The COVID-19 pandemic has affected almost every facet of our lives. For many, the pandemic has forced us also to consider our own mortality.
As a pulmonary and critical care physician, I often make decisions about life and death on a daily basis, but the current situation is unlike any I have faced before. Early in my career, the AIDS epidemic was just evolving and decisions regarding what lifesaving measures to offer to whom were being questioned as never before. As a medical resident in the late 1980s, I recall being gently admonished for placing a young AIDS patient with pneumonia in the intensive care unit on a ventilator by a senior physician who asked, “Why would you do that? There is nothing to offer him.”
As we did then, we now are facing a new viral infection with limited treatment options. With the AIDS epidemic, the issue was lack of treatment for a then-untreatable disease. The coronavirus pandemic has brought the threat of limiting care due to a lack of effective treatment and a potential lack of resources, as well as the risk of spreading disease to those who are trying to heal others.
Reports have emerged from Europe and Asia of patients who have not been offered advanced life supportive care such as admission to the intensive care unit, ventilator support or even admission to the hospital due to an overwhelming crush of COVID-19 patients.
A recent editorial in The New England Journal of Medicine discussed the fair allocation of scarce medical resources in the current pandemic. The piece endorsed, if necessary, the prioritization of saving the most lives and years of life, making it acceptable to remove a patient from the intensive care unit to provide room for others with a better outlook, and even the use of a lottery to decide who might get care between two individuals with a similar prognosis.
As of this writing, nowhere in the United States have we had to face such difficult decisions. But even locally, contingency plans are being formulated for such a situation. While we hope that the pandemic does not worsen to the point that it outstrips our resources, there are important discussions that we all can have now regarding what we want regarding our health care, in the event that we fall ill and cannot speak for ourselves.
Advanced care planning is the sharing of preferences and individual goals for how one would wish to be treated medically in the event of illness, injury or with advanced aging. Identifying the individual who will make health care decisions for you when you cannot is the first step to this process. This is someone whom you trust to follow your wishes, even if it might conflict with their own. It may be a spouse, partner, loved one, family member or even a friend.
Next is sharing with that person the things that make life worth living and the things you would not want to live without. An understanding of what living well means to you is crucial in that person’s ability to make decisions for you. This might include discussions regarding the limits of care; for example, whether you would want to be resuscitated in the event of cardiac arrest or whether to be placed on a mechanical ventilator to assist with breathing if your lungs fail. From this, an advanced directive can be completed — a written document identifying the decision-maker and outlining your wishes in the event that you cannot decide for yourself.
While advanced care planning might sound intimidating, there are resources that can help. Honoring Choices Virginia (https://honoringchoices-va.org/) is a collaborative effort started by the Richmond Academy of Medicine and local health systems to offer advanced care planning. During the COVID-19 pandemic, virtual advanced care planning clinics are being offered. Other online resources include the Conversation Project (https://theconversationproject.org/) and PREPARE for Your Care (https://prepareforyourcare.org/).
During this troubling time, it is helpful to remember what Dr. Atul Gawande wrote in his beautiful book, “Being Mortal”: “Our ultimate goal, after all, is not a good death but a good life to the very end.”