Joshua J Smith
These are times of trade-offs.On the one hand, we want to be with our family members and get help
In early March, when the COVID-19 outbreak reached pandemic status, anguished cries wen up about critical shortages of mechanical ventilators at hospitals.
In the two months from early March to early May, two things have changed: First hospitals quickly received a surplus of ventilators. Second, as doctors got more experience treating Coronavirus patients, they discovered they didn’t need the ventilators as much as they thought they would.
“Initially we thought we’d see patients get rapidly worse, and we would rather place them on a ventilator in a more controlled fashion than in a crisis when they’re crashing,” said Dr. Marc Rovner, a pulmonologist at Indiana University Health’s Methodist Hospital.
But now, doctors are using mechanical ventilators as a last-ditch tool for making the difference between life and death.
Now “we don’t go right from being OK to being on a ventilator,” Dr. Rovner explained. “We try to wait as long as possible and look for trends that [a patient is] getting better. We put you on a ventilator because we think it’s getting worse: more shortness of breath, breathing faster, getting very anxious about breathing, oxygen saturation below a point we consider safe.”
That’s because, as Kathryn Dreger, a doctor of internal medicine and professor of medicine at Georgetown University, wrote in the New York Times, “These machines can’t fix the terrible damage the virus is causing. [It] buys us time. Ventilators keep oxygen going to the brain, the heart and the kidneys. All while we hope the infection will ease.”
There are some other downsides to ventilator life support that you may not be aware of:
It’s invasive. It calls for inserti9ng a 10-incg long plastic tube into the patient’s windpipe, either through the mouth or through a surgical incision called a tracheostomy in the neck. And because it’s a long process (see below), a feeding tube may be inserted into the stomach.
It’s tricky. “Too much air pressure damages the lung,” says Dr. Dreger, “but too little means the oxygen can’t get in. Doctors try to optimize, to tweak.”
It’s a long, drawn-out process. Coronavirus patients who need ventilator support are usually on it for two or three weeks – sometimes even longer – and in a medically induced coma.
There can be serious complications. According to a study in the Journal of the American Medical Association, as many as 25% of patients’ kidneys fail completely, requiring dialysis. Patients ‘hearts can begin to struggle and fail. Blood pressure can drop, causing shock. Ventilator pressure can collapse lungs or increase risk of pneumonia.
Coming off the ventilator can be hard. It takes a long process of weaning to gradually get patients breathing on their own. Some will struggle enough to need the ventilator again.
Aftereffects can be serious and long lasting. “Research finds that one-quarter of patients who survive a critical illness and an ICU stay experience PTSD,” especially after large amounts of sedation, Johns Hopkins Medicine reports. Weeks of sedation can also cause “profound complications, damaging muscles and nerves, making it hard for those survive to walk, move or even think as well as they did before they became ill,” Dr. Dreger notes.
Patients older than 80 have particularly low survival rates on ventilators, so if you’re that old, it’s important to ask yourself these questions:
What do I value about my life?
If I’ll die unless I’m put in a medical coma and placed on a ventilator, do I want that life support?
What’s the longest you want to be hooked up to a mechanical ventilator?
Do I want to stay on it even if my kidneys shut down?
Do I want tubes feeding me so I can stay on the ventilator for weeks?
Are you up for a prolonged rehabilitation?
Or would you rather be made comfortable for the end of life?
Once you know the answers, make sure your family caregivers or a health proxy know too. And make sure the hospital does – in writing.
“A lot of people are going to die on the vent, which is a lousy way to die,” Dr. Dreger told an interviewer. “A lot of family are going to have to say, ‘What did mom or dad, husband or wife, want me to do?’ And have to make it up because they’re not able to be there by their side or not able to ask.”
If you have any questions about coping with the Coronavirus outbreak, or your retirement years in general, please feel free to call or email us. Just as we always have, we’ll be happy to give you honest, objective answers.