The entire world is now affected and the resources are getting exhausted. Even the best healthcare systems are failing to tackle the explosion of COVID-19. Judicious use of resources is therefore very essential. Many of the COVID-19 patients will be frail, terminally ill, etc. in whom intubation/mechanical ventilation or resuscitation may be futile. So, is it high time to adopt DNR/DNI for such patients? If yes, for which patients? Should the administrations/governments/ethical aspects be less rigid so that such rules can be adopted? What is the local rule/policy in your place?
The severity of Covid-19 which causes multiorgan failure is considered critical. This cohort has a mortality of 50%. However this figure increases with frailty and comorbidities.
The UK National Institute for Clinical Excellence guidance recommends a holistic approach using a clinical frailty scale in conjunction with assessment of comorbidities and patient wishes to decide on appropriate ceilings of therapy.
The UK National Institute for Clinical Excellence guidance is available at:
https://www.nice.org.uk/guidance/NG159
My opinion: As a physician, when you accept responsibility for the care of a patient, you must provide the best care possible for that patient, at the time, based upon your skills, resources and circumstances at the time. You are not the government and you are not God, don't try to be, focus on the best you can do to support the wishes and the outcome of that patient. If the patient requests DNR, then fine, but if the patient wants help, then you must do the best you can. I found a good test was, "Are you able to sleep that night?" If not, you are going to have problems (Unless the physician is a sociopath; but they should have been weeded out in premed)
In my opinion, such a patient also deserves resuscitation. Medical personnel should be equipped with PPE. It is worth using intubation or SADs, and for chest compression - ACCD.
Thank you very much for sharing your opinions and materials. I agree with the fact that as a doctor we should do our best till the last breath of the patient and provide resuscitation too. There should not be an exception for COVID-19 patients too. However, during the pandemic period, especially when there is severe constrain of resources; it is also important that we use the resources for the best possible outcome and benefit of the community. Therefore, if the clinical assessment of COVID-19 patient with multi-organ failure indicates that the patient is unlikely to make it even with best (local) possible management, the patient can be offered end-of-life care and discussion of DNI/DNR can be initiated from the health care team. However, I also feel that for the procedure, there should be a consensus/policy. We should prepare an objective guideline for decision making for selecting such a patient for end of life care.
Everything in medicine is about risk and potential benefit.
CPR in Covid patients exposes large numbers of healthcare professionals to a high viral load.
In ICU settings we do not have to be as black and white as making patients 'for CPR' or 'not for CPR'.
Outcomes of cardiac arrest differ between VT/VF and asystole / EMD.
The prognosis of a patient with asystole after a decline is grim.
However VT/VF precipitated by insertion of a central venous catheter or deranged electrolytes may be treated by a single defibrillation.
These patients are being closely monitored and if a Covid patient has an asystolic arrest I would not initiate CPR. However if the patient had a sudden VT/VF arrest I would initiate CPR and defibrillation.
I would be grateful if you could consider this question.
How can we maintain supplies of blood for transfusion during the Covid-19 pandemic?
https://www.researchgate.net/post/How_can_we_maintain_supplies_of_blood_for_transfusion_during_the_Covid-19_pandemic
An unfortunate adverse effect of behaviour during social distancing for the Covid-19 pandemic has arisen. There has been a dramatic fall in the number of blood donors in Saudi Arabia a result of social isolation during the Covid-19 Pandemic. Supplies of blood are being depleted. This is likely to be a global phenomenon
If insufficient blood of the correct type is available a woman may have a cardiac arrest as a result of not being transfused blood for severe acute bleeding following delivery of a child, for example. There would be no point in attempting resuscitation in that setting as the cause (i.e. lack of blood) would be irreversible.
This will be most challenging for patients with rare blood groups.
This situation will be most challenging for patients with rare blood groups.
I would therefore be grateful if we could consider the answer to the question I posed.
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