“People always ask me as an ER doctor, ‘What can I do to help you?’ One of the most important things you can do is have an advance care plan,” Dr. Elizabeth Clayborne tells MSNBC’s Alex Witt, “Go to CDC.gov to look at state specific plans, or an online platform like MyDirectives, because thinking about that ahead of time instead of when it’s an emergency is one of the most useful things that you can do for me as an ER provider.”
Advance plans are especially vital now. To give just one example: A person who wants to die at home may free up an ICU bed for a coronavirus patient.
By Dr. Elizabeth P. Clayborne
As an emergency room physician, I’m used to working in a hectic environment. I have never experienced anything as heartbreaking and traumatic as the COVID-19 pandemic. It’s an intense and difficult time for everyone, especially patients and health care providers. Compounding that challenge is the increasingly common experience of doctors being forced to make impossible decisions for patients for whom we have no medical history and who did not plan their care in advance.
Physicians such as myself are becoming overwhelmed and the need to know patients’ advance care plans is more vital than ever. Scarce resources such as ventilators and ICU beds will become precious and it is essential that we reserve these treatments for patients who want them and can most benefit from their use.
Whether you are 18 or 80, advance care plans make it easier for doctors to provide care that honors the wishes of an individual if they are unable to speak for themselves. In the ER, we have minutes to make a decision that will dictate if a person might live on a machine or pass a natural death. I always make decisions based on what I think is best for the patient, but unless people have an advance care plan, that is exceedingly difficult. If I’m told about a patient’s wishes, not only does my work become more person-centered — it can also be quicker. As we handle massive influxes of patients amid dwindling yet crucial resources, time is everything.
‘Die Naturally and with Respect’
One of the most common dilemmas that families and medical professionals alike must navigate are DNR, or “Do Not Resuscitate” orders. Especially now, this ethical question is at the forefront of public discussion, as hospitals evaluate their DNR policies amid COVID-19.
I know patients and families are afraid to say that they don’t want to be put on life support, even if it means their quality of life may decrease, because they assume that they will receive no medical treatment. This falsehood is indicative of a troubling pattern. Too many people are not considering their health care decisions in advance, and as a result, are not being educated on what many of these terms and practices even mean.
I always tell people that “DNR” can mean to “Die Naturally and with Respect.” For some patients, they would rather have their pain and symptoms controlled and have a focus on the quality of their life rather than the quantity of days that they are alive. Others wish to be put on life support for a variety of reasons. It is simply essential that patients be given the space and resources to make an informed decision. If a person expresses in their advance care plan, for example, that they wish to be cared for at home, then that can help make an ICU bed available for a person who requires hospitalization.
For years, many physicians have asked our government, employers and health insurance providers to encourage everyone to create an advance care plan so we are able to understand patient’s wishes and can respect their decisions if they become critically ill. With or without a pandemic, having an advance care plan in place benefits both patients and providers. It allows patients to communicate their medical wishes to their families, doctors, nurses, and other caregivers and helps providers administer the desired care in a timely manner. As we’ve learned from global reporting on COVID-19, being able to treat patients efficiently is essential to reducing fatalities, maintaining lifesaving resources and preserving the effectiveness of our health care systems.Get the Opinion newsletter in your inbox.
Vital to have a plan amid global crisis
Everyone deserves the peace of mind of knowing their wishes will be respected, even and especially if they become incapacitated. In making an advance care plan, patients should consider some basic questions: (1) Who do you want to represent you if you can’t communicate during a health crisis? (2) What are your values and treatment goals? (3) What medical history and information do you want anyone who treats you to have?
My highest aim as a physician is to provide person-centered care. I can’t do that unless my patients clearly articulate and communicate their wishes while they are able to do so. CDC.gov has online resources for advance care planning that are state specific, but it is very helpful to have an electronic record that can be kept up to date. For example, I use a free online platform MyDirectives.com. Plans created online can be altered quickly and securely as needed and can be shared with family and medical providers, so everyone is on the same page.
It’s human nature to avoid subjects that remind us of our own mortality, especially in a time of heightened anxiety. But it shouldn’t take a global health crisis to illustrate the importance of discussing our goals of care and what our family should do if we become acutely ill. These conversations are difficult and raw, but pale in comparison to the grief that may come – and that I have seen materialize for too many families – when a loved one is in an emergency situation and they don’t know how to best advocate for them.
As in every area of life, I encourage people to hope for the best outcome in a medical crisis and prepare for the worst. It is always considerate and responsible to have an advance care plan in place. In an international crisis — for patients, families, and medical personnel on the frontlines of the COVID-19 pandemic — it is indispensable.
Dr. Elizabeth P. Clayborne is an emergency medicine physician based outside of Washington, D.C. She has a master’s degree in bioethics. Follow her on Twitter: @DrElizPC
Read the op-ed on USA Today online here: https://www.usatoday.com/story/opinion/2020/04/09/coronavirus-crisis-plan-end-life-care-help-yourself-others-column/2973529001/
Dr. Elizabeth Clayborne of the University of Maryland’s Prince George’s Hospital Center talks to Cheddar News about fighting on the front lines of the coronavirus pandemic while being pregnant herself.
“I’d really like to emphasize that in addition to putting ourselves on the line we’re also being prepared for the storm of people that could come and overwhelm our facilities and when that surge arrives we’re often going to have to make important decisions about who to care for what scarce resources like beds and ventilators to use. So, I always emphasize the importance of people having an advance care plan and talking to their loved ones while they’re home to ensure they have an understanding of what you would want done in case you do become acutely ill,” said Dr. Clayborne. “And that’s specifically important so that doctors like me don’t have to be overwhelmed with having to make these difficult decisions if we do indeed become overwhelmed by the number of people that come at one time. So you can go to CDC.gov to fill out advance care plans that are state specific or you can use something like MyDirectives.com, which is an online platform does the same thing.”
By Dr. Michael Wasserman
Texas Lt. Gov. Dan Patrick recently suggested older adults should sacrifice themselves amid the COVID-19 pandemic. This brings forth my greatest fear: that ageism in society will lead leaders and others to look the other way while we die of preventable causes in large numbers.
Patrick must not talk to his grandchildren very much. If he did, he would know that they want his love and not his money. Our society is being given the ultimate ethical test.
Would I forgo my own life to save the life of my grandchild? I would. Would I offer my life for the economy, as they claim? You’ve got to be kidding me.
This is America. While we believe in the free market, we also believe in each other. To throw in the towel at this early stage of the pandemic and offer older adults to the altar of COVID-19 is unconscionable.
The important question for anyone over the age of 60 isn’t whether they want to sacrifice their lives, but whether or not they’ve created and shared an advance care plan. That means making our own personal, individualized choices regarding our health.
Those choices are usually related to how we feel about our cognition, function and quality of life. For instance, I may want my family and my health-care providers to know that if I can no longer recognize my family or continue my love of writing, I wouldn’t find value in my life.
Or, to put it in current terms, if I’m at that level of cognitive function and I get hit with COVID-19, then keep me comfortable. Don’t send me to the hospital and above all, don’t waste valuable ICU resources on me.
That’s not just me. It also happens to be the overwhelming majority of the patients whom I’ve cared for over my 32-year career as a geriatrician.
But someone else may well choose to “have everything done,” as is their right. To repeat: This is America. We’re not supposed to ration health care here. During debate over the passage of the Affordable Care Act, the very notion that we might have “death panels” lit conservatives’ hair on fire.
So we all have a right to say how we want our health managed as we get up there in years. We just have to make it clear.
The good news is the government has actually encouraged physicians and health systems to offer advance care plans to patients. Unfortunately, there’s been little public education about creating one.
There are digital platforms like MyDirectives.com that make it easy to do, and at no cost. Because we are isolating older adults to protect them from the virus, the need for an advance care plan to be readily available through the internet is critical.
Such a plan is not a means to avoid treating an older adult. It’s a means to assure that our health-care wishes are heard. It’s a way to assure that we’re treated with dignity and respect.
What I am fearful of in our society is that ageism will define the care that is delivered to older adults in the coming weeks and months. If an older adult gets COVID-19, starts getting short of breath and ends up in an emergency room, what should happen? Right now there are three scenarios.
If I have an advance care plan filled out and available to the emergency room doctor, and my wishes are to not be put on a ventilator if a poor outcome is expected, then I expect to be treated with palliative and hospice care for comfort.
If I don’t have an advance care plan, and the emergency room doctor assumes that I want everything done, I may end up on a ventilator with prolonged suffering until I die.
Alternatively, because I’m old, I could be assumed to have little value to society, or less value than someone younger than me, and be “allowed” to die.
That is not the health-care system that I was trained in. That is not consistent with the Hippocratic Oath, or the country I love.
Wasserman is a geriatrician and president of the California Association of Long Term Medicine.
View the op-ed in New York Daily News here.
Jeff Zucker, CEO and co-founder of MyDirectives joined host Kate Delaney on the America Tonight Podcast to discuss the importance of advance care planning, especially in the midst of our current COVID-19 global health crisis.