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.

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