As the coronavirus pandemic continues to sweep the United States, some hospitals are considering whether to make changes to policies and practices when it comes to do-not-resuscitate situations.
Such conversations come as hospitals brace for a surge of patients, despite dwindling supplies of personal protective equipment for doctors and ventilators for seriously ill patients.
A do-not-resuscitate order, also known as a DNR, is a medical order that tells health care professionals not to perform CPR if a patient stops breathing or their heart stops beating. It’s an agreement that a doctor will write after discussion with a patient who agrees that this is what they want. If the patient isn’t able to have such a discussion, the patient’s family can make that choice.
Dr. Deborah Birx, White House coronavirus response coordinator, said during a briefing on Thursday the country doesn’t need a blanket DNR for coronavirus patients.
“There is no situation in the United States right now that warrants that kind of discussion,” Birx said. “You can be thinking about it in a hospital, certainly many hospitals talk about this on a daily basis, but to say that to the American people, to make the implication that when they need a hospital bed, it’s not gonna be there, or when they need that ventilator it’s not going to be there — we don’t have evidence of that right now.”
But some worry that performing CPR on patients with Covid-19 can expose health care workers to the virus. With the shortage of personal protective equipment, this procedure could put them and other patients at risk.
“That’s one of the big concerns: how likely is survival in a patient and what is the risk to the health care workers as a result of the resuscitation,” CNN’s Chief Medical Correspondent Dr. Sanjay Gupta said on New Day on Thursday morning.
“There’s been these rumors that there were these blanket do-not-resuscitate orders. Hospitals that we’ve talked to said that that’s not necessarily the case but they are having conversations with families early on,” he said. “All of that is being discussed much earlier.”
‘Our goal is to have these conversations proactively’
Geisinger Health System, which includes 13 hospital campuses in New Jersey and Pennsylvania, confirmed to CNN in a written statement on Wednesday that conversations about whether to change DNR practices are taking place within its hospitals, but that “we do not plan to override patient or family wishes.”
“Geisinger’s policy for heroic measures on COVID-19 patients is still in development but will mirror our well-established obligations and policies to do what is right for our patients in similar end-of-life situations,” the statement said.
“A critical part of the policy will be consultation with patients and families to discuss the course of treatment in the event of life-threatening complications,” the statement continued. “We do not plan to override patient or family wishes, but rather our goal is to have these conversations proactively with families early on during treatment so there is uniform understanding of care that is safe and compassionate for patients, families and staff alike.”
Northwestern Medicine, which includes Northwestern Memorial Hospital in Illinois, also told CNN in a written statement on Thursday that “similar to many health systems around the country and the world, we are conducting internal discussions on how to care for patients with COVID-19. At this time, we do not have any changes to patient care policies to announce.”
Some other large hospital systems have been discussing issues around do-not-resuscitate orders, The Washington Post reported Wednesday night.
“It’s true that there have been discussions abroad about how physicians must prioritize patients — and it’s my understanding that those will still be on a case-by-case basis,” Dr. Darria Long Gillespie, senior vice president of clinical strategy at Sharecare and a clinical assistant professor at the University of Tennessee School of Medicine, wrote in an email on Wednesday.
She added that she does not foresee a universal do-not-resuscitate approach for all Covid-19 patients, which ignores age and baseline health, on the horizon.
A longstanding debate in medicine
Nancy Kass, the Phoebe R. Berman professor of bioethics and Public Health and deputy director for public health at Johns Hopkins University in Baltimore, told CNN that she doesn’t think blanket DNR orders for coronavirus patients would be appropriate, with some important caveats.
“A blanket DNR order is not helpful in this situation, nor for other situations going forward because I think it opens the door to DNR orders for subgroups of patients or patients with particular conditions being reasonable policies and I don’t think that makes sense,” Kass said.
Kass added, though, that she thinks that patients shouldn’t have the right to request medical care that doctors think is not likely to be helpful in any circumstance, not just related to coronavirus patients. It’s a longstanding debate in medical ethics, she said.
In the United States, Kass said that she thinks systems often err on the side of allowing families to request “a remarkable number of things” that physicians may not necessarily believe could help a patient — and that conversation is particularly relevant to the Covid-19 response since medical personnel are put at great risk due to shortages of protective equipment.
The fact that the conversation is occurring because of a lack of staff and equipment in this country “is stunning” and “unsettling,” Kass said.
“It is really unsettling, because you know it’s one thing to feel like your loved one died from a horrible disease, or nobody could do anything and that is so deeply sad,” Kass said. “But people would not have the same kind of anger they might have when they feel, on some level, that this might have been preventable had people only had the right equipment.”
‘A significant shortage of PPE’
World Health Organization officials warned during a media briefing on Wednesday that globally there is a “significant shortage” of medical supplies.
“We need to be clear: The world is facing a significant shortage of PPE for our frontline workers — including masks and gloves and gowns and face shields — and protecting our health care workers must be the top priority for use of this PPE,” Dr. Maria Van Kerkhove, WHO infectious disease epidemiologist, said during that briefing.
All elements of the supply chain for supplies appear to be under “extreme strain,” Dr. Mike Ryan, WHO executive director of health emergencies programme, said during the briefing.
“There are problems in the supply chain all along that chain. The simple issue is demand,” Ryan said. “There are shortages of PPE, shortages of ventilators and other products for the medical response to Covid. We also have to avoid shortages in other medical supplies, as supply chains come under strain.”