Preparing for death becomes grim new reality for hospitals during coronavirus pandemic

Doctors and nurses are writing their wills.

Patients are signing do-not-resuscitate orders.

There are serious discussions about implementing universal DNRs – not trying to resuscitate patients if doing so poses too great risk for nurses and doctors.

Given what is happening in the U.S., in Spain, in Italy – all countries with advanced health systems – these measures have become part of the daily health-care conversation.

Preparing for death has become the grim new reality for everyone walking into a hospital during the coronavirus pandemic.

Some will dismiss this talk as histrionic. After all, Canada has fewer than 5,000 cases and just more than 50 deaths. It’s not as if our system is overwhelmed.

At least not yet.

But, day after day, the COVID-19 threat is shifting from the abstract to the all too real.

The data, while frustratingly limited, reveal that 6 per cent of patients are being hospitalized for severe symptoms such as pneumonia and 2 per cent are ending up in intensive-care or critical-care units.

That means there are probably at least 300 people hospitalized with COVID-19 and about 100 of them are on ventilators. (Why the exact numbers are protected as though they are a state secret is puzzling.)

This could very well be the calm before the storm.

An important lesson we can take from the horrific events that are unfolding in other Western countries is how fast things can go south.

The U.S. went from 1,300 cases and 38 deaths on March 12 to 85,000 cases and almost 1,500 deaths two weeks later.

Will Canada’s epidemic explode in a similar manner? We were a little quicker to embrace social distancing than the U.S. was, but we were slower to close our borders to travellers.

The simple answer is we don’t know yet how bad this will get.

The time to prepare for the unthinkable is when we still have time to think, not when intensive-care units are overflowing, and not when ventilators are in short supply.

When people go for coronavirus testing, they need to be asked if they have if they have advance care plans that include DNR instructions.

Of course, we should all have these directives, but they seem more urgent now.

COVID-19 deaths can be slow and brutal. Patients have described symptoms such as their organs melting from intense fever and drowning slowly from lack of breath. And those are the survivors.

When dying patients are on ventilators, the equipment is not available for others. If there are shortages of lifesaving equipment, Solomon-like decisions will have to be made.

We should always avoid futile or non-beneficial treatment but now those decisions have come to the forefront because of rationing and risks.

COVID-19 is a respiratory illness that requires respiratory therapists, nurses, anesthesiologists and others to intubate patients and to hook them up to ventilators and heart-and-lung machines. Inserting tubes and cameras and responding to “codes” (when patients suffer cardiopulmonary arrest) can all be messy procedures, exposing workers to multiple bodily fluids.

That places them at particular risk for infection with COVID-19, and that danger grows the more hectic hospitals become.

Of course, there is personal protective equipment – shields, masks, gloves, caps and so on – designed to minimize the risk. But there are already disturbing reports of PPE shortages. What happens when case numbers start multiplying rapidly?

We cannot send health workers – be they paramedics, ER staff, ICU doctors and nurses, or the all-important cleaning staff – into the escalating coronavirus battle without proper armour.

Protecting them has to be a priority.

The risks are not just theoretical. In Spain and Italy, 8 per cent to 12 per cent all COVID-19 cases are among health-care workers. Day after day, there are reports of deaths. On Friday, there was the first report of a nurse dying in New York. (During SARS, almost half the cases in Canada were among health-care workers, and two nurses and a doctor died.)

Hospital staff all worry, too, about bringing the coronavirus home, and putting their family members at risk. Many are having difficult “what if I die” conversations.

The coronavirus pandemic has already upended economies and social mores. It is now about to reveal the precariousness of the health system and, for patients and health professionals alike, how we make some seemingly unthinkable choices.