Month: April 2020

CPR (Cardiopulmonary Resuscitation) in the age of Covid 19-What You Need to Know

nancyvalko Covid 19, CPR, law, medical ethics

Several years ago, a nurse friend was with her boyfriend at a concert hall when he collapsed with no heartbeat or breathing. She called for 911, started CPR and asked for an AED (automatic external defibrillator) , which is located in most offices and public buildings. An AED is a sophisticated, yet easy-to-use (even for a lay person with training), medical device that can analyze the heart’s rhythm and, if necessary, deliver an electrical shock, or defibrillation, to help the heart re-establish an effective rhythm.

However, the concert staff didn’t know where it’s AED was.

My friend continued to deliver mouth to mouth an chest compressions while a crowd gathered, some of whom were physicians who told her to stop because it was hopeless.

Finally, an ambulance arrived and took the boyfriend to a local hospital. He not only survived but was discharged 3 days later in good condition and determined to start a healthier lifestyle.

So I was stunned to read an April 21, 202 New York Post article “NY issues do-not-resuscitate guideline for cardiac patients amid coronavirus” (Covid 19) that said New York state had just issued “a drastic new guideline urging emergency services workers not to bother trying to revive anyone without a pulse when they get to a scene, amid an overload of coronavirus patients.” (Emphasis added)

While paramedics were previously told to spend up to 20 minutes trying to resuscitate a person in cardiac arrest, the new guideline was deemed “necessary during the COVID-19 response to protect the health and safety of EMS providers by limiting their exposure, conserve resources, and ensure optimal use of equipment to save the greatest number of lives.’’

First responders were outraged and their union leader said “Our job is to bring patients back to life. This guideline takes that away from us.”

Earlier this month, the Regional Emergency Services Council of New York had issued a new guideline that said cardiac arrest patients whose hearts can’t be restarted at the scene should no longer be taken to the hospital for further life-saving attempts because the city hospitals had been “inundated with dying coronavirus patients to the point where there are frequently no ICU beds.”

One paramedic acknowledged that only a small percentage of people in cardiac arrest-3 or 4 out of 100-are brought back to life through  CPR and other aggressive interventions such as drugs and hospitalization but insisted that “for those three or four people, it’s a big deal.”

On April 22 and just hours after the initial New York Post article was published, the new guidelines were rescinded. New York City’s Fire Department and first responders never adopted the no-revival directive from the state and kept using the traditional 20-minute policy.

WOULD YOU KNOW WHAT TO DO IF SOMEONE COLLAPSES WITH NO HEARTBEAT OR BREATHING?

When I started as a nurse in many decades ago, we were trained in CPR and taught how to use AMBU bags (mask, valve and self-inflating bag) to breathe for patients in arrest or distress in place of mouth to mouth resuscitation. AMBU bags are now standard equipment on ambulances and other rescue services.

Over the years, techniques for CPR changed especially in 2008 when the American Heart Association released new recommendations that bystanders can skip mouth to mouth resuscitation and use “Hands-Only CPR” to help an adult who suddenly collapses:

“In Hands-Only CPR, bystanders dial 9-1-1 and provide high-quality chest compressions by pushing hard and fast in the center of the victim’s chest.”

Now, the Covid 19 pandemic has changed CPR guidelines.

As the April 16, 2020 Notre Dame Fire Department concisely explains on pandemic-modified CPR guidelines for bystanders:

“Bystander CPR (cardiopulmonary resuscitation) improves the likelihood of an individual’s survival from cardiac arrest occurring outside of the hospital. However, coronavirus is spread through respiratory droplets when an infected person coughs, sneezes or talks. If a rescuer breathes into a cardiac arrest individual’s mouth, there will likely be an exchange of respiratory droplets. Household members who have been exposed to the individual at home should not hesitate to attempt life-saving rescue measures.

A non-household bystander who attempts to rescue a cardiac arrest individual should wear a face mask or cloth over his/her mouth and nose and place a face mask or cloth over the mouth and nose of the individual to reduce the risk of transmission.

In the case of an adult in cardiac arrest, lay rescuers should perform at least hands-only CPR. For children, lay rescuers should perform chest compressions and consider mouth-to-mouth ventilation, if willing and able, given the higher incidence of respiratory arrest in children.

To perform Hands-Only CPR, you place your hands in the center of the chest and pump hard and fast at a rate of 100 to 120 compressions per minute.

If an AED (automated external defibrillator) is available, please proceed with opening the AED and following the automated prompts to initiate life-saving intervention. Defibrillation is not expected to be a highly aerosolizing procedure. If an AED is not available, please proceed with Hands-Only CPR.

For all cardiac related emergencies, EMS (911) should be called…For more information, refer to the American Heart Association’s interim CPR guidance.

CONCLUSION

As a nurse, I have participated in many instances of cardiac or respiratory arrest and it’s always stressful. However, the joy of participating in saving someone’s life is indescribable. And even when we were unsuccessful, we had the consolation of knowing that we did everything we could for that person.

I encourage everyone to take a course to learn CPR. To find such a course, you can contact your local hospital or go to the American Heart Association’s Find A Course  or to the Red Cross website.

And I personally thank the courageous New York Fire Department and first responders for upholding the standards of care for all their patients.

 

Health Care Rationing, Covid 19 and the Medical Ethics Response

nancyvalko CHA, Covid 19, disability, euthanasia, futility, law, medical ethics, ventilators/life support

While the key medical model in the US for Covid 19 deaths has just again been revised from 240,000 to 100,000 to now just 60,000 by August along with concerns about the possible overuse of ventilators in Covid 19, there is still a push for medical health care rationing guidelines.

As the April 8, 2020 Wall Street Journal article “As Coronavirus Peaks, New York City’s Hospitals Prepare ‘Live or Die’ Guidance” notes, some hospitals and health care systems are coming up with guidelines and scoring systems to allocate ventilators. At the same time, New York lawmakers have recently passed a measure to protect hospitals and clinicians from certain medical malpractice lawsuits while the Covid 19 virus strains the health system.

Disability groups are complaining about discrimination in health care rationing plans that would “illegally deprive people based on age, mental cognition or disability”. In addition, a recent Center for Public Integrity analysis shows that policies in 25 states would ration care in ways disability advocates have denounced.

While such rationing plans are usually said to be based on determining which patients have little if any chance of a good outcome, i.e.  medical futility, even the American Medical Association has admitted in its Code of Ethics that “However, physicians must remember that it is not possible to offer a single, universal definition of futility. The meaning of the term “futile” depends on the values and goals of a particular patient in specific clinical circumstances.” (Emphasis added)

THE CATHOLIC MEDICAL ETHICS PERSPECTIVE

Medical ethics in Catholic health care institutions are often considered the most stringent in terms of protecting human life from conception to natural death. So what do Catholic ethics authorities say about rationing?

On April 3, 2020, the US Catholic Conference of Bishops (USCCB) issued a powerful statement “Bishop Chairmen Issue Statement on Rationing Protocols by Health Care Professionals in Response to Covid-19” that stated:

“Every crisis produces fear, and the COVID-19 pandemic is no exception. However, this is not a time to sideline our ethical and moral principles. It is a time to uphold them ever more strongly, for they will critically assist us in steering through these trying times.”

and

“Good and just stewardship of resources cannot include ignoring those on the periphery of society, but must serve the common good of all, without categorically excluding people based on ability, financial resources, age, immigration status, or race.” (Emphasis added)

The statement cited other Catholic health care groups like Catholic Medical Association, the National Association of Catholic Nurses and the National Catholic Bioethics Center that all issued helpful statements.

However another Catholic group mentioned, the Catholic Health Association, has also issued a problematic statement on the rationing issue titled “Code Status and COVID-19 Patients “ stating that:

“CPR may be medically inappropriate in a significant portion of elderly, critically ill patients with COVID-19 and underlying comorbidities. As per Parts 3 and 5 of the Ethical and Religious Directives for Catholic Health Care Services, if it is shown that the burdens exceed the benefits, it is morally acceptable to withhold such procedure.” (Emphasis added)

And even worse:

“If treating clinicians, including more than one physician, determine that CPR is not medically appropriate, a Do Not Attempt Resuscitation Order (DNR) may be written without explicit patient or family consent.” (All emphasis added)

In a separate April 7, 2020 statement from the  National Catholic Partnership on Disability titled “Rights of Persons with Disabilities to Medical Treatment During the COVID-19 Pandemic , the NCPD states “As The Office of Civil Rights of the U.S. Department of Health and Human Services has recently reminded us, America’s basic civil rights laws, including the Americans with Disabilities Act, prohibit discrimination:

“[P]ersons with disabilities should not be denied medical care on the basis of stereotypes, assessments of quality of life, or judgments about a person’s relative ‘worth’ based on the presence or absence of disabilities. ”  (Emphasis added)

CONCLUSION

Over my many decades as a nurse, I have seen the question of “quality of life” deteriorate from what can we do to improve the quality of life for every patient to judging whether or not a patient has sufficient quality of life to justify treatment or care like a feeding tube.

During that time, Alzheimer’s and major CVAs (strokes) in advanced age have come to be seen as fates worse than death that should not be a burden on people and their families or a waste of health care resources.

Before my own mother developed Alzheimer’s and a terminal cancer, she often told me that she never wanted to be a “burden to her family”. I never considered her a “burden” when I cared for her and she was comfortable and fed to her last day. I will never tell my children what my mother told me.

And especially with assisted suicide polls showing much public support, we cannot afford to play into the idea that some people are “better off dead” regardless of whether or not they “choose” a premature death or someone else “chooses” it for them.

We should also remember the lethal legacy of the 2005 Hurricane Katrina disaster. Flooding caused the New Orleans mayor to issue an unprecedented mandatory evacuation of the city with the exception of major hospitals. But when conditions worsened at the large Memorial Medical Center and evacuation efforts were slow, some medical staff allegedly euthanized some of the patients.

However and despite strong evidence, a massive PR campaign portraying those patient deaths as “compassionate” resulted in the 2007 grand jury refusing to indict the doctor and 2 nurses charged.

As we see this debate over medical ethics in crisis situations continue today, we must continue to insist that every person deserves a natural lifespan without discrimination.

Ventilator Rationing, Universal DNRs and Covid 19 (Coronavirus)

nancyvalko conscience rights, Covid 19, disability, Living wills, medical ethics, nursing, pro-life, ventilators/life support

As a nurse myself, it is hard to watch my fellow nurses bravely fighting on the front lines of this pandemic without being able to be there with them.

Nurses are a special breed. In my over 50 years as a nurse, I found that most of us chose nursing because we want to help people and alleviate suffering. We work the long hours on our feet, skip meals, hold hands and listen, cry when our patients die, etc. because we truly do care.

But the health care system has been changing. A dark new ethics movement is infecting our system and telling us not only that our patients have a right to choose to end their lives but also that some of our patients even “need” to die and that we can’t care for all of them during the Covid 19 pandemic.

Worst of all, we are being told that we can now know how to decide which patients are “expendable”.

VENTILATOR RATIONING

A 71 year old man with a heart condition arrives at a hospital is diagnosed with Covid 19. His condition worsens and he is placed on a ventilator to help him breathe. Then the infection rate spikes in the city and the hospital is overrun with severely ill patients, many between 20 and 50 years old and otherwise healthy.

The health care team is forced to decide which patients should they focus on and care for.

This is the scenario posed in a March 20, 2020 Medpage article “Ethics Consult: Take Elderly COVID-19 Patient Off Ventilator?— You make the call” along with an online survey with 3 questions:

1. Would you prioritize the care of healthier and younger patients and shift the ventilator from the elderly man to patients with a higher probability of recovering?
2. Would you change your decision if the elderly patient had been in intensive care for a non-COVID-19-related illness?
3. Would you prioritize the older man over college students who had likely been
infected during spring break trips?

After almost 4000 votes, the survey showed 55.65% voting yes on prioritizing the care of the healthier and younger patients, 78.11% voting no on changing their decision about the elderly patient if he didn’t have Covid 19 and 71.12% voting no on prioritizing the elderly man over college students likely to have been infected on a spring break trip.

So while most people fear becoming infected with Covid 19, less well-known ethical dangers may also affect us-especially those of us who are older or debilitated.

Every day, we hear about the shortage of ventilators needed for Covid 19 patients and the overworked and understaffed health care professionals providing the care. Now both mainstream media and medical journals are publishing articles about the ethical dilemma of denying CPR (cardiopulmonary resuscitation) or a ventilator to older patients or those with a poor prognosis with Covid 19 in a triage situation.

Triage is defined as “A process for sorting injured people into groups based on their need for or likely benefit from immediate medical treatment. Triage is used in hospital emergency rooms, on battlefields, and at disaster sites when limited medical resources must be allocated.” (Emphasis added)

But this definition does NOT include deciding how to triage people based on age or “productivity”.

UNIVERSAL DNRs

A March 25, 2020 Washington Post article “A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic” posed the question: “how to weigh the ‘save at all costs’ approach to resuscitating a dying patient against the real danger of exposing doctors and nurses to the contagion of coronavirus.”

This is not just an academic discussion.

As the article reveals, “Northwestern Memorial Hospital in Chicago has been discussing a do-not-resuscitate policy for infected patients, regardless of the wishes of the patient or their family members — a wrenching decision to prioritize the lives of the many over the one.” (Emphasis added) And Lewis Kaplan, president of the Society of Critical Care Medicine and a University of Pennsylvania surgeon, described how colleagues at different institutions are sharing draft policies to address their changed reality.

Bioethicist Scott Halpern at the University of Pennsylvania is cited as the author of one widely circulated model guideline being considered by many hospitals. In an interview, he said a universal DNR for Covid 19 patients was too “draconian” and could sacrifice a young person in otherwise good health. He also noted that the reality of health-care workers with limited protective equipment cannot be ignored. “If we risk their well-being in service of one patient, we detract from the care of future patients, which is unfair,” he said.

The article notes that “Halpern’s document calls for two physicians, the one directly taking care of a patient and one who is not, to sign off on do-not-resuscitate orders. They must document the reason for the decision, and the family must be informed but does not have to agree.” (Emphasis added)

This could not only upend traditional ethics but also the law as “Health-care providers are bound by oath — and in some states, by law — to do everything they can within the bounds of modern technology to save a patient’s life, absent an order, such as a DNR, to do otherwise.”

Both disability and pro-life groups have condemned such health care rationing with Covid 19, especially for older people and people with disabilities.

However, this and more is apparently already happening.

In an April 1, 2020 Wall Street Journal article “What the Nurses See: Bronx Hospital Reels as Coronavirus Swamps New York” a co-worker told the nurse interviewed that the nurses were no longer doing chest compressions to resuscitate Covid 19 patients because “it uses lots of protective gear and puts workers at greater risk than chemical resuscitations”. This was corroborated by other nurses who said this has become an “unspoken rule.”

CONCLUSION

How can we protect ourselves and our loved ones in these circumstances?

At the very least and whether or not we are older or have disabilities, we should consider or reconsider our advance directives.

As the Life Legal Defence Foundation  writes in their “SPECIAL MESSAGE ABOUT COVID-19 AND ADVANCE HEALTH CARE DIRECTIVES”:

As COVID-19 spreads around the globe, the public is learning about the importance of mechanical ventilators in providing temporary breathing support for many of those infected. Ventilators are saving lives!

A false understanding of respirators and ventilators has become commonplace in recent years. Many people think that these and similar machines’ only role is prolonging the dying process. The widely publicized treatment of COVID-19 patients is helping to dispel that myth. Many patients rely on machines temporarily every day for any number of reasons and go on to make full recoveries.

Unfortunately, many individuals have completed advance health care directives stating or suggesting that they do not wish to receive breathing assistance through mechanical ventilation.

Please take the time to review any advanced medical directives (including POLST forms) signed by you or your loved ones to make sure they are clear that mechanical ventilation is not among the forms of care that are refused. If there is any ambiguity, you may want to consider writing, signing, and dating an addendum specifying that mechanical ventilation is authorized. (Emphasis in original)

I would add that other treatments or care such as DNRs and feeding tubes also not be automatically checked off. I believe it is safer to appoint a trusted person to insist on being given all information concerning risks and benefit before permission is given to withdraw or withhold treatment.

Even as the nation is racing to get more ventilators and staff as we cope with this terrible pandemic, we all must continue to affirm the value of EVERY human life.