key: cord-322066-m8dphaml
authors: Kutscher, Eric; Kladney, Mat
title: Primary Care Providers: Discuss COVID-19-Related Goals of Care with Your Vulnerable Patients Now
date: 2020-05-06
journal: J Gen Intern Med
DOI: 10.1007/s11606-020-05862-7
sha: 
doc_id: 322066
cord_uid: m8dphaml

nan

patients. It is difficult to discuss the possible long-term consequences of intubation because frankly we cannot predict if these complications will occur for each patient. We do not know who will require increased pressures or FiO2, resulting in sustained lung injuries. We do not know who will breathe asynchronously with the ventilator, thus requiring increasing doses of sedatives. We do not know who will simply die from their underlying illness, despite mechanical ventilation. We do not know who will survive to extubation, only to ultimately succumb to pneumonia or urosepsis while undergoing rehabilitation. All of these unknowns often result in doctors uncomfortable in talking about risks and benefits of intubation with their patients until it is clear that the patient has progressed to a point of needing respiratory support. And there is, inherently, never a right moment to have this conversation.

Uniquely, many of the unknowns about intubation are answered with data on COVID-19 from other countries. Patients often require a prolonged intubation of 10-14 days, and patients who are older, have cardiovascular disease (including hypertension), diabetes, or malignancy have worse outcomes. 1 4 For many in the United States, patients who have died while intubated have been alone and without visitors. 5 For those that do survive, the risk of cachexia and a prolonged recovery is almost inevitable.

Volunteering as the anonymous doctor on a COVID hotline, it was clearly not my role to discuss with these callers whether or not intubation is something they would want. It was instead my role to triage concerns and get people complete medical evaluation if needed. Yet, I felt a dissonance: a conversation I felt like I ought to have but could not.

In the emergency department, it is not the job of the ED physician to explain intubation to a decompensating patient needing emergent intervention. With thousands of expected cases of COVID causing respiratory distress at the same time here in New York City, it is even more unrealistic for us to expect our emergency medicine colleagues to have long nuanced goals of care conversations in the acute setting. This is exacerbated by new visitation policies at most NYC hospitals barring all visitors for adult patients.

We as primary care doctors have the privilege of knowing our patients the best. We identify as their doctor and their advocate. Through our repeated encounters, our patients learn to trust us, and we learn to trust them. Thus, in this time of medical crisis, we must step up to help patients better understand this pandemic. We must reach out to our most vulnerable patients and take advantage of our deep relationships to have difficult conversations. We must ask our patients about their concerns about COVID-19, and share information about how to avoid the virus. We must also ask our patients about what medical interventions they would want if they were to contract COVID-19 and require respiratory support. We must be clear and transparent in our thoughts and recommendations, tailoring them to each individual, and communicating them with our best intentions to help patients find a path that is right for them. Given the data we know about COVID-19 and the risks and benefits of intubation, we must use our best medical judgment to help patients understand realistic outcomes and make informed decisions.

For many of our conversations, we may not reach a conclusion as to how to best address respiratory support in this pandemic. But by at least opening the conversation and discussing the options, our patients can be active participants in their care. For those who ultimately decide that intubation is outside of their goals, we must help document these wishes through proper legal forums to make sure their desires are respected.

The role of the primary care doctor is to partner with our patients to help them find their voice in the medical system. With COVID-19, this means having hard conversations with our most vulnerable patients. It means helping many of our beloved patients understand that "do not intubate" is most likely the best choice for them.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

The Novel Coronavirus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) -China

Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study

Clinical Characteristics of Coronavirus Disease 2019 in China

Opinion: I'm on the Front Lines. I Have No Plan for This