This post is going to be very grim. I hope you will take it as useful information and food for thought. Despite the call for more ventilators, these breathing machines are not a panacea for elderly patients.
As Coronavirus sweeps the country, and as governors beg for federal assistance, the reality of mechanical ventilation for elderly patients has been lost in the whirlwind of discussion about procurement and triage for the worst-case scenarios.
Ventilator manufacturers are besieged with requests for large orders from potential hot spots around the country. Some companies have been approached by high net-worth individuals seeking ventilators for personal use.
Since Sam posted this, other writers have jumped on the same topic:
What You Should Know Before You Need a Ventilator (NYTimes, April 4, 2020)
The Dark Side of Ventilators (Washington Post, April 6, 2020)
80% of New York’s Patients Put on Ventilators Ultimately Die (Business Insider, April 9, 2020)
Having enough ventilators is not a cure-all for respiratory failure due to COVID-19
No physician or government official wants to be in the position of rationing critical medical treatments. No wealthy person wants to admit there are some problems that money cannot overcome. Both perspectives reflect a woeful overestimation of the value of mechanical ventilation in the frail and elderly. It is my belief that some frail and elderly patients, if better informed, might choose to decline mechanical ventilation for the respiratory failure of COVID-19. They might, instead, opt for palliative care and morphine to slip away quietly.
Some elderly patients might opt for palliative care and morphine in lieu of mechanical ventilation
Exactly how COVID-19 disease varies from other viruses remains to be determined but two facts are emerging. First, the mechanical ventilation for COVID-19 requires higher pressures, more oxygen, and prolonged treatments when compared to other forms of respiratory failure. And, second, mechanical ventilation for COVID-19 is significantly less successful than for similar diseases.
The respiratory failure of these inflammatory lung diseases generally falls under the disease process known as Adult Respiratory Distress Syndrome (ARDS). This is a process that is well studied and well understood. In ARDS, the lungs fill with fluid, both in the air exchange sacs and the tissues surrounding them, blocking the passive exchange of oxygen and requiring the active, mechanical thrust of pressurized and concentrated oxygen through this morass of fluid into the blood-stream.
Sixty percent of ARDS patients over the age of 85 do not survive despite mechanical ventilation
ARDS is uniformly fatal among the elderly without mechanical ventilation. But even with aggressive treatment the outcome is far from guaranteed and the complications are manifold.
Sixty percent of ARDS patients over the age of 85 do not survive despite mechanical ventilation. Of the forty percent who do survive, over sixty percent will suffer dramatically diminished physical abilities that progress until death during convalescence. Fifty-five percent will have reduced cognitive abilities.
The outcome of COVID-19 patients on ventilators is likely to be worse.
The first reports from China show the mortality rate of Coronavirus patients on ventilators to be very high – regardless of age
The first reports from China show the mortality associated with mechanical ventilation to be 97 percent in one study and 86 percent in another. The first reports from Seattle show a mortality much closer to the ARDS figures quoted above. Anecdotal reports from Italy fall somewhere in between.
And consider this, for ARDS survivors of all ages, almost two thirds will suffer from depression and post-traumatic stress disorder as a result of the trauma of the treatment. Many of these will have permanent lung damage.
If they survive, no elderly patient is the same after their turn on a breathing machine
In summary, almost no elderly patient will return to their pre-infection performance status after their turn on a breathing machine.
Does this mean that we should restrict access to these machines based on age? No, or, not necessarily. Should we restrict access to these machines for those who are disabled or suffering from underlying conditions? No. Should we offer these machines to those with wealth, power, or celebrity? Absolutely not. Nor should we promote their use without a frank discussion about their risks, benefits, and complications.
Updating advance directives is of paramount importance
Rather, we should continue the struggle to obtain the resources to support patient autonomy (a patient’s right to accept or decline a medical treatment) and endorse the decisions informed patients make to demand or decline aggressive treatments.
In this new reality of health care system failures in COVID-19 hotspots and the looming, prolonged flood of hospitalizations among the elderly, updated advance directives are of paramount importance. This can be done via a conversation with your health care proxy in which you verbally specify that you do, or do not, want mechanical ventilation. It does not require updating paperwork or the services of a lawyer.
Selflessness or self-determination?
Choosing to decline a ventilator and to die with the comfort of palliative care might be the choice of a minority of frail and elderly patients. But for them, it might be less an act of selflessness than an act of self-determination.
Photo credit: ECNS.cn news site (medical worker taking care of a Coronavirus patient in Wuhan)