As the world grapples with the spread of COVID-19 (coronavirus), medical providers in the United States are trying to provide emergency care to people infected with the virus without risking their own health, or that of other patients. And unfortunately, that has led some hospital staffers to consider making a horrific choice: giving DNRs, or do-not-resuscitate orders, to patients without their consent, or that of their families.
The Washington Post profiled several of the hospitals considering this dangerous move, like Northwestern Memorial Hospital in Chicago. Richard Wunderink, an intensive-care medical director there, said the hospital is consulting with Illinois Governor J.B. Pritzker to see if state law allows them to make that decision, indicating that the hospital is already seriously considering involuntary DNRs as an option. “It’s a major concern for everyone,” he said. “This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances.”
Atrium Health in the Carolinas, Geisinger in Pennsylvania and regional Kaiser Permanente networks are also cited as considering allowing doctors to “override the wishes of the coronavirus patient or family members” if they deem it to be necessary. “We are now on crisis footing,” Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, told the Washington Post. “What you take as first-come, first-served, no-holds-barred, everything-that-is-available-should-be-applied medicine is not where we are. We are now facing some difficult choices in how we apply medical resources — including staff.”
R. Alta Charo, a University of Wisconsin-Madison bioethicist, also argued that while some may find the idea of essentially letting patients die without helping to be abhorrent, it’s necessary. “It doesn’t help anybody if our doctors and nurses are felled by this virus and not able to care for us,” she said. “The code process is one that puts them at an enhanced risk.” Scott Halpern, a University of Pennsylvania bioethicist, recommended having two physicians together making the decision to stop resuscitations, and that families must be notified but not agree.
The reason helping someone when they’re coding can be dangerous is because inserting things like tubes and cameras down someone’s throat for endoscopies, bronchoscopies, or intubation, or performing compressions on a patient’s chest, can send microscopic droplets containing the virus into the air. And that’s exactly why some of these providers are considering just letting patients die, even if they or their families never consented to a DNR.
But George Washington University Hospital in Washington, D.C., has other ideas. “From a safety perspective you can make the argument that the safest thing is to do nothing,” chief medical officer Bruno Petinaux said. “I don’t believe that is necessarily the right approach. So we have decided not to go in that direction. What we are doing is what can be done safely.” Their protocol is to drape plastic sheeting, which you can get at Home Depot, over a patient before starting compressions. With patients intubated, there’s no risk of suffocation, and it minimizes the risk of infecting others.
The University of Washington Medical Center in Seattle is likewise considering other options, like limiting the number of medical providers who respond to a patient in cardiac or respiratory arrest. These decisions show there are alternatives beyond abandoning people to die, without even giving them or their families a say in the decision.
On March 26, Dr. Deborah Birx, the Trump Administration’s coronavirus task force coordinator, pushed back against this narrative, saying:
Please, for the reassurance for the people around the world, to wake up this morning and look at people talking about creating DNR situations, do-not-resuscitate situations for patients, there is no situation in the United States right now that warrants that kind of discussion….
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 gonna be there, we don’t have an evidence of that right now.
While hospitals haven’t thus far stopped resuscitating patients with the coronavirus, as the number of cases increase, there will be decisions that need to be made. Those decisions should be made with patients, before they reach the point of needing critical, life-saving care — not after. Allowing doctors to make these decisions unilaterally sets a dangerous, disturbing precedent. And once doctors are allowed to become executioners, there will be no turning back.
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