Hospitals consider universal do-not-resuscitate orders for coronavirus patients – msnNOW

Hospitals consider universal do-not-resuscitate orders for coronavirus patients – msnNOW

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 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.

Subscribe to the Post Most newsletter: Today’s most popular stories on The Washington Post

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 conversations, 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 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 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.”

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-Madison bioethicist, said that while the idea of withholding treatments may be unsettling, especially in a country as wealthy as ours, 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 all of the most critically ill patients in the 12 days since they had their first coronavirus case have experienced steady declines rather than a sudden crash. That allowed medical staff 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-not-resuscitate 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.

Some of the most anxiety-provoking minutes in a health-care 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 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.”

The world is battling the COVID-19 outbreak which started in the city of Wuhan, China, and has spread around the globe killing thousands. The World Health Organization declared the outbreak a global pandemic on March 11.

(Pictured) A worker wearing protective suit looks at signs partially covered in foam while cleaning and disinfecting an underpass to prevent the spread of coronavirus disease in downtown Budapest, Hungary on March 26.

People walk past some fruit stall during a coronavirus outbreak on March 26 in Hong Kong.

Police officers gather at night on an empty Trocadero square in front of the Eiffel tower on March 25 in Paris, France.

Flanked by Vice President Mike Pence (L) and Treasury Secretary Steven Mnuchin, President Donald Trump speaks during a briefing on the coronavirus pandemic on March 25 in Washington, D.C.

A general view shows a deserted via del Tritone during the emergency to stop the spread of the coronavirus on March 25 in Rome, Italy.

Empty yellow trailers used to hold airplane fuselages sit idle in front of a mural on a door at Boeing Co.’s manufacturing facility on March 25 in Renton, Washington.

People walk in an empty Lincoln Memorial Reflecting Pool in Washington D.C on March 25.

A sign is displayed at a coffee shop on March 25 in New York City.

A cleaner disinfects an alley of the Vila Ipiranga slum, in Niteroi near Rio de Janeiro, Brazil, on March 25.

Migrant workers walk with their children as they look out for transport to return to their villages, after India ordered a 21-day nationwide lockdown to limit the spreading of the virus, in Ahmedabad, on March 25.

A worker moves toilet paper at a storage facility of the Franz Mensch company, in Buchloe, Germany, on March 25.

People join a queue to buy maize meal at a supermarket in Harare, Zimbabwe, on March 25. Zimbabwe’s public hospital doctors went on strike on Wednesday over what they called a lack of adequate protective gear as the pandemic begins to spread in the country.

People walk along Sandymount strand practicing social distancing, in Dublin, Ireland, as seen in this picture released on March 25.

Indian firefighters spray disinfectants as a preventive measure, in Guwahati, India, on March 25.

Director of Civil Defence Emergency Management Sarah Stuart-Black speaks during a press conference ahead of a nationwide lockdown at Parliament on March 25, in Wellington. New Zealand will go into lockdown from 11:59 pm on Wednesday. New Zealand currently has 205 confirmed cases of COVID-19. 

This combination of pictures, shows an electronic 2020 Tokyo Olympic Games countdown clock on March 24, showing remaining days to the opening ceremony before the postponement announcement, left, and the clock on early March 25 after the announcement showing today’s date instead of the countdown days, right, outside Tokyo Station.

Staff closes the main gate at Taronga Zoo on March 25, in Sydney, Australia. Taronga Zoo has temporarily closed its doors to the public as the Australian government introduces stricter social distancing measures and the shut down of non-essential services, while restaurants and cafes are allowed to remain open for takeaway only. 

Police officers stop vehicles and check their papers on a highway during 21-day nationwide lockdown in Kochi, India on March 25.

Russia’s President Vladimir Putin wears a yellow protective suit on his visit to the Novomoskovsky multipurpose medical center for patients suspected of the COVID-19 coronavirus infection, on March 24, in Moscow, Russia.

Canada’s Leader of the Government in the House of Commons Pablo Rodriguez speaks in the House of Commons as legislators convene to give the government power to inject billions of dollars in emergency cash to help individuals and businesses through the economic crunch, at Parliament Hill on March 24 in Ottawa, Canada.

Closed shops and cafes in an empty street, with the Eiffel Tower in the background, in Paris on March 24.

People practice social distancing as they sit on chairs spread apart in a waiting area for take-away food orders at a shopping mall in hopes of preventing the spread of the coronavirus in Bangkok, Thailand on March 24.

A man walking a dog past graffiti with the writing, “Wash Your Hands, We’re In This Together”, in Belfast, Northern Ireland on March 24.

Pigeons fly at a deserted Gateway of India monument in Mumbai, India on March 24. Indian Prime Minister Narendra Modi has decreed a 21-day lockdown across the nation of 1.3 billion people “to save India” from the coronavirus pandemic.

President Donald Trump, with Director of the National Institute of Allergy and Infectious Diseases Anthony Fauci, takes questions during the daily briefing on the novel coronavirus at the White House on March 24 in Washington, D.C.

A woman wearing a protective mask walks by a shop with bears installed in line to show social distancing in Paris on March 24.

Liverpool Street Station during the first day of enforced lockdown in the UK, in order to stop the spread of the coronavirus on March 24 in Liverpool, England.

Members of the California National Guard 115th Regional Support Group help pack boxes of food at the Second Harvest Food Bank of Silicon Valley on March 24 in San Jose.

Daily wage workers left jobless due to travel restrictions aimed at containing the coronavirus, wait their turn to receive free food in Rawalpindi, Pakistan on March 24.

Two delivery boys on bicycles are seen, as the spread of the coronavirus disease (COVID-19) continues in Edinburgh, Scotland, on March 24.

A woman looks at her mobile phone as she sits near a fountain which has its statues covered with mouth masks in Antwerp, Belgium, on March 24. 

New York Governor Andrew Cuomo speaks in front of stacks of medical protective supplies during a news conference at the Jacob K. Javits Convention Center which will be partially converted into a temporary hospital during the outbreak of the coronavirus disease (COVID-19) in New York City, on March 24.

Tailors sew protective masks at a workshop of the Aviatsiya Halychyny brand, which changed its production lines from fashion clothing to produce protective masks to contain the spread of the coronavirus disease (COVID-19) in Lviv, Ukraine on March 24.

A resident looks through a metal door while military police walk through the neighborhood to verify that the population follows the curfew order, as part of the measures against the spreading of the coronavirus disease (COVID-19), in Tegucigalpa, Honduras on March 24.

A security guard stands by beds installed inside the Festival palace as Cannes Mayor David Lisnard decided to open a part of the palace to welcome needy and homeless as a lockdown is imposed to slow the rate of the coronavirus disease (COVID-19) in France, on March 24.

A woman walks her dog under a “don’t panic” sign hanging at the entrance of a food market that was shut down in order to reduce the spread of the coronavirus, in Tel Aviv, Israel on March 23.

A woman stands inside the disinfection chamber at Juanda International Airport, in Surabaya, East Java, Indonesia, March 24

Military vehicles cross Westminster Bridge after members of the 101 Logistic Brigade delivered a consignment of medical masks to St Thomas’ hospital on March 24, in London, England. British Prime Minister, Boris Johnson, announced strict lockdown measures urging people to stay at home and only leave the house for basic food shopping, exercise once a day and essential travel to and from work.

Security personnel wearing facemasks patrol on the streets in Shaheen Bagh area after removing demonstrators continuously protesting against a new citizenship law, while the government imposed a lockdown as a preventive measure against the COVID-19 novel coronavirus in New Delhi on March 24.

The Ruby Princess Cruise Ship is seen off the coast of Sydney on March 24, in Sydney, Australia. A passenger of the Ruby Princess who tested positive to COVID-19 has died in hospital this morning. There have been 133 cases of COVID-19 connected to the Ruby Princess.

People wearing facemasks buy supplies at a crowded vegetable market at Piliyandala on the outskirts of Sri Lanka’s capital city Colombo on March 24, as the authorities briefly lifted a curfew to allow residents to stock up on essentials amid concerns over the spread of COVID-19.

Community organizer Henry Liu maintains social distance while greeting a resident as InterIm Community Development Association delivers free food to seniors in the Chinatown-International District during the coronavirus disease (COVID-19) outbreak in Seattle, Washington, March 23.

David Vazquez, a street performer dressed as the Joker, waits in hopes of pedestrians who will pay to take pictures with him in Mexico City, March 23. Vazquez, who also worked as a trainer in a gym until it shut down today, said business for street performers has plummeted, with the few clients still stopping opting to take their pictures from a distance or posing beside him awkwardly, amid the worldwide spread of the new coronavirus. “We have to pay rent, light, gas, telephone,” said Vazquez. “Where will we get that money? We all want to work.”

A child walks next to members of the “Psalm 100” evangelical church, dressed as angels and holding placards making reference to coronavirus (COVID-19) are seen during a demonstration at the Paso del Norte international border bridge as taken from Ciudad Juarez, Mexico, March 23. 

Employees eating during lunch break at an auto plant of Dongfeng Honda on March 23 in Wuhan in China’s central Hubei province. People in central China, where COVID-19 was first detected, are now allowed to go back to work and public transport has restarted, as some normality slowly returns after a two-month lockdown.

President Donald Trump speaks at a press conference in the James Brady Briefing Room of the White House on March 23 in Washington D.C.

Medical staff watch people waiting in line to get a coronavirus test outside the La Timone hospital, in Marseille, France, on March 23.

Empty streets in Tunis reflect the nationwide quarantine declared by the government to halt the spread of the novel coronavirus, in Tunisia, on March 23.

Cleaning crew in protective gear spray public places with disinfectant to halt the spread of Covid-19 in the Icarai neighborhood in Niteroi, Brazil on March 23.

Employees of the Vienna International Airport reload boxes with medical protective gear during the spread of coronavirus disease at the Vienna International Airport in Schwechat, Austria, on March 23.

50/50 SLIDES

Slideshow by Photo Services

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 did not want her name used because she was not authorized to speak by her hospital.

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 a variety of lifesaving medications and equipment ranging from epinephrine injectors to a defibrillator to restart the heart.

As soon as possible, a breathing tube will be placed down the throat and the person will be 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 is 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 7-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, Tim 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.” He said the hospital is monitoring health-care 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 is 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 own 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 negative pressure 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 he 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 or PAPR 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.”

Ben Guarino in New York and Desmond Butler contributed to this report.

Microsoft may earn an Affiliate Commission if you purchase something through recommended links in this article.


Please enter your comment!
Please enter your name here