstances, if a terminally ill patient or their family were reluctant to accept our recommendation for DNR, we would give them more time. The COVID-19 outbreak influences DNR decisions because we will need to make code status determinations earlier to ensure that we do not perform medically inappropriate codes. Any patient, COVID-19 or not, for whom clinical assessment suggests CPR is unlikely to be beneficial should have a DNR. Early goals of care discussions are encouraged.
If we have a lot of sick COVID-19 patients, we won’t have enough ventilators or beds in our ICUs. How are we planning for that possibility?
Right now our hospitals are running under ‘contingency capacity’, meaning we provide usual standards of care while doing everything we can to stave off a crisis like Italy is facing. All healthcare institutions, including UW Medicine, are actively pursuing ways to increase their surge capacity in order to maintain standard of care for all of our patients.
Our goal is to never reach a crisis. If we do, ICU beds and ventilators may become a scarce medical resource that must be carefully allocated in order to maximize benefit for the greatest number of people. If we reach that point, decisions about who receives ICU-level care will be based on guidance from healthcare authorities. Locally, triage teams will aid in the allocation of scarce resources at a patient level. We are currently drafting and reviewing crisis planning that will go into effect only IF other measures to prevent a crisis are not enough.
How will we know when we’ve gotten there?
Ideally, the decision that we have reached a point where crisis standards of care apply will be made by the local and/or state health authorities. UW Medicine’s Incident Command Medical Technical Specialist Lead, Dr. John Lynch, will inform the staff if we have reached that point.