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The last line in the sand

/ 07:00 AM April 01, 2021

As the COVID-19 surges and overwhelms the healthcare system, what are the chances of surviving or dying when hospital beds are no longer available, breathable air is running out, and the HCWs – the ones left – are beside themselves staring helplessly at life as it fades away? What choices are there to be made? What difficult conversations must we finally have?

Dr. Jose Emmanuel Martin Palo, director of the Acute and Critical Care Institute of The Medical City, writes about the hardships and the burden they carry and why it is about time “to have a frank conversation” with the patients as well as those in the frontlines “about what to expect when fighting the disease at its worst, and about choosing how or even when to fight.”

Last year, already in the thick of the pandemic crisis, one of our unpublicized initiatives was “The Last Ventilator” project. A multidisciplinary group of medical leaders, acute care specialists, palliative care experts and ethicists worked on policies to guide frontline clinicians on how to assign the very last life-saving breathing equipment when there was more than one candidate. We examined the practices of other countries, statements from relevant organizations, searched our own organizational and personal values before finalizing the guidance.

Lines in the sand The Medical City covid-19 hospital ICU

Photo by The Medical City Media and Communications Division

We never had to activate the policy. But there were echoes of these kinds of terrible choices that still reached us: a family choosing which parent to devote resources to and attempt to save, a ventilator being disinfected for reuse after being promptly disconnected from a patient whose family had chosen to discontinue life support. Much is written about the loneliness of hospitalization and the all-too-common possibility of dying among strangers. There is less that is written about an organization or a clinician who needs to choose which person to try to save – or the consequences of those choices. It is easy to imagine what happens to the patient, but not to the family or the clinician that makes these choices.

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“Much is written about the loneliness of hospitalization and the all-too-common possibility of dying among strangers. There is less that is written about an organization or a clinician who needs to choose which person to try to save – or the consequences of those choices.”

A year in, and we are facing a surge that far outstrips our capacity to serve. The assignment of the last invasive ventilator is not even the relevant question anymore – it is the assignment of the last bed that can be used to administer oxygen. Patients with pneumonias are being turned away from many hospitals even at the emergency departments. As director of Acute and Critical Care and a practicing intensivist, my greatest fear is now true: we will fail our mission to save many of the save-able. So, I feel, besides making the common appeal to practice the most basic of self-protections against COVID-19 disease, it is time to have a frank conversation with the patients my team serves, as well as our colleagues in the frontlines – about what to expect when fighting the disease at its worst, and perhaps, about choosing how or even when to fight.

When COVID-19 ravages a body, the first indication of serious disease is a failure of the respiratory system. Besides the administration of steroids and special drugs to try and tame inflammation, respiratory support requires increasing amounts of oxygen, then oxygen under pressure, then mechanical ventilation in various modes. Some patients are ventilated prone, some are medically paralyzed, and the worst even require oxygenation of their blood outside their body in special heart-lung machines. Many have problems with blood pressure regulation requiring continuous infusions of adrenalin-like drugs and many have kidney failure needing dialysis. It requires a team of experts and all of the critical care armamentarium to fight it in this form. And it is really, really hard to win. Each step is more invasive than the one before, and yet deterioration is common, sudden, and too frequently fatal. The word I use to describe this disease is “traitorous.” I have been able to inquire after a few survivors, asking about how they did after their ICU stays. There aren’t many to follow-up with. 

“It is time to have a frank conversation about what to expect when fighting the disease at its worst, and perhaps, about choosing how or even when to fight…
We found that less than 1 out of 6 of those above 75 makes it out of the ICU. And that no one above 80 had done so.”

Recently, the Society of Critical Care Medicine released the results of their global registry, comprised of more than 20 000 patients with COVID-19 disease requiring some form of life-saving organ support. In it, we find that almost half of patients that require a ventilator die. And less than a third survive if requiring additional forms of support. This reflects our own early experience, but besides this, we found that less than 1 out of 6 of those above 75 makes it out of the ICU. And that no one above 80 had done so. This, in spite of the resources of the most advanced ICU in the Philippines, that is equal to any abroad. This, in spite of the unavoidable suffering that we hope is only temporary in the fight for survival. 

In the face of this, it is not right to continue to offer advanced care for all. The value of critical care lies in saving those who would die without advanced care, and we find here that for many of our frailest elderly it did not make a difference. 

Therefore, choosing to limit invasive care in favor of comfort care and dignified palliation is a path that can be chosen. Instead of the machines and medicine to support failing organs, medicines to take away the breathlessness and pain. Instead of the hospital, home when possible. Instead of doctors, nurses and other strangers, family. This is a different kind of “hard” – and many will have a difficult time accepting such an idea. Many of us in healthcare are all too often driven by a need to do “all that can be done” even absent a valued outcome. But I suspect that patients themselves would like to have control over their choice of strategy. 

“…Choosing … instead of the machines and medicine to support failing organs, medicines to take away the breathlessness and pain. Instead of the hospital, home when possible. Instead of doctors, nurses and other strangers, family”.

So, this is a call for everyone to start having these difficult conversations, to define for ourselves what is most important to us, and the lines in the sand we do not wish to cross. To say, “I will go this far, but no further.” And to let our loved ones know. Because too many are stricken and lost without even the opportunity for clarity, and we are far from the end of this continuing tragedy.

It is very, very hard to win. For those that choose to fight, we at the EDs and ICUs will continue to do our work, to the best of our ability and for as long as we are able. But for those that choose a gentler path, the acceptance of human limits and our common mortality may not mean losing at all.

ADVT.

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