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Critical Care Medicine

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

JAMA

Published Online: March 27, 2020

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Article Information and Disclosures

J. Randall Curtis, MD, MPH^1,2;

Erin K. Kross, MD^1,2;

Renee D. Stapleton, MD, PhD³

Author Affiliations

¹Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle
²Cambia Palliative Care Center of Excellence, University of Washington, Seattle
³Larner College of Medicine, Division of Pulmonary and Critical Care Medicine, University of Vermont, Burlington

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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

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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

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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.2020.4326 PubMed Google Scholar

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/.

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.2018.4657 PubMed Google Scholar Crossref

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.

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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.2016.08.023 PubMed Google Scholar Crossref

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.07-0745 PubMed Google Scholar Crossref

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/s00134-015-4192-4 PubMed Google Scholar Crossref

AMA CME Accreditation Information

Credit Designation Statement: The American Medical Association designates this Journal-based CME activity activity for a maximum of 1.00  AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to:

1.00 Medical Knowledge MOC points in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program;;
1.00 Self-Assessment points in the American Board of Otolaryngology – Head and Neck Surgery’s (ABOHNS) Continuing Certification program;
1.00 MOC points in the American Board of Pediatrics’ (ABP) Maintenance of Certification (MOC) program;
1.00 Lifelong Learning points in the American Board of Pathology’s (ABPath) Continuing Certification program; and
1.00 CME points in the American Board of Surgery’s (ABS) Continuing Certification program

It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting MOC credit.