How to protect your body and your doctors soul during Covid19

i’m dr clayborn

i’ll be taking care of you today

you can become ill or injured at any

time

do you want a stranger taking care of

you

as an er doctor i want to know who i’m

taking care of when i rush into an

emergency

what happens when the majority of

patients are in shock distress

or unable to speak for themselves

and what about now during covet 19 when

family members can’t go into the

hospital

and paramedics are limited in what they

can do before they drop you off

who speaks for you where is your voice

do you have goals of care do you have

medical conditions or medications that i

need to know about

all of this information is essential to

me being able to treat you in the first

few minutes

an advanced career plan that you create

and that i have access to

is the best thing that i can have to

allow me to care for you and more

importantly

for you to have a voice in your own care

i want to tell you a story

as i tell you this story i want you to

close your eyes

and think of your grandmother or your

mother

perhaps an aunt or a sister this is the

story of mrs t

she came to the emergency department in

march of this year

as she arrived in respiratory distress

the paramedics who brought her in were

sweating underneath their ppe as we

rushed her into a negative pressure room

because her oxygen saturation

was dangerously low i looked at mrs t

in the bed and i felt sad

she was alone bedridden and clearly had

been shuffled back and forth between the

nursing home

and hospital as evidenced by the old

tape marks from prior ivs that were in

her arms

and scars from central line catheters

that had been placed in her neck

she looked emaciated and hollow her eyes

barely open

i could tell that she was tired i

flipped through her paperwork

and i found a next-to-kin listed a

daughter with an out-of-state number

who i was unable to reach and things

were rapidly deteriorating

her forms listed her as a full code but

were dated from over a year ago

with no more time to make a decision i

intubated mrs t

i placed a breathing tube down her

throat to secure her airway and help her

breathe

her blood pressure dropped so i drove a

large sensor

central catheter into her groin to help

administer medications

despite all these measures mrs t’s heart

stopped

i knew that cpr would be futile in this

elderly woman with

multiple medical problems who is likely

now dying from cobat 19

but we did our best to resuscitate her

her ribs snapped under the pressure of

chest compressions

and made crunching sounds with each

motion

blood started spewing out of her

breathing tube as we tried to suction it

out

we gave her multiple rounds of

medications and after 12 minutes

we got her back well what was left of

her

i fully knew that while mrs t’s heart

was beating

her mind the thing that made her a human

being

was likely irreversibly damaged

mrs t coded two more times until we were

finally unable to bring her back

despite all the fancy medications and

tools at our disposal

when i finally called her time of death

i couldn’t help but to feel guilty

if she had been my grandmother i would

have been ashamed

that in the last hours of her life she

was poked and prodded

exposed and naked in a room full of

strangers who were scared for their own

lives

as they did high-risk procedures that

were unlikely to make a difference in

the very end

i knew that we had finally crossed that

very fine line

from the hippocratic loaf first do no

harm

i’m all too familiar with patients like

mrs t

as our doc our bodies begin to age

medicine has evolved to add more and

more years to your life

but this does not necessarily mean that

they’re quality years of life

this can be even more devastating when

illness or injury strikes

you at a very young age leaving you

completely dependent

or very ill so what’s the solution

what can you do with so much fear and

uncertainty facing us all

i have an answer that can empower you

that can give you some sense of control

and can protect you when you’re unable

to speak for yourself

you can plan ahead what i mean by that

is that you can make an advanced care

plan

one of the most important parts of

advanced care planning is making an

advance directive

a document that tells doctors like me

what to do in an emergency to guide your

care

ask questions like what to do if your

heart stops or if you need assistance

breathing

who to talk to in an emergency and what

treatments you would like based on your

health condition

it’s important when filling out this

document that you do the heavy lifting

of

thinking carefully about this now what

does quality of life mean to you

you have to do this before you get sick

before

your family has to make a decision

before an er doctor has to put her life

on the line to save you

what is important to you is it important

for you to be able to walk outside

perhaps change the channel on a tv talk

to a loved one

feed yourself or bathe yourself if you

could never do any of these things again

would your priorities change

i want you to think about that now

contemplate what the implications are

for your family

or your body and for your soul

people with advanced care plans are

three times more likely to have their

wishes followed

without an advanced care plan cancer

patients are seven times more likely to

undergo mechanical ventilation

and eight times more likely to have

attempts of resuscitation

at the end of life nursing home

residents without an advanced care plan

have

more hospitalizations are less satisfied

with their care

and have 33 percent higher costs of care

and remember these decisions are not

without a cost of our society

50 percent of us health care spending

treats

5 percent of the population a third of

medicare spending is incurred in the

last year of life

often on treatments that are unwanted

and unnecessary

and despite knowing all of this fewer

than 30 percent of americans have an

advanced care plan

this year i personally had to revisit my

advanced care plan

i was seven months pregnant when covet

19 hit

working in an underserved emergency

department outside of washington dc

we’re seeing severe cases of the

coronavirus rampage communities with

long-standing health disparities

i was caring for people who looked just

like me a few years older

or perhaps my parents age who were

coming in and dying in a matter of days

it was terrifying at that time our

testing

treatment and understanding of the virus

was just beginning

i wasn’t sure what the risk was to my

unborn child or my 18 month old at home

i remember having a conversation with my

husband describing what i should do

if i became ill or went into preterm

labor

it was important for me to have him

understand what my quality of life was

if and how to protect that and our baby

i updated my advanced directives and

asked all of my family to make sure that

they had recent forms that we could

easily

access electronically on a platform like

mydirectives.com

i made sure that they understood it

wasn’t enough just to tell me what they

wanted

but to appropriately document and share

that with their doctors and families

so that it easily could be looked up in

an emergency if needed

this is important for people of all ages

advanced care plans allow you to

identify a proxy

somebody you trust who you’ve told about

your wishes and medical conditions

and who’s willing to speak for you if

there is an emergency and you cannot

talk for yourself

this is important and a lifeline for

doctors like me who need to access

information quickly

if there’s an urgent situation that

needs an immediate response

i also told my family that advanced care

planning wasn’t something we visit once

and never talk about it again and it’s a

process

something we should discuss regularly

especially when anyone’s health or

circumstance has changed

this allows us to all stay on the same

page and understand what is most

important

for that family member fortunately i

gave birth to a healthy baby girl in may

and i spent three months cocooned at

home with my family

watching as the world and the u.s

battled covet 19

and everything that came with it when i

returned to work

the first thing i noticed is that the

same problem still existed

we were still caring for patients not

knowing what their wishes were

an advanced care plan not only protects

your body

and your health care and your values it

also protects the front-line providers

who are taking care of you

it protects me from having guilt or

anguish

from torturing patients at the end of

life when i’m not sure that’s what they

would have wanted

it protects your family from having the

immense burden of having to make a quick

decision

but not ever really being sure what you

would have wanted

it saves millions for our health care

system

from spending on interventions that are

often ethically and clinically

inappropriate and it prevents health

care workers

who are putting their lives on the line

every day for strangers

from exposing themselves when it is

unnecessary and unwanted

i often tell families and patients when

we’re having difficult conversations

about dying

that i think of dnr as die naturally and

with respect

just because you’re telling me that you

want to have a natural death

doesn’t mean that i’m not going to do

anything for you i’m going to treat your

pain

i’m going to control your symptoms i’m

going to make sure that you’re

comfortable

i’m going to respect you as an

individual

the best gift i can give to a patient is

a good death

and please don’t complete advanced care

planning with death panels or doctors

playing god

contrary to popular to belief i have no

desire to make these difficult decisions

for you

my job is to clearly and honestly

communicate

what medical interventions are available

and what might be right for you

based on your health condition but you

have to tell me what’s most important to

you

and only then can we have shared

decision making

that respects you as an individual i

want to know what you want

where is your voice and what are your

values for some people this might mean

to do everything

for others it might mean to focus on

symptom management and pain

and perhaps your goals of care align you

with something in between

i have another story of a patient who i

treated miss cobe at 19.

his name was mr j he was 81 years old

and he had three sons and seven

grandchildren

he came from assisted living where he

had been sick for over a week

when he arrived in the emergency

department his breathing was shallow and

quick

he looked scared and he was blinking a

lot

he had a written advance directive that

stated that he did not want any

interventions

i found a number for one of his sons on

this document i called him to tell him

what was going on

i explained that their father was very

ill and likely dying and that his

advanced directive instructed that he

wanted palliative care only

i asked the son what their father would

say if he was able to speak for himself

dad never wanted any machines i was told

he had been very clear with his sons

that he had lived a good life and if the

time came

he preferred to not have any

interventions or be resuscitated

i knew that this meant that mr j was

going to die but instead of feeling

guilty

or sad i was relieved i knew that i

could control his symptoms

ease his pain reduce anxiety

i asked his sons if they wanted to come

to the hospital to be with their father

at the time we were allowing three

visitors for patients that were near

death

they all arrived and were able to come

into the room and sit with their father

hold his hand and be there as he took

his last breaths

he was warm covered comfortable

and surrounded by family in the very end

he had

a good death many of us are scared right

now

we don’t know what the future holds and

there are so many dangerous and

unpredictable events taking place all

around

us it is in these times that is most

important to sit and reflect

on what you value most in life

appreciate and relish in these things

they are not promised and they may not

be there tomorrow

but for today you can calm yourself in

the storm

by making it clear what you want for

your body and your soul

this is essential for people of all ages

an emergency can strike at any moment

make an advance care plan protect

yourself

protect your family and protect me

thank you

you