You’re likely sitting at home. Just like millions of others. Not to be confused with laziness, you are selflessly fulfilling your duty to country, family and neighbor alike by social distancing.
As a physician on the front lines, I thank you for this act of caring. But if my news feed is any barometer, I also suspect that boredom is setting in. Likewise based on my inbox, many of you are longing for another way to help fight this epidemic. Again, I thank you, and I am here to tell you about a second boring, but important, way you can help. Now is the time to write your advance directive if you don’t already have one.
In my first rotation of medical school, a wise family doctor taught me an important axiom: “the least effective medicine is the one the patient does not take.” To this day, I try to remember this sage advice each time I’m in clinic, and I’ve since learned countless similar truisms. Now a resident caring for patients infected with COVID-19, I can foresee a close cousin to that adage I learned back during my first days of medical school about to be born: “the worst allocation of a ventilator, is to a patient who wishes not to be ventilated.”
This may seem like a situation that would never occur. And it shouldn’t. But the trouble is, these decisions, by definition, happen when you are critically ill; therefore, at the moment they arise you are generally not fit to make them. This inherent difficulty has been only amplified amid this epidemic. We have found that the respiratory status of patients with COVID-19 can deteriorate rapidly, reducing the time we have to discuss and decide with our patients.
Additionally, with strict visitor restrictions in place, communication with family members must all happen electronically. All this while strain on physicians is at an all-time high. Soon another, and the most feared, difficulty may be thrust upon us by this virus — using a ventilator on this patient may mean there isn’t one left for the next. In such moments, when we are forced to resuscitate a patient and no one can tell us their wishes, we have one hope before reverting to the standard assumption of doing everything — the advance directive.
Advance directives vary in their appearance and complexity, but in essence they help answer two key questions — who do you want to make decisions when you can’t, and if critically ill what level of life support, such as ventilators, CPR, and feeding tubes, do you desire. Beyond just clinical guidance, they reassure the care team’s souls that when we must initiate invasive and often painful interventions that we are doing what you want. Similarly, for family and friends, they are invaluable in both guiding the difficult choices that predictably arise during critical illness, and assuaging the grief which inevitably accompanies such life and death decisions. Last, and most important, they ensure you get care which is in concordance with your wishes.
Unfortunately, there is a key problem with advance directives — most people don’t fill them out. Survey data estimate only about one-third of Americans have filled out an advance directive. Reasons vary for these low completion rates, but there are three that are often cited:
- People don’t know the documents exist.
- The complexity of the documents.
- Our aversion to discussing our mortality.
If you’re reading this, the first excuse is gone. Regarding the complicated documents, there are websites with free and simple forms paired with helpful tutorial videos. If the documents remain unclear after using these resources, your primary care doctor can help guide these discussions, now via telemedicine. Lastly, it is key to know these are not documents only for the aged and dying (although they are even more important for these populations). I’m 28 years old and healthy, and I recently updated mine.
With unparalleled volumes filling our nation’s intensive care units, never has it been more important, or more helpful, to complete an advance directive. And (for many of you), you have never had more time to do so. So, I write to ask for you to take a moment, pause the Netflix, stop your scrolling and delay the stress-baking to fill one out. Your doctors, your loved ones and you will appreciate it, in advance.
Michael Rose (Michaelrayrose@gmail.com) is a resident in internal medicine in Baltimore.