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Originally Posted by mountainjogger
Paul.
I agree this can be a gut wrenching issue to confront in the best of times.
I have not seen reports from China or S.K. either. And I am not fluent enough with their laws and cultural expectations regarding DNR's do know if their approach easily translates to the US and other western societies.
However, having been involved in the representation of several providers in my state where uninvolved family members object to valid DNR orders I can say two things. First, although the process varies state by state, DNR orders are usually entered pursuant to a state statute which normally requires knowing consent from the patient or the patient's rep. And even when orders comply with this process, many family members object and want the patient keep alive, no matter the prognosis or the cost.
But these are not normal times. The dangers to medical providers posed by resuscitation appear to be significant. And we may not have enough resources to keep people alive no matter the cost.
So, we may be headed into a situation where these decisions have to be made even if the patient or their rep do not agree. Query if the bulk of our population in the US understands this.
Stay safe.  |
I think it's prudent to have this discussion among providers. Even the most efficient resuscitative efforts are not as effective as we'd like to believe. I'm not an intensivist and not versed with the numbers, but it's probably safe to say that greater than 50% of patients who would require CPR for an arrhythmia will die despite best efforts, and that a significant portion of those who survive initially may not survive until discharge. The studied populations tend to have cardiovascular disease and often accompanying chronic lung disease if they were smokers.
When you compound the situation with patients who have severe ACUTE on chronic respiratory compromise in addition to cardiovascular disease and arrhythmia, I'm sure the numbers are much worse. In this case, the calculus needs to be done. Is it worth throwing a team of 10-15 healthcare workers into the exercise of CPR when you may only save 1 in 5, or more likely 1 in 20 patients, with the risk of infecting at least 10% of that team in the best case? When the virus is aerosolized, it is remarkably infectious. There are anecdotal reports from the ENT community in Iran where a sinus surgery performed with protective gear (N95 masks, gown, gloves, hair covers, face shields, but not full PPE with PAPR) likely resulted in the infection of an entire team.
It's a horrible set of decisions and policies that are being made and penned now respectively. There is no good or palatable choice, only several bad options. I have several friends from medical school on the front lines right now, and they are giving everything they've got. I don't think it's unreasonable to consider nurses, respiratory therapists, docs, environmental cleaning, etc. services to be irreplaceable resources. We need time to get proper protective gear for providers, and part of that will be making these tough decisions up front, rather than too late.