[Skip to Content]
[Skip to Content Landing]

The Importance of Addressing Advance Care Planning and Decisions About Do-Not-Resuscitate Orders During Novel Coronavirus 2019 (COVID-19)

Educational Objective
To understand the proposed components of informed assent framework
1 Credit CME

The novel coronavirus disease 2019 (COVID-19) pandemic is challenging health care systems worldwide and raising important ethical issues, especially regarding the potential need for rationing health care in the context of scarce resources and crisis capacity. Even if capacity to provide care is sufficient, one priority should be addressing goals of care in the setting of acute life-threatening illness, especially for patients with chronic, life-limiting disease.

Clinicians should ensure patients receive the care they want, aligning the care that is delivered with patients’ values and goals. The importance of goal-concordant care is not new or even substantially different in the context of this pandemic, but the importance of providing goal-concordant care is now heightened in several ways. Patients most likely to develop severe illness will be older and have greater burden of chronic illness—exactly those who may wish to forgo prolonged life support and who may find their quality of life unacceptable after prolonged life support.1 In addition, recent reports suggest that survival may be substantially lower when acute respiratory distress syndrome is associated with COVID-19 vs when it is associated with other etiologies.2,3

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

Article Information

Corresponding Author: J. Randall Curtis, MD, MPH, Cambia Palliative Care Center of Excellence, University of Washington, 325 Ninth Ave, PO Box 359762, Seattle, WA 98104 (jrc@u.washington.edu).

Published Online: March 27, 2020. doi:10.1001/jama.2020.4894

Conflict of Interest Disclosures: Dr Curtis reports receipt of grants from the National Institutes of Health (NIH) and from Cambia Health Foundation. Dr Kross reports receipt of grants from NIH outside the submitted work. Dr Stapleton reports receipt of grants from NIH and the National Institute on Aging outside the submitted work.

Role of the Funder/Sponsor: None of the funders had a role in the preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: The authors would like to thank Anthony L. Back, MD; Ruth A. Engelberg, PhD; James Fausto, MD, eMHA; Dee Ford, MC, MSCR; and Christine Ritchie MD, MSPH, for their contributions to the practical steps for informed assent.

References
1.
Fried  TR , Bradley  EH , Towle  VR , Allore  H .  Understanding the treatment preferences of seriously ill patients.   N Engl J Med. 2002;346(14):1061-1066. doi:10.1056/NEJMsa012528PubMedGoogle ScholarCrossref
2.
Wu  C , Chen  X , Cai  Y ,  et al  Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China.   JAMA Intern Med. 2020; doi:10.1001/jamainternmed.2020.0994PubMedGoogle Scholar
3.
Arentz  M , Yim  E , Klaff  L ,  et al.  Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State.   JAMA. 2020. doi:10.1001/jama.2020.4326PubMedGoogle Scholar
4.
Rubenfeld  G .  The coronavirus is a chance to have the end-of-life conversations we need. The Globe and Mail. March 16, 2020. Accessed March 3, 2020. https://www.theglobeandmail.com/opinion/article-the-coronavirus-is-a-chance-to-have-the-end-of-life-conversations-we/.
5.
Sudore  RL , Schillinger  D , Katen  MT ,  et al.  Engaging diverse English- and Spanish-speaking older adults in advance care planning: the PREPARE randomized clinical trial.   JAMA Intern Med. 2018;178(12):1616-1625. doi:10.1001/jamainternmed.2018.4657PubMedGoogle ScholarCrossref
6.
Goodman  E .  The Conversation Project is dedicated to helping people talk about their wishes for end-of-life care. Institute for Healthcare Improvement. Published 2020. Accessed March 21, 2020. http://theconversationproject.org.
7.
Back  AL , Arnold  RM , Edwards  K , Tulsky  JA .  COVID-ready communication skills. VITALtalk. Published 2020. Accessed March 21, 2020. https://www.vitaltalk.org/guides/covid-19-communication-skills/.
8.
Ornstein  KA , Aldridge  MD , Garrido  MM ,  et al  The use of life-sustaining procedures in the last month of life is associated with more depressive symptoms in surviving spouses.   J Pain Symptom Manage. 2017;53(2):178-187 e171. doi:10.1016/j.jpainsymman.2016.08.023PubMedGoogle ScholarCrossref
9.
Curtis  JR , Burt  RA .  Point: the ethics of unilateral “do not resuscitate” orders: the role of “informed assent”.   Chest. 2007;132(3):748-751. doi:10.1378/chest.07-0745PubMedGoogle ScholarCrossref
10.
Bosslet  GT , Kesecioglu  J , White  DB .  How should clinicians respond to requests for potentially inappropriate treatment?   Intensive Care Med. 2016;42(3):422-425. doi:10.1007/s00134-015-4192-4PubMedGoogle ScholarCrossref
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close