This article first appeared on Harvard Health Publishing
By Ashwini Bapat, MD and Emeric Bojarski, MD
The scourge of COVID-19 is spreading. Thousands of Americans are dying.
What can you do to help? Yes, practice social distancing, wash your hands, and donate masks to local hospitals. Also, talk to your loved ones about advance care planning.
What is advance care planning?
Advance care planning means contemplating and deciding the type of medical care you would want if you had a life-threatening illness; you are never too young or too healthy to start these conversations. It involves identifying your goals and values, learning about life-sustaining interventions — such as cardiopulmonary resuscitation (measures to restart your heart and breathing), intubation (use of a ventilator to help you breathe), or artificial nutrition (being fed through a tube in your nose or stomach) — and sharing with loved ones and your doctors your preferences. An advance directive is written documentation of these preferences.
These preferences are not set in stone and can be revised. Doctors will ask you about your care as long as you can communicate. If you are unable to communicate, doctors will ask your loved ones. Advance care planning empowers loved ones to advocate for the type of care you would have wanted and doctors to provide care honoring your wishes.
The urgency of advance care planning in the COVID-19 pandemic
COVID-19 can affect the chronically ill and the healthy, the elderly and the young. Patients with severe COVID-19 pneumonia can struggle to breathe and deteriorate rapidly. Decisions regarding CPR, intubation, or transition to comfort care are made quickly. When patients are too sick to respond, their loved ones are asked to speak on their behalf. Protective isolation measures for COVID-19 preclude loved ones from sitting at the bedside for these decisions, making an already challenging discussion more difficult. If a loved one cannot be reached, the breathless patient will be intubated, and resuscitation will be attempted.
In this crisis, where patients are sick, distressed, and isolated, knowing what interventions a patient would want and making these wishes clear is critical.
Key components of advance care planning
While you are home with family during this time of social distancing, do your homework. Discuss these three key components of advanced care
- Name and document a healthcare proxy. This is also known as a medical power of attorney or a surrogate decision maker. If you are unable to make medical decisions for yourself, your healthcare proxy will make decisions on your behalf, based on your wishes and values. After designating a healthcare proxy, make sure they are comfortable with this role and understand the responsibilities. Document your healthcare proxy utilizing your state’s form and share this documentation with your doctor.
- Discuss your values and wishes. If you are unable to communicate, the healthcare proxy may be asked questions like “Your father has pneumonia and is having a hard time breathing. Would he want a breathing tube?” or “If your father is intubated he may never come off the breathing tube. Would he prioritize living longer with a breathing tube that could be uncomfortable, or would he prioritize comfort, even if it meant having a shorter life?” Knowing your values and beliefs — and communicating them to your healthcare proxy — empowers your healthcare proxy to make the best decisions for you. Consider the following questions:
- If time was short, how would you want to spend it?
- Are there any kinds of treatment you want or don’t want (i.e., CPR, ventilator, artificial nutrition)?
- When would it be okay to transition from curative care to comfort care?
Ease into the conversation by utilizing free guides at The Conversation Project and the National Hospice and Palliative Care Organization. It doesn’t have to be morbid; turn the conversation into a game night (over FaceTime or Zoom if needed) by playing Go Wishor a socially-distant Death Over Dinner party.
- Decide on a do not resuscitate (DNR) order. This is a written instruction to forego CPR, involving chest compressions and ventilator support when a person’s heart or breathing stops. Pursuing or foregoing resuscitation should reflect your goals and values, and should be made in collaboration with your doctor. This order has no bearing on other medical interventions such as antibiotics, dialysis, or fluids, which will be provided or withheld based on a patient’s wishes. Older individuals with chronic illness are more likely to develop severe illness from COVID-19, and it is exactly these individuals who may want a natural death, or for whom there is no expected medical benefit, or for whom quality of life after CPR would be unacceptable.
The bottom line
Advance care planning brings up challenging emotions, and these conversations can be hard. But the day your loved ones are asked what you would want, this planning will make those conversations less distressing, and will enable your doctors to provide the best care for you.
During this pandemic, do your part to help. Get your affairs in order now, because COVID-19 won’t wait.