Paul A. Byrne, M.D.
We are in the midst of a Coronavirus Disease (COVID-19) pandemic. Early reports included multiple, now more than 40 deaths in a nursing home in the State of Washington. Twenty percent of the COVID-19 deaths in New York and New Jersey are residents of nursing homes. Many other nursing homes have increased deaths. Is this because the COVID-19 virus is so virulent, or other factors?
“The Associated Press conducted its own survey in the U.S. and found there had been nearly 11,000 COVID-related nursing home deaths across the country as of April 24. However, just 23 states have been publicly reporting nursing home deaths.” https://medicalxpress.com/news/2020-04-failure-covid-nursing-home-deaths.html (Accessed 4-28-20)
This is not surprising considering that patients in nursing homes are older and have co-morbidities and therefore, are more susceptible to succumb to an infection.
Most in nursing homes require assistance in living. A prerequisite for acceptance into most, if not all, nursing homes is an Advance Directive for Healthcare. It is common that the Advance Directive will include a Do Not Resuscitate (DNR) order.
In addition, some may have already unwittingly been put into Palliative Care (PC). Most residents of nursing homes and their relatives do not have full and complete information about PC.
Triggers for PC are not limited to incurable diseases that are painful, but include declining ability to complete activities of daily living, weight loss, uncertainties regarding prognosis, limited social support and a serious illness (e.g., homeless, chronic mental illness), perceived psychological or spiritual distress of the patient or family. https://getpalliativecare.org/resources/clinicians/ (Accessed 4-28-20)
PC sets the stage for more deaths for the most vulnerable. How? PC focuses on alleged relief of symptom-burden, not necessarily treatment of the cause, i.e., the underlying medical conditions, treatment of which could alleviate the symptoms. For example, an elderly patient with cancer is noted to have a change in mental status. This could be a result of medication, a urinary tract infection, dehydration, or a myriad of other treatable conditions not related to the cancer. Yet, in PC the symptom-focus response may be to give Valium-like drugs or narcotics to sedate the patient, omit evaluation and simple tests to diagnose the actual problem, and not provide common medications or interventions that could successfully treat the medical condition causing the symptom(s).
There are many concerns during this time of sheltering at home and social distancing. Separation of loved ones in nursing homes from family and visitors, including clergy, done for their protection from COVID-19, was sudden and not predictable and raises other questions concerning care needs of these vulnerable persons.
Doctors and death – redefinitions and participation
How did we get here? Medicine changed drastically and horrifically in 1968 with “brain death” when a Committee at Harvard published “A Definition of Irreversible Coma.” “Brain death” calls a person with a beating heart and circulation, “dead.” Everyone in coma is alive, nevertheless the Harvard Committee without any scientific or medical references, declared that someone unconscious in coma, on a ventilator without brainstem reflexes of the eye and ear, and unable to take a breath on their own, but many other signs of life including being warm with normal color, a beating heart, blood pressure, pulse, oxygen being taken in and carbon dioxide going out, can be considered “dead.” To call a person dead while there are many signs of life and then to participate in organ procurements by stopping the beating heart and removing it thereby making the person definitively dead was a major change in the direction of medicine. This change had and still has an impact on medical practice. Doctors were blinded to the most basic good of the presence of life itself and were now participating in causing deaths albeit with the intention of helping others live. Laws were passed to protect this new definition of death. In 1970 Kansas was the first state to pass a “brain death” statute. Judges and legislators from all 50 states became involved making it legal to call someone dead while the heart was beating with many other signs of life.
Advance Directives and Do Not Resuscitate (DNR) orders
In 1990 Medicare and Medicaid were amended to require hospitals and skilled nursing facilities to inform patients of their rights to make decisions concerning their medical care and to periodically inquire as to whether a patient executed an Advance Directive and document the patient's wishes regarding their medical care. As a result, when entering any hospital or nursing home the patient and/or those who represent the patient are asked if the patient has a Living Will or Advance Directive. This is commonly done by an admission clerk, not a treating physician. If the patient does not have an Advance Directive, quite commonly a “sample” is provided for consideration.
Every state had a “brain death” statute before a Living Will statute. A Living Will is a written statement detailing a person's desires under some future, hypothetical, circumstances not to be treated. Decisions about non-treatment in the future violate two basic principles of medicine. The first is that a physician gathers all timely, relevant information about the patient before a diagnosis and plan of treatment are made. The second is that a doctor is expected to provide the most up-to-date treatments that can be most beneficial to the patient. Neither of these are available when a Living Will is executed.
Another form of Advance Directive is a Power of Attorney for Health Care. This allows one to designate someone to speak for him/her.
POLST (Physician Orders for Life Sustaining Treatments) is a type of Advance Directive designed to have patients choose to get less treatment and care and once signed by a physician becomes a legal medical order binding future caregivers from providing the care refused. The future, including the onslaught of a coronavirus, cannot be known by the person completing an Advance Directive.
Once society and medicine has accepted 1) calling people “dead” who are really alive, participating in their deaths, 2) advance directives that aim at refusing or limiting treatments and care, it is an easy step to 3) palliative care principles that further limit treatments with their focus on symptoms, not cures.
Then enter coronavirus especially in nursing homes. Everything is in place for those with weak or absent immunity to acquire the virus. Those with underlying disease are more likely to get sicker. Almost everyone in a nursing home has an Advance Directive in place not to be treated and receive less care.
People with disabilities and the elderly are considered to be more likely to die from COVID-19 and therefore they may be denied life-saving or life-sustaining treatments to enable a person who is viewed as more likely to survive to receive treatment.
Nursing home residents, relatives and friends are affected by the involuntary mandated imposition of no visitors. If a person, labeled a “client,” in a nursing home has an acute illness, they are subject to whatever is provided. Their Advance Directive is in place for non-treatment, even for unspecified imaginable illnesses. Many are frail; they are without relatives; treatment depends on whatever personnel in the nursing home provide. Their Advance Directive indicates that the person has chosen not to receive some treatments; thus, it is so easy to translate this into no treatment.
The palliative care movement, preceded by “brain death” and Living Will statutes, is another related change in medical care in our country. Palliative care involves a palliative care team (which can include physicians, nurses, social workers, and chaplains) that helps the family determine when the patient’s care should be shifted away from cure and toward death. Palliative care is less treatment and no care and is a major part of the System of Death that exists in Medicine, the Law and the Church.
The person in the nursing home and their relatives did not appreciate this. This was done before COVID-19. Now, nursing home residents, relatives and friends are stuck with it.
Shortly after the onset of COVID-19, the anticipated need for ventilators started the push to make more ventilators. However, patients in nursing homes with a DNR order will not get a ventilator, even if it might be a temporary treatment that would allow recovery from the virus. Is the death rate among the elderly higher because of their age and co-morbidities alone or because they will not be offered a chance to survive whether that be on a ventilator or possibly due to other innovative care strategies that may have a reasonable chance for even greater effectiveness and improved survival? The Advance Directive may be the mechanism to the ending of their life even if unintended by the patient.
In general, many patients seem to have the idea that ventilator use would mean a comatose existence on a machine indefinitely. How many are informed that ventilator use can be temporary and a means to continued living? The use of ventilator guidelines is being questioned for COVID-19 patients. Are death rates from COVID-19 higher in nursing homes because in the face of advance directives that limit potentially curative therapy, treatments, whether with a life-saving ventilator or with other modalities, are being denied to the elderly?
Palliative Care proponents want opioids to relieve breathlessness and pain. Opioids do not relieve breathlessness per se but make a patient sedated and breathe less because they decrease respiratory rate and volume. The patient too sedated to take hydration or nutrition, dies. They may appear more comfortable but if they are too sedated to respond, one does not really know how they feel inside. They could be motionless and still have nausea, itching, pain, constipation, dysphoria, feel unable to handle their secretions, and other undesired side-effects.
While attention is drawn to their age and co-morbidities in discussing the increased death rates among nursing home residents and while these are valid considerations, what is not discussed is how healthcare has changed to a system of death that does not aim for protection and preservation of lives of those considered a drain on society’s resources.
First came “brain death” with the goal to eliminate persons who needed ventilators. Next, came Living Wills and Advance Directives to discourage life-saving treatments, including ventilators, assisted nutrition and hydration, and even antibiotics. Then most nursing home residents have a “DNR – Do Not Resuscitate” order, which often results in, decreased treatments and care even if not directly related to resuscitation.
Add taxpayer funds to the push for PC for all, even if not dying or in pain. Enter Coronavirus-19 with sudden, social isolation for all, even those not sick. It is no surprise that elderly persons are more vulnerable to disease, but are they getting the care that protects and preserves their life and health and gives them their best chance of recovery?
A ventilator may or may not preserve the life of a person, especially when the person is older with co-morbidities and COVID 19, but denial of a needed ventilator associated with DNR in PC can shorten life and hasten death.© Paul A. Byrne, M.D.
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