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Hospitals Weigh Do-Not-Resuscitate Guidelines for COVID-19 Patients

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As doctors in Italy continue to make heartbreaking decisions about which critically ill COVID-19 patients to save, medical professionals in the United States are beginning to have difficult conversations about how to make life-or-death decisions for their patients. A new report from the Washington Post outlined that these decisions may include a blanket “do not resuscitate” order for all COVID-19 patients regardless of their wishes.

On Wednesday, the Washington Post spoke with several doctors across the United States from hospitals updating their ethics guidelines in anticipation of a major surge in COVID-19 patients. The Centers for Disease Control and Prevention (CDC) reports there are nearly 55,000 confirmed COVID-19 cases in the United States, nearly half of which are in New York. Hospitals in New York City are already facing an overwhelming surge of COVID-19 patients.

Hospitals are reviewing guidelines across the board on how to ethically provide care in an overwhelming situation, including what they call a “code blue,” when a patient experiences respiratory or cardiac arrest and must be resuscitated immediately.

When a patient codes, typically a team of eight to up to 30 medical professionals rushes to the patient. Procedures often require inserting a tube in the patient’s throat, hooking them up to a ventilator and a number of other procedures. All of this work requires personal protective equipment like face masks, face shields, gloves and gowns.

Treating patients with an infectious virus makes a code blue response even more difficult. Procedures like intubating a COVID-19 patient sprays infectious respiratory droplets around the room. Hospitals are already facing a major shortage of personal protective equipment.

If a COVID-19 patient goes into respiratory or cardiac arrest, the response team must take extra precautions and use protective equipment that’s already in short supply. Otherwise, doctors risk getting sick themselves or spreading the virus to other patients.

“It doesn’t help anybody if our doctors and nurses are felled by this virus and not able to care for us,” R. Alta Charo, a University of Wisconsin-Madison bioethicist, told the Post. “The code process is one that puts them at an enhanced risk.”

Normally health professionals work to do everything possible to save every patient, it’s part of their oath when a patient doesn’t have a do-not-resuscitate (DNR) order. But in a scenario where the health care system is overtaxed, the priority switches to what actions can save the most patients. This is the reality doctors in Italy have been facing. And some hospitals are considering a “draconian” blanket do-not-resuscitate order for COVID-19 patients to protect as many people as possible.

“If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” bioethicist Scott Halpern at the University of Pennsylvania told the Post.

People with disabilities have already expressed concern about the guidelines and decisions hospitals are preparing to make to decide whose lives to prioritize if the health care system’s resources are overwhelmed. Karin Willison, The Mighty’s disability editor, wrote how these rationing policies and pandemic guidelines pose a threat to people with disabilities and chronic illnesses.

“These rationing policies are a symptom of the deep ableism ingrained in the medical profession,” Willison wrote, adding:

People with disabilities are often seen as less worthy of care, less valuable as human beings. Of course, many individual doctors and nurses on the front lines of this pandemic are heroes, working for days at a time without proper protective equipment to save the lives of all their patients, regardless of disability, chronic illness or age. But if the system itself does not protect people with disabilities and chronic illnesses, some of us will pay the ultimate price at the hands of those who do not see our value.

Most hospitals as of yet have not committed to concrete policies for patients with COVID-19 who code — and those guidelines would only be used as a last resort. Some hospitals are working to modify procedures, so that responding to a code requires less personnel for example, while others are checking state law to better understand what they may have to do.

“We are now on crisis footing,” Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, told the Post. “What you take as first-come, first-served, no-holds-barred, 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.”

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Header image via Ridofranz/Getty Images

Originally published: March 26, 2020
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