Living Wills and COVID-19
Kaiser Health News is reporting the coronavirus pandemic is prompting many seniors to create or modify their Living Wills. The topic of intubation is the leading concern leading to the crafting or rethinking of Living Will strategies. This is happening amidst a wealth of disparate COVID-19 information that makes forming reliable conclusions for decision-making, dubious at best. This is not just a "seniors" issue. Just this past Friday, I met with a 50 year old single mother who raised these very concerns.
Initial reports were suggesting the use of a ventilator was showing signs of promise in severe cases of COVID-19. This machine pumps oxygen throughout a patient's body while lying in bed, sedated, with a breathing tube down their windpipe. Unfortunately, further into the pandemic timeline, these same machines that help patients to overcome respiratory failure appear to have discouraging effects on the patients' survival rates.
Even more dismal is the prognosis of an older adult with COVID-19 placed on a ventilator with an underlying medical condition like lung, kidney, or heart disease. These older COVID-19 patients who do survive, spend considerably longer (two weeks or more) on a ventilator and tend to come out of the treatment extremely weak, de-conditioned, often suffering delirium, and requiring months of rehabilitative care. Unfortunately, these post-ventilator conditions have not been limited to seniors with compromised medical conditions.
As a result, many seniors are revising their Advance Healthcare Directive to address the case of COVID-19 specifically, and are opting out on the use of a ventilator. For example, Joyce Edwards from St Paul, Minnesota, who is unmarried and living on her own with no children, spoke to the issue stating, "I have to think about what the quality of my life is going to be. Could I live independently and take care of myself and the things I value the most? There's no spouse or adult children to take care of me. Who would step into the breach and look after me while I am in recovery?" And then, there is the costs. "How will it be paid for? Will I lose all my assets paying for rehab? Or, will it be taken as reimbursement after I die?"
Joyce's situation is not uncommon in the United States. American seniors are more likely to live alone than ever before: the new mantra of "aging in place." Living alone, however, does not mean they do not have family, somewhere. Still, in the case of contracting COVID-19 and the difficulties recovery can present, many seniors prefer not to upend the lives of their children to prolong their own lives. Some seniors prefer to 'go quietly into the good night' after a life well-lived. They are conceding, in writing, that COVID-19 should be considered a situation where the exercise of extraordinary measures should not be undertaken to keep them alive. This is not how they wish to spend their final months, weeks, or days. It is especially true in the case of intubation, where a patient is essentially in a comatose state and unable to communicate with loved ones before they might pass on.
Then there is the gray area of choice regarding respiratory failure due to COVID-19. While some seniors may be saying NO to a ventilator, there are other procedures where doctors can give high-flow oxygen and antibiotics. Positive airway pressure ("PAP") machines are another mode of respiratory ventilation. BiPAP and CPAP machines deliver oxygen, but without the sedation required during intubation, which allows the patient to be alert, more comfortable, and have interaction with family and friends.
Having discussions with your spouse, family, or doctor if you are alone, about COVID-19 and what to do if you contract the disease and how you might amend your Living Will to reflect your desires are more important than ever. Dr. Rebecca Sudore, a professor of medicine at the University of California at San Francisco, suggests directing the discussion away from using a ventilator or not, to a more general discussion of how an older adult sees their future.
The discussion should include questions about what is most important to you as an older adult:
Is your priority your independence or time with your family?
Is being able to walk and be physically capable important to you, or can you live happily with compromised lungs in a more sedentary lifestyle?
Is your goal to live as long as possible or is it about the quality of your years on earth?
In an open and calm discussion, answering these and other general questions will provide the context that will lead you to your decision about ventilators and other breathing machines.
There is always a lot to think about when it comes to end-of-life wishes. We are here to help you decide what documents are appropriate to adequately express your wishes. Please give us a call at 301.892.2713 or click here for an easy and convenient way to schedule your consultation.
For your safety and ours, we are still taking precautions and limiting initial consultations to videoconferencing. We look forward to talking with you.
"Living with your bags packed!"