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Am Fam Physician. 2020;102(5):312-315

Author disclosure: No relevant financial affiliations.

Case Scenarios

SCENARIO #1

In March 2020, my area became a hot spot for coronavirus disease 2019 (COVID-19). One of my regular patients, a 72-year-old with chronic obstructive pulmonary disease, called my office stating that he had severe shortness of breath. The patient had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) two days earlier, but initially he had only mild symptoms. After receiving the diagnosis, the patient expressed fear of being alone in the hospital and wanted to stay at home no matter what. I confirmed the patient's preference for his do-not-resuscitate/do-not-intubate status and completed the Physician Orders for Life-Sustaining Treatment form. His spouse, designated as the health care agent, supports the patient's wishes. The patient declined home-based services, including hospice. During today's telemedicine visit, the patient is gasping, fatigued, and reports using 4 L of oxygen instead of the usual 2 L. He states, “Doc, I think I am dying. I don't want to go to the hospital, but I'm not sure my spouse can manage my care. What should I do?” When time is of the essence during public health emergencies, how can physicians implement a crisis care plan that meets patients' needs while honoring their values and preferences?

SCENARIO #2

The COVID-19 pandemic has unexpectedly expanded in my area, and a 58-year-old patient called my team, requesting a telemedicine visit for mild shortness of breath. The patient reported no chest pain or other symptoms. During the visit, I reviewed her recent oncology consultation detailing remission following lobectomy and radiation therapy for stage 2 lung cancer. Her preference is listed as full code, but she has never discussed the benefits and risks of cardiopulmonary resuscitation and mechanical ventilation with her physicians. She hopes to live as long as possible, provided that her quality of life is good, and wants to see her children graduate from school. The patient is worried that she has COVID-19 and is scared. With time to plan ahead and with lessons learned from the COVID-19 pandemic, what approaches can help vulnerable patients anticipate and appropriately plan for the possibility of decompensation?

Commentary

In public health emergencies such as the COVID-19 pandemic, some patients—especially older patients or those who have chronic health conditions—are confronted with treatment choices as they face life-threatening illness. Drawing on longitudinal relationships, primary care physicians can help patients and their families reach decisions that best align with patient goals. These crucial conversations may take place under intense pressure. COVID-19, for example, can cause sudden decompensation, leading to abrupt respiratory failure and death. Other factors, including unpredictable clinical courses and resource limitations, may further complicate guiding patients through goal-aligned decision-making.

Patients' expressed wishes (e.g., to stay at home no matter what) can conflict with their goals (e.g., to die with minimal discomfort). Dying with severe dyspnea from COVID-19 pneumonia is traumatic and may contribute to complicated grieving and lifelong regret and guilt for caregivers. In addition to relationship-based advance care planning, physicians can use palliative care and ethical principles to develop high-quality crisis care plans that best meet patient needs, even during emergencies.

Emergent and Nonemergent Crisis Planning During Public Health Emergencies

When a patient who prefers comfort-focused care decompensates quickly at home, a physician needs a viable crisis plan (developed in advance or in real time) that balances the ethical principles of autonomy and duty to provide care.1 An appropriate plan could be based on the following steps.

  • Review written advance directives and/or a patient's previously stated wishes with the health care agent (or next of kin, depending on state laws).

  • Perform a rapid clinical assessment. Telemedicine evaluation may be the safest and most efficient way during a pandemic to assess clinical status, including respiratory distress and mental status. Pulse oximeters, which can be purchased for home use, can determine oxygen saturation during a telemedicine or office-based visit. In patients with COVID-19, hypoxia portends more severe disease even in mildly symptomatic patients.2 Video-based telemedicine evaluations can assist physicians and can be used to guide decision-making.3

  • Ensure that the patient and the health care agent monitor for potential deterioration while clearly and sensitively sharing concerns about prognosis. Take time and give space to allow the patient and family to ask questions about prognosis.

  • Clarify goals of care.4 A physician can use ethical approaches to help reconcile any discord between a patient's previously stated wishes and current medical management options.5,6 Evidence-based tools such as the Respecting Choices framework (Figure 1) can guide physicians' discussion of available treatment options in alignment with the patient's priorities, even in urgent situations.7

  • Document goals and plan of care. Document the patient's choices for place of care and for the treatments they do and do not want to receive. With proper documentation in the medical record, other physicians involved in the patient's care can better understand the patient's wishes. It is critical to update advance directives and to involve the health care agent and family members whenever possible.

  • Quickly recommend and implement a care plan. If the patient selects hospitalization for symptom management, the physician should share the goals and care plan with emergency medical services staff at the time of transfer. If a seriously ill patient wishes to remain at home despite risks, the physician should strongly recommend home hospice care and make a referral for immediate same-day admission. During the COVID-19 pandemic, hospice programs have adapted their practices to manage home care through a combination of remote and in-person care.

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Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside.

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