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Hospitals Considering a Universal DNR for All Coronavirus Patients to Protect Staff

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Hospitals Considering a Universal DNR for All Coronavirus Patients to Protect Staff

2020-03-26 17:51:081 Oct 2018 01:53 AM EST

By Laura Tucker, Staff writer; Image: Hospital during coronavirus COVID-19 (Image: Public domain)

With the number of coronavirus patients that are flooding emergency rooms, there is concern that the life-saving efforts are actually putting more people in danger. This has led some to consider initiating a universal Do-Not-Resuscitate order, feeling it will help more people in the long run. 

The conversations surrounding this issue are looking at the risk of staff as well as the limits on protective gear, such as masks, gowns, and gloves. When a patient "codes," a large group of health-care workers gown up and put gloves and masks on as well to care for the patient whose heart or breathing has stopped.

They are bound by oath and sometimes even the law to do everything they can to save a person's life, providing there is no DNR order to not try to save them. With mounting COVID-19 cases and the shortage of personal protective equipment (PPE), hospitals are considering changing the emergency orders and forcing everyone with COVID-19 into an emergency situation. 

Of course, changing or eliminating that directive means the patients have less chance for survival. But hospital administrators and doctors believe this is what may be needed to save the most lives.

At Northwestern Memorial Hospital in Chicago, they have been discussing a DNR policy for all infected patients, regardless of the patient's wishes or those of their family. An intensive-care medical director at the hospital, Richard Wunderlink, said whether the policy change would be permitted would have to be up to Illinois Gov. J.B. Pritzker. 

"It's a major concern for everyone," he said. "This is something about which we have had lots of communication with families, and I think they are very aware of the grave circumstances."

Officials at George Washington University Hospital in the District of Columbia admit to having similar conversations. But for now, they will continue to use modified procedures with infected patients, such as putting a plastic sheet over the patient to create a barrier. 

In Seattle, one of the country's coronavirus clusters, the University of Washington Medical Center is dealing with the issue by limiting the number of staff allowed near a contagious person in cardiac or respiratory arrest.

Larger hospital systems are considering changing the guidelines to allow doctors to override the wishes of the patient or family on a case-by-case basis. They're considering this because of the risk to doctors and nurses and a shortage of protective equipment. However, they would not impose a DNR on every COVID-19 patient.  

University of Pennsylvania surgeon Lewis Kaplan, who is also president of the Society of Critical Care Medicine, said colleagues at other hospitals are sharing how they are drafting new policies.

"We are now on crisis footing," he explained. "What you take as first-come, first-served, no-holds-barred, everything-that-is-available-should-be-applied medicine is not where we are. We are now facing some difficult choices in how we apply medical resources — including staff." 

The concern isn't only about the health of workers contracting the disease — it's also about the workers infecting other patients in the hospital and the lack of lifesaving procedures and equipment.

University of Wisconsin-Madison bioethicist R. Alta Charo insists it's a pragmatic response. "It doesn't help anybody if our doctors and nurses are felled by this virus and not able to care for us," she said. "The code process is one that puts them at an enhanced risk." 

Wunderlink said they have the time to talk with families and ask them to sign DNRs, as their patients experience steady declines and not a sudden crash. They explain to families about the risk to workers and that having to stop to put on protective gear delays their response and decreases the chance of saving someone's life. Family members often make the difficult decision to sign DNR orders.

When a code blue alarm is sounded, it sends as many as 30 people into a room to initiate life-saving procedures. "It's extremely dangerous in terms of infection risk because it involves multiple bodily fluids," explained a Midwest ICU physician who wished to remain anonymous. 

Even when not dealing with a pandemic, there are ethics involved when a patient codes. There is not a clear answer whether it's still a hopeful situation or whether it has become useless. And while that is being decided, many gloves, gowns, masks, and other protective equipment is used.

Chief medical officer Bruno Petinaux at George Washington University Hospital said there has been much discussion about whether to resuscitate COVID-19 patients. 

"From a safety perspective, you can make the argument that the safest thing is to do nothing," he stated. "I don't believe that is necessarily the right approach. So we have decided not to go in that direction. What we are doing is what can be done safely."

Yet, he recognizes that the decision comes down to the resources a hospital has, and "every hospital has to assess and evaluate for themselves." His hospital still has sufficient equipment and manpower, so they aren't there yet, but he's not ruling out a change in the future. 

The proecedure at George Washington for coding coronavirus patients involves using a machine called a Lucas device to deliver chest compressions — but there are only two in the hospital. If there is not one accessible, doctors and nursres have been told to drape plastic sheeting over the patient to minimize the spread of droplets and then continue with chest compressions.

UW Medicine in Washington state's chief medical officer, Tim Cellit, said the policy to send in fewer doctors and nurses in a coding situation is about "minimizing use of PPE as we go into the surge." So far the percentage of infections among those tested is less than in the general population, so he is hoping it means the precautions are working. 

Bioethicist Scott Halpern at the University of Pennsylvania is not a fan of the "draconian" blanket decision to stop resuscitation efforts and force a DNR. "If we risk [a young person's] well-being in service of one patient, we detract from the care of future patients, which is unfair," he reasoned.

Fred Wyese, an ICU nurse in Muskegon, Michigan, said they have thought about this issue for years. "They made us do all kinds of mandatory education and fittings and made it sound like they are prepared," he complained. "But when it hits the fan, they don't have the supplies, so the plans they had in place aren't working." 

Nevertheless, he sees the efforts to resuscitate as futile. "By the time you get all gowned up and double-gloved, the patient is going to be dead," he said. 'We are going to be coding dead people. It is a nightmare."

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