opinion
As an emergency room physician, I’m used to working in a hectic environment. I have never experienced anything as heartbreaking and traumatic as the COVID-19 pandemic. It’s an intense and difficult time for everyone, especially patients and health care providers. Compounding that challenge is the increasingly common experience of doctors being forced to make impossible decisions for patients for whom we have no medical history and who did not plan their care in advance.
Physicians such as myself are becoming overwhelmed and the need to know patients' advance care plans is more vital than ever. Scarce resources such as ventilators and ICU beds will become precious and it is essential that we reserve these treatments for patients who want them and can most benefit from their use.
Whether you are 18 or 80, advance care plans make it easier for doctors to provide care that honors the wishes of an individual if they are unable to speak for themselves. In the ER, we have minutes to make a decision that will dictate if a person might live on a machine or pass a natural death. I always make decisions based on what I think is best for the patient, but unless people have an advance care plan, that is exceedingly difficult. If I’m told about a patient’s wishes, not only does my work become more person-centered — it can also be quicker. As we handle massive influxes of patients amid dwindling yet crucial resources, time is everything.
'Die Naturally and with Respect'
One of the most common dilemmas that families and medical professionals alike must navigate are DNR, or “Do Not Resuscitate” orders. Especially now, this ethical question is at the forefront of public discussion, as hospitals evaluate their DNR policies amid COVID-19.
I know patients and families are afraid to say that they don’t want to be put on life support, even if it means their quality of life may decrease, because they assume that they will receive no medical treatment. This falsehood is indicative of a troubling pattern. Too many people are not considering their health care decisions in advance, and as a result, are not being educated on what many of these terms and practices even mean.
I always tell people that “DNR” can mean to “Die Naturally and with Respect.” For some patients, they would rather have their pain and symptoms controlled and have a focus on the quality of their life rather than the quantity of days that they are alive. Others wish to be put on life support for a variety of reasons. It is simply essential that patients be given the space and resources to make an informed decision. If a person expresses in their advance care plan, for example, that they wish to be cared for at home, then that can help make an ICU bed available for a person who requires hospitalization.
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For years, many physicians have asked our government, employers and health insurance providers to encourage everyone to create an advance care plan so we are able to understand patient’s wishes and can respect their decisions if they become critically ill. With or without a pandemic, having an advance care plan in place benefits both patients and providers. It allows patients to communicate their medical wishes to their families, doctors, nurses, and other caregivers and helps providers administer the desired care in a timely manner. As we've learned from global reporting on COVID-19, being able to treat patients efficiently is essential to reducing fatalities, maintaining lifesaving resources and preserving the effectiveness of our health care systems.
Vital to have a plan amid global crisis
Everyone deserves the peace of mind of knowing their wishes will be respected, even and especially if they become incapacitated. In making an advance care plan, patients should consider some basic questions: (1) Who do you want to represent you if you can’t communicate during a health crisis? (2) What are your values and treatment goals? (3) What medical history and information do you want anyone who treats you to have?
My highest aim as a physician is to provide person-centered care. I can’t do that unless my patients clearly articulate and communicate their wishes while they are able to do so. CDC.gov has online resources for advance care planning that are state specific, but it is very helpful to have an electronic record that can be kept up to date. For example, I use a free online platform MyDirectives.com. Plans created online can be altered quickly and securely as needed and can be shared with family and medical providers, so everyone is on the same page.
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It’s human nature to avoid subjects that remind us of our own mortality, especially in a time of heightened anxiety. But it shouldn’t take a global health crisis to illustrate the importance of discussing our goals of care and what our family should do if we become acutely ill. These conversations are difficult and raw, but pale in comparison to the grief that may come – and that I have seen materialize for too many families – when a loved one is in an emergency situation and they don’t know how to best advocate for them.
As in every area of life, I encourage people to hope for the best outcome in a medical crisis and prepare for the worst. It is always considerate and responsible to have an advance care plan in place. In an international crisis — for patients, families, and medical personnel on the frontlines of the COVID-19 pandemic — it is indispensable.
Dr. Elizabeth P. Clayborne is an emergency medicine physician based outside of Washington, D.C. She has a master’s degree in bioethics. Follow her on Twitter: @DrElizPC
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April 09, 2020 at 08:35PM
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ER doctor: Your end-of-life care plan can help save time and lives amid coronavirus - USA TODAY
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