As the number of COVID-19 infected cases has risen to nearly 400,000 in the United States, we are seeing metropolitan areas crushed with the flood of patients.
Two weeks ago, The Washington Post ran a story that reported some institutions were considering a COVID-19 “do not resuscitate” policy.
Knowing how easy it is for the virus to spread and the dwindling supply of personal protective equipment (PPE), it forces us to ask about our moral obligation to provide CPR for these patients.
It feels offensive that one would even consider withholding a lifesaving procedure.
First responders, hospital staff and physicians are trained to respond. One must act immediately without knowing much about the patient.
In most instances, there is little, if any time, to consider questions such as, “What are their values?” and “Would they even want this?”
CPR and Advanced Cardiac Life Support (ACLS) have become part of our culture. We watch them on television where the patient is saved over 75% of the time.
The truth of the matter is in real life CPR is not what is seen on shows like “Grey’s Anatomy.” It’s violent.
With 100 chest compressions a minute, ribs get broken. An endotracheal tube is inserted into the lungs, and the patient is bagged or put on a ventilator.
Frequently, patients need cardiogenic shocks that leave electrical burns. A lengthy resuscitation can leave a patient with a pneumothorax (collapsed lung) or coughing up blood.
Even with these complications, CPR can be worth it if the patient is ultimately able to survive.
The problem is the public assumes health care workers are more successful than they are.
On average, 100,000 Americans over the age of 65 receive CPR each year. Unfortunately, less than one in five survives.
About half of all survivors suffer some neurological impairment due to an inadequate supply of oxygen while they were down. A staggering two-thirds will be readmitted within a year.
Often, the public and media do not see CPR and ACLS for what they are. These procedures are a last-ditch effort to save a patient’s life.
When thinking about requiring do not resuscitate orders for COVID-19 patients, several values come into conflict.
One issue is not knowing the patient’s wishes. Once a patient has cardiac arrest, one cannot ask what they value or what they want to do.
Most of the time, their family does not know what the patient would want, so they ask for everything.
The case of a COVID-19 patient is even worse because there is so much about the virus we do not know.
Most health care workers are frustrated because they often begin emergent procedures on patients with many comorbidities (“two or more disorders or illnesses occurring in the same person”) not knowing if the patient even wanted the procedure.
Stating one’s wishes or writing a living will helps ease the burden for families and guides the health care staff.
Another moral issue is related to allocation of resources. In a pandemic with scarcity of resources, the use of CPR and ACLS consumes many resources beyond just a ventilator.
When a patient “codes” in the hospital, typically six to 10 health care workers are involved.
With the shortage of PPE, it is possible an attempt to save a COVID-19 patient’s life will infect the whole room because, during the process of resuscitation, liquid droplets become aerosolized.
Normally, this is not a problem because facilities have plenty of PPE and staff. What we are seeing in places like New York, is that staff and physicians are as much a health care resource as PPE or ventilators.
If a significant amount of health care workers become sick, hospitals will cease to function.
It is not that workers are more important than patients. The issue is that in order to continue saving lives, the hospital must protect its medical team.
If it were not for the mass number of cases, the risk of exposure probably would be justified.
In the case of a COVID-19 patient, the risk of infecting physicians and nurses must be weighed against the chance that the patient will survive.
From a moral standpoint, requiring do not resuscitate orders for all COVID-19 patients is inappropriate.
It commits a false generalization, which opens the door for bias that can leave vulnerable populations and demographics at risk.
Some patients who were relatively healthy prior to infection might do well after CPR. Other patients might respond to CPR quickly and need few resources.
On the other hand, the medical team must consider the chance of success. It would probably be irresponsible to preform CPR on a COVID-19 patient for a second time or the first time should they have several comorbidities.
The low chance of success does not justify the risk to the staff.
As people of faith, if we believe all lives are precious, we must also look at the whole picture, considering the patient and the risk of staff exposure. We have to consider how we will save the most lives over an extended period of time.
Answers to these difficult questions are much more complicated than a blanket order for a generic class of patients.
Such complex issues require thoughtful engagement. There are no easy answers or clear-cut solutions.
It is tragic that health care experts have to consider these scenarios, so let us pray for wisdom and discernment as they navigate these challenging and uncertain times.