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