April 01, 2020

Venting About Ventilators

Yesterday, the New York Times published a short article I wrote about what family caregivers can do to try to keep vulnerable older family members safe during the coronavirus epidemic. We as individuals and as a society should do our utmost to keep everyone healthy; my article suggests a few strategies to help those older people who live in the community but need help with personal care or other basic daily functions. 

In many cases, our strategies will succeed, but we have to be realistic and think about the possibility that, despite our best efforts, some older adults—those in their 70s, 80s, or 90s—will get sick. A minority will get so sick that physicians will propose transferring them to the intensive care unit (ICU); most of those brought to the intensive care unit will be breathing so poorly that doctors will advise a ventilator, or breathing machine. 

The popular press makes it sound as though with ICU treatment in general and a ventilator in particular, older patients infected with Covid-19 will live and without this form of treatment, they will die. The reality may be quite different. A report of the experience of nine Seattle-area hospitals just published in the New England Journal of Medicine sheds some light on the question.

The authors report on 24 patients with Covid-19 who were sick enough to be admitted to the ICU. Five of them were over age 80 and five were between 70 and 80. This is a very small sample, but the paper is one of the few published reports that included detailed information about each patient. The outcomes were sobering.

In this group of 10 very sick older Covid-19 patients, 8 died, for a mortality rate of 80 percent. By comparison, among the 14 very sick Covid-19 patients under age 70, 5 died, or 36 percent. A subset of the 24 extremely ill patients received mechanical ventilation—a tube was inserted into their lungs that was connected to a machine that breathed for them. Among the 7 patients over 70 who were both in the ICU and intubated, 6 died, or 86 percent, compared to 4 out of the 11 intubated patients under age 70 (36 percent). The sole case of an older patient with Covid-19 who was intubated and lived was notable for the complete absence of underlying chronic conditions (comorbid conditions, as defined by the study, include asthma, chronic obstructive pulmonary disease, obstructive sleep apnea, infection with human immunodeficiency virus, immunosuppression, diabetes mellitus, chronic kidney disease, and ischemic or hemorrhagic stroke).

An earlier study from China found that among 52 patients admitted to the ICU with Covid-19, the survival rate for people over 70 was 10 percent compared to 45 percent among those under 70.  

Data from the National Health Service in England reporting on the British experience through March 27 found that of 157 patients admitted to an intensive care unit with Covid-19, 73 percent of those aged 70 or older died compared to 35 percent among those under 70. 

In summary, in these three reports, survival rates were low for older patients admitted to the ICU, particularly for anyone who was put on a ventilator. That doesn’t mean it never happens. But it strongly suggests that if you are over 70 and if, despite all the best efforts at prevention, you do get the virus, and if you are one of the minority who become extremely ill with the infection, the outlook is poor. 

Many though by no means all people, if they know the end is likely to be near, do not want aggressive medical treatment that offers little or no benefit. This goes for people with advanced cancer, severe heart disease, or any of a variety of other conditions that are usually fatal. They’d rather receive medications such as morphine to ease their shortness of breath and medications such as lorazepam to ease their anxiety than to undergo extremely uncomfortable treatment that has only a small chance of prolonging their lives. Severe Covid-19 is another condition for the oldest Americans to consider adding to the list.

We all hope we won’t get the virus and that if we do get it, we’ll have a mild case. We hope that if we have a more serious case, we won’t be sick enough for doctors to propose transferring us to the ICU and using a ventilator. But if you are over 70 and you become severely ill with Covid-19, you will be facing a situation that may be as dire as advanced cancer. To be sure, if you survive the coronavirus infection, you might have a good quality of life (though this, too, is uncertain as we know little about life-after-the-virus for those who have been in an ICU) and you might live for some time. If you benefit from treatment of advanced cancer, on the other hand, the benefit may be short-lived. But in both cases, you have a choice. You can decide that you want any and all treatments, however burdensome and however likely or unlikely they are to improve your condition. Or you can opt for a more palliative approach. You don’t have to accept treatment that you regard as excessively burdensome. You don’t have to spend what might be—but might not be—your last days in an ICU with a machine breathing for you, unable to eat or speak. You can choose instead to be treated with intravenous fluids, oxygen, assorted medications, and other forms of supportive care but to decline admission to an ICU and intubation. Your general state of health (before coming down with a coronavirus infection) and your personal preferences should guide your decision.

Most people with Covid-19 infections do not become so desperately ill that they are admitted to an ICU and intubated. Specifying in advance whether you would want this kind of treatment by signing a simple advance directive and discussing your wishes with your health care proxy is a type of insurance policy. Like flood insurance and fire insurance, you hope you will never need to make use of it. But it’s good to have it, just in case.

March 02, 2020

Save Our Seniors

            For over 100 years, scientists and infectious disease specialists have been anticipating another influenza pandemic like the 1918 “Spanish flu” which killed approximately 50 million people world-wide. In the US alone, the death toll was 675,000; the disease spread across the globe, affecting some 500 million people, aided and abetted by troop demobilization when World War I came to an end. We have never had an outbreak quite like it, but there have been years when the influenza strain was particularly virulent, principally when the genetic material of the virus “shifted” rather than “drifted”: every year, the influenza virus mutates to a lesser or greater degree, and if the change is dramatic, the general population will be especially susceptible to the illness. Over the decades, we have found new and better strategies for minimizing the impact of influenza: we have developed moderately effective vaccines, we have designed protocols to limit the spread of the disease when an outbreak occurs, and we have better ways of caring for patients who do become ill. Despite our best efforts, influenza remains a major source of morbidity and mortality every year, with the CDC reporting that so far this season, there have been 32 million cases of the flu, resulting in 310,000 hospitalizations and 18,000 deaths. Long-term care facilities (institutions providing either short-term rehabilitative care or long-term nursing care), with a total of about 1.7 million beds, are a hot spot for the spread of the flu. The patients in these facilities tend to be old, to have multiple chronic medical conditions, and weakened immune systems. They live in close quarters and have frequent contact with one another. Not surprisingly, skilled nursing facilities look as though they may also be fertile ground for the new COVID-19 virus.
            Just this weekend, an outbreak of a respiratory illness was reported at the Life Care Center of Kirkland, Washington, not far from Seattle. Among the 108 residents and 180 staff members of this skilled nursing facility, over 50 reportedly have respiratory symptoms. At the same time, the Department of Public Health of Washington State reported a cluster of 6 confirmed cases of COVID-19 at the Evergreen Hospital, of whom 4 were connected to Life Care Center of Kirkland (3 residents and one staff member). This is a rapidly evolving story: one of those residents, a man in his 70s described as having underlying chronic medical problems, has since died. Health officials in Washington State suspect the virus has been circulating for some time, probably weeks, undetected because it was not being tested for. Meanwhile, the anxiety level is mounting in the Seattle area, as well as in neighboring Oregon and California, where cases have also been reported. The good news is that we know what basic steps to take to contain the spread of the disease in skilled nursing facilities. We know because we have been developing expertise to handle another, sometimes deadly viral illness, influenza, for the past 100 years.
            The CDC just issued guidelines to long-term care facilities reminding them of what these practices are. They are really quite simple and, while they won’t eliminate the threat, they are likely to diminish it significantly. The recommendations deal with ways to prevent spread into a facility, to prevent spread within a facility, and to prevent spread between facilities.
            With regard to limiting spread into a facility, the CDC promotes posting signs telling visitors to stay away if they have respiratory symptoms. Likewise, employees should stay home if they are feverish, coughing, or sneezing. Finally, protocols should be established to evaluate every new admission for signs of respiratory illness.
            In terms of preventing spread within a facility, staff should monitor all residents for respiratory symptoms. Anyone who develops symptoms should be confined to his or her room. Standard “droplet” and “contact” precautions should be maintained by staff. Lastly, good hand hygiene should be facilitated with the widespread distribution of Purell dispensers—as well as old-fashioned soap and water. 
            Avoiding spread between facilities requires informing the receiving institution, typically a hospital, that a patient with respiratory symptoms consistent with COVID-19 is being transferred. Communication with the local department of health is also key.
            There are differences between influenza and COVID-19 that may influence how effective the strategies used against flu will prove to be in the current situation. Perhaps the most glaring difference is that we don’t have a vaccination for COVID-19—one of the best ways to minimize the impact of influenza in a long-term care facility is to vaccinate residents and staff before the beginning of the flu season.  Another key difference is that individuals infected with the new virus appear to be infectious even if they have no symptoms. We are unlikely to be able to keep long-term care residents perfectly safe, just as we cannot eliminate the risk of falls or functional decline, but there are steps we can take that will make a difference.

February 05, 2020

Let's Hear It for Caregivers!

            As a geriatric and palliative care physician, I have provided medical care to many patients in their homes. They are typically very sick: some of them are frail, some suffer from dementia, a number are approaching the end of life. They have spent time in doctors’ offices and x-ray suites and in emergency rooms, they have been hospitalized, and they have had more than their share of operations and procedures. Most of them are at a point in their lives where want to stay at home for treatment. But because of their own physical or mental limitations, they cannot participate extensively in their own medical care. They do not have the mobility to get to a pharmacy to fill prescriptions, they do not see well enough to draw up their own insulin in a syringe, and they do not have the dexterity to change the bandage on a skin ulcer. They depend on a family member or, in some cases, a hired aide, to help them. It is for these patients and the family members who take care of them that I decided to write a book. It would be directed principally at caregivers, at the unpaid, unsung, and unsupported millions who are the backbone of care for frail older people.
            I have met many of my patients’ family caregivers. They are caring, conscientious people who want to do the right thing for their mother or father, sibling or spouse. But they aren’t comfortable administering intravenous medications or giving injections because they worry they might make a mistake, with potentially serious consequences. They want the best medical care for their relative, and if that means bringing them to the hospital every time their shortness of breath gets worse or they have chest pain, that’s what they will do, even if their family member pleads with them to let them stay home. Caregivers would feel guilty if they did anything else because they don’t feel knowledgeable enough to adjust medication doses or oxygen flow rates on their own or to suggest such a course of action to the physician. They haven’t gotten the training necessary to troubleshoot when the medical equipment they are expected to use misbehaves. As a result, many of the oldest and frailest patients are repeatedly hospitalized. The hospitalization commonly leaves them weaker, more confused and more debilitated than they were before admission. Some of them spend months going first to the hospital, then to rehab, then back to the hospital, only to die, perhaps before ever returning to the comforts of home. Not the path that they wanted.
            I discovered that by working closely with family caregivers, by providing them with the knowledge and support they need, this cycle can be interrupted. It’s a multi-step process that begins with a review of the patient’s overall medical condition. It turns out that often either the patient, the caregiver, or both have serious misconceptions about the nature of the patient’s illnesses, how they will evolve over time, and how they are likely to affect the patient’s well-being. Then we talk about what is most important to the patient. Is it to live as long as possible, no matter what the cost in pain, suffering, or institutionalization? Is it to remain as comfortable as possible? Or is it to stay at home and remain independent? Usually, patients want to live as long as possible and be comfortable and be independent at home. The reality is that life is full of trade-offs, and medical care for frail adults is no exception. Based on a realistic understanding of the patient’s general health and a frank conversation about the goals of medical care, we can develop strategies for addressing the medical problems the patient is most likely to develop. If she has chronic lung disease, for example, we can be fairly certain she will periodically develop worsening shortness of breath. When that happens, should the caregiver bring her relative to the office? To the emergency room? Or could she try modifying the amount of oxygen her family member is getting, perhaps supplemented by antibiotics, consulting with a member of the medical team by phone?
            Key to the success of this approach is the relationship between patient, caregiver, and physician. Critical as well is the willingness of the physician to partner with patients and their caregivers. But its effectiveness also depends on the caregiver having basic knowledge about the patient’s medical condition and strategies for addressing problems as they arise.  I believed that a book that guides families along the way could help overcome some of the obstacles to patients getting the kind of care they want as they age. And so, what would become The Caregiver’s Encyclopedia: A Compassionate Guide to Caring for Older Adults was conceived.

            I started the book by discussing how to navigate through medical institutions such as the hospital, the physician’s office, and the rehab facility. Then I decided to add a section about the most common chronic conditions such as heart failure, high cholesterol, and high blood pressure. Next, I added a section on management of acute symptoms: since patients typically say “I’m short of breath” and not “I’m having an exacerbation of congestive heart failure,” I organized this part by symptom. Then I realized I could demonstrate how the caregiver’s response to an acute medical symptom such as nausea or dizziness might vary depending on the goals of care, so I modified the chapters accordingly. The result is a comprehensive guide to medical care for frail older people. I hope that families will view it as a companion to take with them as they proceed along the caregiving journey. It can be a difficult journey, but it can also be rewarding and enjoyable.  Caregivers just need the right tools and a friendly guide to assist them.

January 19, 2020

Where Have All the Doctors Gone?

The New York Times began the new year with a spate of bad news, including a column with the imploring title “Older People Need Geriatricians” and the despairing subtitle, “Where Will They Come From?” The author, Paula Span, who has for years written insightful and informative articles about aging, made a number of valid points about the shortage of geriatricians: projections are that the US will need over 33,000 geriatricians in just five years, but there are only about 7000 in practice today; and one-third of training slots in geriatric fellowship programs went unfilled last year. 

What struck me about the article is that I recall the NY Times running a very similar piece a few years ago. A quick search revealed that indeed, exactly 4 years ago, the Times had a piece called “As the Population Ages, Where Are the Geriatricians?” This essay pointed out that geriatricians are just about the lowest paying subspecialists in the US, earning less than half of what a cardiologist typically makes. They even make significantly less than a general internist—though geriatricians have more training.

The Times is not the only major newspaper to bring the issue to public attention. As far back as 2013, the Wall Street Journal had a column “Desperately Needed: More Geriatricians.” A year later the same paper ran another piece with the same theme but a possible fix. Entitled “A Remedy for the Looming Geriatrician Shortage,” it reported on a consortium involving four medical schools, Icahn, Johns Hopkins, Duke, and UCLA, that focuses on training medical school teachers. Instead of aspiring to develop full-fledged geriatricians, they offer 3-5 day, intensive training modules to medical school faculty members to enable them to transmit expertise in falls, dementia, incontinence, delirium, and other geriatric topics to their students. Funded by the Reynolds Foundation, the program had managed to train 430 physicians over the course of 10 years. The “Program for Advancing Geriatrics Education” (PAGE) ended in 2017.

The real problem, as implicitly acknowledged by PAGE, is not so much the shortage of geriatricians as the lack of geriatric medical expertise. So why has it been so difficult to remedy the situation—the gap between supply and demand has been growing, not shrinking? And what are we going to do about it?

Several explanations have been advanced, each with a corresponding solution. Since compensation for geriatricians is comparatively poor, economists argue, just improve salaries. This means modifying the Medicare fee schedule since the patients under discussion are almost all on Medicare. Since it’s going to be very hard to increase the size of the total pie, giving a larger share to physicians who see geriatric patients will mean giving a smaller share to cardiologists and orthopedists. That won’t go over well with the cardiologists and the orthopedists, not to mention the gastroenterologists, ophthalmologists and other procedure-oriented specialists, who are all well-paid under the current system. Pervasive ageism is another probable cause. More physicians are likely to want to care for older patients if the society as a whole values older people. Society doesn’t and physicians, who are after all members of society, tend not to either. In fact, the reason that so many of the young physicians who accept geriatric fellowship residency slots are from other countries is that ageism is perhaps not so endemic in the developing world. Changing attitudes is going to be even more difficult than modifying the Medicare fee schedule. 

In light of the obstacles faced by each of the proposed solutions, we need to turn to a quintessentially geriatric way of looking at the world: instead of seeking a magic bullet, instead of expecting that there is one root problem and therefore just one problem that needs fixing, we should accept that the problem is multifactorial. Poor reimbursement, ageism, the absence of procedures, insufficient role models all contribute to the shortage of geriatricians and the lack of geriatric expertise among generalist physicians (both internists and surgeons). The fix will likewise have to be multifactorial. Build on pioneering strategies that involve co-management by a geriatrician and an orthopedist for hip fracture patients. Develop screening tools for frailty and refer the frailest of the frail to geriatricians. Maybe we can’t make a great deal of headway in any of these arenas, but perhaps we can improve things a little bit in each of them. And that would be a good start.