3/25/20
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. 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.
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 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 did not want her name used because she was not authorized to speak by her hospital. Bioethicist Scott Halpern at the University of Pennsylvania is the author of one widely circulated model guideline being considered by many hospitals. 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.
