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Ideal living will includes detailed instructions for care

By Keith Roach, M.D. on

DEAR DR. ROACH: At what point in COVID-19 does a person's do not resuscitate order become an issue? When does treatment become an "exceptional or extraordinary" effort? It would seem that organ transplants, if not coma/prolonged artificial ventilation would qualify. I have never seen anything on this issue. -- R.S.

ANSWER: A do not resuscitate order is not one-size-fits-all. Ideally, a person considers carefully what they want and, with the help of an expert, writes up a document (called a "living will") to go over how that relates to a variety of circumstances.

Since it's impossible to consider every possible situation, it is also wise to discuss your feelings with a designated person who becomes a patient's health care proxy through a document called a "durable power of attorney for health care." This person can then help the team of doctors and others taking care of the patient in situations not specifically addressed by the living will. A living will may also specify that a person would want everything medically appropriate done, except in the case that they have been diagnosed with a serious or terminal disease.

In the case of COVID-19, many people who have contracted the infection have preexisting health conditions that have made them vulnerable, and have a living will indicating they don't want "exceptional or extraordinary" care. There are many other terms used, such as "heroic," but again, it is best to identify which specific interventions a person would or would not want. For some people, this can even include tube feedings, antibiotics and intravenous fluids.

However, many people with COVID-19 infection are healthy, young people. In these cases, we usually try absolutely everything we can, since some people, even among the very most ill, will pull through. This includes placing a breathing tube (intubation of an endotracheal tube) and the use of a ventilator (also called respirator). Very ill people are turned onto their stomachs (called a prone position), as this helps the lungs, and survival is better.

One of the very last resorts we have is extracorporeal membrane oxygenation (ECMO), which is a machine that essentially takes over the lungs' job of oxygenating blood. People placed on ECMO for severe COVID-19 infection still have a 50% risk of in-hospital death, but that's much better than odds without this treatment. Another last-ditch treatment is lung transplantation: This also saves some lives, but is a precious resource that many will not qualify for, nor have an organ available for at the time of need.

Someone with COVID-19 infection and a typical do not resuscitate order would still be treated with the best medications and support we have, but would usually be allowed to pass away rather than be placed on a ventilator, and would certainly not get the truly heroic measures, such as ECMO or lung transplant.

 

One of my colleagues recently wrote that many of the patients she has taken care of, just before intubation, ask to get the vaccine. It is too late at that point. Hospitalization for COVID-19 infection, with its risk of intubation and death, can be prevented in more than 90% of cases by vaccination when a person is still well. If you haven't gotten vaccinated, please get an appointment to do so today. The doctors, nurses, respiratory therapists and all the team members in the hospital in ICU would rather not see you there.

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Dr. Roach regrets that he is unable to answer individual letters, but will incorporate them in the column whenever possible. Readers may email questions to ToYourGoodHealth@med.cornell.edu or send mail to 628 Virginia Dr., Orlando, FL 32803.

(c) 2021 North America Syndicate Inc.

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