By BARRY PRICE
[Editor’s note: Views expressed in guest editorials are not necessarily those of the Mission Times Courier. Guest editorials are chosen based on the timeliness of the topic and if they have some thought-provoking value for discussion.]
With so many media reports about the scarcity of ventilators, you could easily have missed those few articles alerting us to the downsides of these machines. If you did, going to the hospital with a serious case of Covid-19 would be like a pilot flying into hurricane force winds with no warning.
Judging from the data now available, only 50% of Covid-19 patients put on a ventilator actually survive, and the mortality rate for older patients with underlying medical conditions is considerably higher. Even with a mortality rate of 50% or higher, however, a patient (or their health-care advocate) might ask, “what do I have to lose?” The answer might be a lot more than you think, particularly if you decide that the quality of your life is as meaningful as life itself.
Most elderly Covid-19 patients who survive a lengthy ventilator experience will never again enjoy anywhere near the quality of life they had before getting Covid-19. According to Dr. Kathryn Dreger, a professor of Medicine at Georgetown University, the heavy sedation that accompanies this treatment often means survivors have serious long-term mobility and mental acuity problems.
“Many spend most of their recovery time in a rehabilitation center, and older patients often never go home. They live out their days bed-bound, at higher risk of recurrent infections, bed sores and trips back to the hospital.”
At minimum, Dr. Dreger’s sobering words serve as a flashing yellow light. Approach intubation with caution! But the hopeful might note that Dr. Dreger doesn’t produce any hardcore statistics definitively showing that the odds of an older patient’s full recovery from a lengthy stay on a ventilator are in fact very slim. Remember though, this pandemic is so recent, analysts have not had time to develop the statistics necessary to show what doctors in the Covid-19 trenches are seeing first-hand.
A quick search of medical articles that have looked at long-term patient outcomes for a disease closely related to Covid-19, however, provides some of the numbers Dr. Dreger is hinting at.
Covid-19 is a more lethal form of Acute Respiratory Distress Syndrome (ARDS), a disease that has been well studied for many years. And, a review of long-term outcomes for ARDS patients who survive ventilation, published in “Respiratory Review” in May of 2016 provides some touchstones for those interested in the quality of life facing Covid-19 survivors hooked up to a ventilator.
Between 11% and 15% of ARDS/ventilator patients die within the first year of leaving the ICU. Two studies cited in the article indicated ARDS patients who survived the ventilator showed “marked cognitive impairment.” One study cited showed cognitive impairment in 55% of ARDS/ventilator survivors after one year of discharge from the ICU. The same article points out that even five years after discharge from the ICU, ARDS/ventilator patients show a 25% reduction in physical function. For many 70 and older, this often means assisted living.
The psychological effects on ARDS patients who survive ventilators are just as noteworthy. Forty-three percent of these patients suffer Post Traumatic Stress Disorder (PTSD) at discharge from the ICU. A year after discharge, 50% of patients were depressed. Even after two years, 58% still had symptoms of depression.
For some the discouraging outcomes for recovering ARDS patients coming off a ventilator will serve as just another yellow caution light. For me, however, the very high probability that a ventilator will not save me, or if it does, leave me bed-ridden, mentally confused, hooked up to a dialysis machine, passing my last few years in a nursing home, and draining away the economic resources my family will need after I am gone serves as a large red flashing sign that reads “Danger stay away!”
Whether you see a flashing yellow light or a flashing red light, the important thing is to think carefully about opting for a ventilator before you ever have to make that decision. It is especially important that you clearly communicate your wishes to the person who will serve as your health-care advocate when you will be too short of breath to think straight. You should also carry with you to the hospital a copy of your advanced health care directive, perhaps even adding to that directive a Covid-19 addendum. One of these has been developed by the Hemlock Society of San Diego. It can be downloaded at HemlockSocietySanDiego.org
— Barry Price is president of the Hemlock Society of San Diego and a resident of Allied Gardens. Reach him at firstname.lastname@example.org.