Hospital staff dressed in protective equipment standby as a patient is taken out of an ambulance at Toronto's Mount Sinai Hospital on March 29, 2020.Chris Young/The Canadian Press
As the death toll of the coronavirus pandemic mounts, some doctors are encouraging Canadians to plan for serious illness and possible death now, rather than leaving family and medical staff to make those difficult decisions once they become ill.
Having discussions around serious illness and death helps ensure people do not get unwanted care, such as cardiopulmonary resuscitation (CPR) or mechanical ventilation, said Daren Heyland, a professor of medicine in the department of critical care medicine at Queen’s University.
“One of the unspoken problems of critical care is that we often apply the wrong care to the wrong person… And so we have people in ICU (intensive care units) on mechanical ventilation who never would have wanted that in the first place,” Dr. Heyland said. “People ought to do this advanced planning for serious illness to ensure that they get the right care for them, and that their substitute decision makers have a less stressed experience filling that role.”
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As the pandemic continues, Dr. Heyland and other experts say it is important that people consider the care they would want and communicate their wishes with others. As of Monday afternoon, 66 Canadians had died of COVID-19.
Roughly 30 per cent of the general population and 70 per cent of individuals who are very ill already have a plan like an advanced directive, a legal document outlining one’s care wishes, according to Merril Pauls, a professor in the department of emergency medicine at the University of Manitoba and chair of the bioethics committee at the Canadian Association of Emergency Physicians. However, he said, these plans, sometimes known as living wills, do not always reach front line health providers. Obstacles to effective communication include people discussing plans with their lawyers but not their doctors or stashing documents in places where others can’t access them. Some patients also do not inform hospital staff about their end-of-life wishes, possibly because they go the hospital intending to get well, not to die, he said.
His association’s journal, the Canadian Journal of Emergency Medicine, recently published a paper emphasizing that in certain scenarios amid the pandemic, patients may not want life-sustaining therapies, such as intubation, mechanical ventilation and hemodialysis. In addition, those treatments will not always be successful. (Dr. Pauls noted there is a persistent notion among the public that these measures are more effective than they are.)
While some hospitals in the U.S. are reportedly considering universal “do not resuscitate” orders for all patients with COVID-19, Dr. Pauls said he did not know of any hospitals in Canada that are currently having to enact these types of policies.
He said discussions about people’s goals for care should be seen as routine, not scary or frightening.
It’s important to understand that traditional advanced care plans, which focus on end-of-life care for patients with terminal illnesses, are not very helpful in the current pandemic situation, Dr. Heyland said. People should now be planning for serious illness where there’s a possibility of death but also survival. That’s because when people catch pneumonia from this new coronavirus, it is a serious but not necessarily fatal illness. Critical care providers will need to make decisions about whether to use life-sustaining measures when they do not know what the outcome for their patients will be, he said.
“If we keep promoting the idea that we should be doing end-of-life care plans, it’s not going to be helpful to us as critical care doctors when we don’t know that this is your death,” he said.
Planning for serious illness includes being able to readily answer, given your current state of health, how important it is for you to receive medical treatments that focus on prolonging your life versus maintaining the quality of your remaining life, Dr. Heyland said. You should articulate how important it is for doctors to do everything possible to keep you alive as long as possible versus wanting a natural death without being attached to machines, he advised.
At the same time, people need to be aware that their wishes may not always be what they get, said Dr. Heyland, who provides resources and guidance for “Advance Serious Illness Preparations and Planning” (ASIPP) on his website, planwellguide.com. He explained that certain procedures may not be appropriate for their condition. For instance, even if you wanted CPR, you would not receive it for brain death from a head trauma or stroke.
“Despite what you wished, you’re not going to get that,” he said.
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