Hos­pi­tals de­bate do-not-re­sus­ci­tate or­ders over fears for staffers’ health


Hos­pi­tals on the front lines of the pandemic are en­gaged in a heated pri­vate de­bate over a cal­cu­la­tion few have en­coun­tered in their life­times — how to weigh the “save at all costs” ap­proach to re­sus­ci­tat­ing a dy­ing pa­tient against the real dan­ger of ex­pos­ing doc­tors and nurses to the con­ta­gion of coro­n­avirus.

The con­ver­sa­tions are driven by the re­al­iza­tion that the risk to staff mem­bers amid dwin­dling stores of pro­tec­tive equip­ment — such as masks, gowns and gloves — may be too great to jus­tify the con­ven­tional re­sponse when a pa­tient “codes,” and their heart or breath­ing stops.

North­west­ern Me­mo­rial Hos­pi­tal in Chicago has been dis­cussing a do-not-re­sus­ci­tate pol­icy for in­fected pa­tients, re­gard­less of the wishes of the pa­tient or their fam­ily mem­bers — a wrench­ing de­ci­sion to pri­or­i­tize the lives of the many over the one.

Richard Wun­derink, one of North­west­ern’s in­ten­sive-care med­i­cal di­rec­tors, said hos­pi­tal ad­min­is­tra­tors would have to ask Illi­nois Gov. J.B. Pritzker for help in clar­i­fy­ing state law and whether it per­mits the pol­icy shift.

“It’s a ma­jor con­cern for ev­ery­one,” he said. “This is some­thing about which we have had lots of com­mu­ni­ca­tion with fam­i­lies, and I think they are very aware of the grave cir­cum­stances.”

Of­fi­cials at Ge­orge Wash­ing­ton Univer­sity Hos­pi­tal in the Dis­trict say they have had sim­i­lar con­versa

tions but for now will con­tinue to re­sus­ci­tate covid-19 pa­tients us­ing mod­i­fied pro­ce­dures, such as putting plas­tic sheet­ing over the pa­tient to cre­ate a bar­rier.

The Univer­sity of Wash­ing­ton Med­i­cal Cen­ter in Seat­tle, one of the country’s ma­jor hot spots for in­fec­tions, is deal­ing with the prob­lem by se­verely lim­it­ing the num­ber of re­spon­ders to a con­ta­gious pa­tient in car­diac or res­pi­ra­tory ar­rest.

Sev­eral large hos­pi­tal sys­tems — Atrium Health in the Caroli­nas, Geisinger in Penn­syl­va­nia and re­gional Kaiser Per­ma­nente net­works — are look­ing at guide­lines that would al­low doc­tors to over­ride the wishes of the coro­n­avirus pa­tient or fam­ily mem­bers on a case-by-case ba­sis due to the risk to doc­tors and nurses or a short­age of pro­tec­tive equip­ment, say ethi­cists and doc­tors in­volved in those con­ver­sa­tions. But they would stop short of im­pos­ing a do-not-re­sus­ci­tate (DNR) or­der on ev­ery coro­n­avirus pa­tient. The com­pa­nies de­clined to comment.

Lewis Ka­plan, pres­i­dent of the So­ci­ety of Crit­i­cal Care Medicine and a Univer­sity of Penn­syl­va­nia sur­geon, de­scribed how col­leagues at dif­fer­ent in­sti­tu­tions are shar­ing draft poli­cies to ad­dress their changed re­al­ity.

“We are now on cri­sis foot­ing,” he said. “What you take as first­come, first-served, no-holds­barred, ‘every­thing that is avail­able should be ap­plied’ medicine is not where we are. We are now fac­ing some dif­fi­cult choices in how we ap­ply med­i­cal re­sources — in­clud­ing staff.”

The new pro­to­cols are part of a larger ra­tioning of life­sav­ing pro­ce­dures and equip­ment — in­clud­ing ven­ti­la­tors — that is quickly be­com­ing a re­al­ity here as in other parts of the world bat­tling the virus. The con­cerns are not just about health-care work­ers get­ting sick but also about them po­ten­tially car­ry­ing the virus to other pa­tients in the hos­pi­tal.

R. Alta Charo, a Univer­sity of Wis­con­sin at Madi­son bioethi­cist, said that while the idea of with­hold­ing treat­ments may be un­set­tling, es­pe­cially in a country as wealthy as the United States, it is prag­matic. “It doesn’t help any­body if our doc­tors and nurses are felled by this virus and not able to care for us,” she said. “The code process is one that puts them at an en­hanced risk.”

Wun­derink said that in the 12 days since North­west­ern had its first coro­n­avirus case, all of the most crit­i­cally ill pa­tients have ex­pe­ri­enced steady de­clines rather than a sud­den crash. That al­lowed med­i­cal staff mem­bers to talk with fam­i­lies about the risk to work­ers and how hav­ing to put on pro­tec­tive gear de­lays a re­sponse and de­creases the chance of sav­ing some­one’s life.

A con­se­quence of those con­ver­sa­tions, he said, is that many fam­ily mem­bers are making the dif­fi­cult choice to sign do-notre­sus­ci­tate or­ders.

Code blue

Health-care providers are bound by oath — and in some states, by law — to do every­thing they can within the bounds of mod­ern tech­nol­ogy to save a pa­tient’s life, ab­sent an or­der, such as a DNR, to do oth­er­wise. But as cases mount amid a na­tional short­age of per­sonal pro­tec­tive equip­ment, or PPE, hos­pi­tals are be­gin­ning to im­ple­ment emer­gency mea­sures that will ei­ther min­i­mize, mod­ify or com­pletely stop the use of cer­tain pro­ce­dures on pa­tients with covid-19, the dis­ease caused by the novel coro­n­avirus.

Some of the most anx­i­etypro­vok­ing min­utes in a health­care worker’s day in­volve par­tic­i­pat­ing in pro­ce­dures that send virus-laced droplets from a pa­tient’s air­ways all over the room.

These in­clude en­do­scopies, bron­cho­scopies and other pro­ce­dures in which tubes or cam­eras are sent down the throat and are rou­tine in in­ten­sive-care units, or ICUS, to look for bleeds or ex­am­ine the in­side of the lungs.

Chang­ing or elim­i­nat­ing those pro­to­cols is likely to de­crease some pa­tients’ chances for sur­vival. But hos­pi­tal ad­min­is­tra­tors and doc­tors say the mea­sures are nec­es­sary to save the most lives.

The most ex­treme of these sit­u­a­tions is when a pa­tient, in hos­pi­tal lingo, “codes.”

When a “code blue” alarm is ac­ti­vated, it sig­nals that a pa­tient has gone into car­diopul­monary ar­rest, and typ­i­cally all avail­able per­son­nel — usually some­where around eight but some­times as many as 30 peo­ple — rush into the room to be­gin live-sav­ing pro­ce­dures with­out which the per­son would al­most cer­tainly per­ish.

“It’s ex­tremely dan­ger­ous in terms of in­fec­tion risk be­cause it in­volves mul­ti­ple bod­ily fluids,” ex­plained one ICU physi­cian in the Mid­west, who spoke on the con­di­tion of anonymity be­cause she was not au­tho­rized to speak pub­licly.

Fred Wyese, an ICU nurse in Muskegon, Mich., de­scribes it like a storm:

A team of nurses and doc­tors, trad­ing off ev­ery two min­utes, be­gin the chest com­pres­sions that are part of car­diopul­monary re­sus­ci­ta­tion, or CPR. Some­one punc­tures the neck and arms to ac­cess blood ves­sels to put in new in­tra­venous lines. Some­one else grabs a “crash cart” stocked with life­sav­ing med­i­ca­tions and equip­ment in­clud­ing ep­i­neph­rine in­jec­tors, de­fib­ril­la­tors to restart the heart, and more.

As soon as pos­si­ble, a breath­ing tube is placed down the throat, and the per­son is hooked up to a me­chan­i­cal ven­ti­la­tor. Even in the best of times, a pa­tient who is cod­ing presents an eth­i­cal maze; there’s of­ten no clear-cut an­swer for when there’s still hope and when it’s too late.

In the process, heaps of pro­tec­tive equip­ment are used — of­ten many dozens of gloves, gowns, masks, and more.

Bruno Petinaux, chief med­i­cal of­fi­cer at Ge­orge Wash­ing­ton Univer­sity Hos­pi­tal, said the hos­pi­tal has had a lot of dis­cus­sion about how — and whether — to re­sus­ci­tate covid-19 pa­tients who are cod­ing.

“From a safety per­spec­tive, you can make the ar­gu­ment that the safest thing is to do noth­ing,” he said. “I don’t be­lieve that is nec­es­sar­ily the right ap­proach. So we have de­cided not to go in that di­rec­tion. What we are do­ing is what can be done safely.”

How­ever, he said, the de­ci­sion comes down to a hos­pi­tal’s re­sources, and “ev­ery hos­pi­tal has to as­sess and eval­u­ate for them­selves.” It’s still early in the out­break in the Wash­ing­ton area, and GW still has suf­fi­cient equip­ment and man­power. Petinaux said he can­not rule out a change in pro­to­col if things get worse.

GW’S pro­ce­dure for re­spond­ing to coro­n­avirus pa­tients who are cod­ing in­cludes us­ing a ma­chine called a Lu­cas de­vice, which looks like a bumper, to de­liver chest com­pres­sions. But the hos­pi­tal has only two. If the Lu­cas de­vices are not read­ily ac­ces­si­ble, doc­tors and nurses have been told to drape plas­tic sheet­ing — the seven-mil kind avail­able at Home De­pot or Lowe’s — over the pa­tient’s body to min­i­mize the spread of droplets and then pro­ceed with chest com­pres­sions. Be­cause the pa­tient would pre­sum­ably be on a ven­ti­la­tor, there is no risk of suf­fo­ca­tion.

In Wash­ing­ton state, which had the na­tion’s first covid-19 cases, UW Medicine’s chief med­i­cal of­fi­cer, Ti­mothy Del­lit, said the de­ci­sion to send in fewer doc­tors and nurses to help a cod­ing pa­tient is about “min­i­miz­ing use of PPE as we go into the surge” of peo­ple se­ri­ously ill with the virus. He said the hos­pi­tal is mon­i­tor­ing health­care work­ers’ health closely. So far, the per­cent­age of in­fec­tions among those tested is less than in the gen­eral pop­u­la­tion, which he hopes means their pre­cau­tions are work­ing.

‘It is a night­mare’

Bioethi­cist Scott Halpern at the Univer­sity of Penn­syl­va­nia is the au­thor of one widely cir­cu­lated model guide­line be­ing con­sid­ered by many hos­pi­tals. In an in­ter­view, he said a blan­ket stop to re­sus­ci­ta­tions for in­fected pa­tients would be too “dra­co­nian” and may end up sac­ri­fic­ing a young per­son who is oth­er­wise in good health. How­ever, health-care work­ers and lim­ited pro­tec­tive equip­ment can­not be ig­nored.

“If we risk their well-be­ing in ser­vice of one pa­tient, we de­tract from the care of fu­ture pa­tients, which is un­fair,” he said.

Halpern’s doc­u­ment calls for two physi­cians, the one di­rectly tak­ing care of a pa­tient and one who is not, to sign off on do-not-re­sus­ci­tate or­ders. They must doc­u­ment the rea­son for the de­ci­sion, and the fam­ily must be in­formed but does not have to agree.

Wyese, the Michi­gan ICU nurse, said his hos­pi­tal has been think­ing about these is­sues for years but still is un­pre­pared.

“They made us do all kinds of manda­tory ed­u­ca­tion and fit­tings and made it sound like they are pre­pared,” he said. “But when it hits the fan, they don’t have the sup­plies, so the plans they had in place aren’t work­ing.”

Over the week­end, Wyese said, a sus­pected covid-19 pa­tient was rushed in and put into a neg­a­tive­pres­sure room to pre­vent the virus spread. In nor­mal times, a nurse in full haz­mat-type gear would sit with the pa­tient to care for him, but there was lit­tle equip­ment to spare. So Wyese had to mon­i­tor him from the out­side. Be­fore Wyese walked in­side, he said, he would have to put on a face shield, N95 mask and other equip­ment, and slather an­tibac­te­rial foam on his bald head, as the hos­pi­tal did not have any more head cov­er­ings. Only one pow­ered air-pu­ri­fy­ing res­pi­ra­tor was avail­able for the room and oth­ers nearby that could be used when per­form­ing an in­va­sive pro­ce­dure — but it was 150 feet away.

While he said his hos­pi­tal’s pol­icy still called for a full re­sponse to pa­tients whose heart or breath­ing stopped, he wor­ried any ef­forts would be chal­leng­ing, if not fu­tile.

“By the time you get all gowned up and dou­ble-gloved, the pa­tient is go­ing to be dead,” he said. “We are go­ing to be cod­ing dead peo­ple. It is a night­mare.”

“This is some­thing about which we have had lots of com­mu­ni­ca­tion with fam­i­lies, and I think they are very aware of the grave cir­cum­stances.” Richard Wun­derink, North­west­ern Me­mo­rial Hos­pi­tal, on the pos­si­bil­ity of a universal do-not-re­sus­ci­tate pol­icy for in­fected pa­tients

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