ChristianaCare: Doctors may overrule coronavirus patients' end-of-life treatment wishes

As Delaware edges closer to an expected surge of coronavirus patients that could overwhelm hospitals, doctors working at the state's largest health provider have been told they do not need to abide by patients' do-not-resuscitate wishes if the treatment would be non-beneficial. 

Attending physicians may overrule the objections of patients and issue the DNR in such cases, according to a ChristianaCare document obtained by Delaware Online/The News Journal dated April 3.

Hospital officials said it would be a rare instance for this to occur and families can still immediately appeal the decision.

"Consistent with the above referenced ChristianaCare policy, an attending physician is not obligated to offer or to provide CPR if resuscitative treatment would be medically non-beneficial, even at the request of a patient or legally authorized representative," according to the document.

Labeled Guidance Regarding Code Status Determination during the COVID-19 Pandemic, the document was signed by two of the hospital provider's top physicians: Dr. Kenneth Silverstein, executive vice president and chief physician executive, and Dr. F. Todd Harad, chief, vascular surgery and associate director, Center for Heart and Vascular Health.

The hospital changed the guidance because risks to doctors and nurses have increased amid the pandemic, while the likelihood of a recovery for a resuscitated patient with "severe" coronavirus symptoms is low, said John Goodill, director of Supportive and Palliative Care Education and Outreach at ChristianaCare.

When "you have progressive life-sustaining measures instituted and you're getting worse despite that, you're not going to survive," he said. "So resuscitating you when you die would not provide any benefit."

Asked if the rule change was designed to preserve ventilators and other hospital equipment, Goodill said it is not "about a scarce allocation of resources.”

Though he said the hospital system is "hoping to not get into a situation that New York is" where health care institutions are operating at overcapacity as coronavirus patients flood emergency rooms.     

“We have enough resources, right now," Goodill said. 

Before the coronavirus pandemic, an attending physician who put in place a DNR without consulting a hospital ethics committee risked a lawsuit from the patient's family, Goodill said.

With the guidance, the attendant can impose the measure with the support from the hospital as an institution, he said. Even with the change, patients or families still can appeal the decision, he added. 

"This new guideline simply puts a little more institutional support around on the side of the providers to put in place a DNR, he said, "even when the family doesn’t agree with it."

Hospitals across the country are examining guidelines that allow doctors to override the wishes of COVID-19 patients, as they may pose a risk to staff.

R. Alta Charo, a University of Wisconsin-Madison bioethicist, told the Washington Post that while the idea of withholding treatment may be unsettling, especially in a country as wealthy as ours, it is pragmatic.

"It doesn't help anybody if our doctors and nurses are felled by this virus and not able to care for us," she said.

'WHO LIVES AND WHO DIES:' In worst-case scenario, ethics guide choices on who gets care

According to ChristianaCare's document, the state's largest health care provider drafted its "Do Not Resuscitate / Allow Natural Death / Treatment Limitations" policy in 1993 and then updated it in 2018.

That policy is still in place.

While that policy outlines certain principles, the April 3 document provides additional guiding considerations around code status determinations during the coronavirus pandemic, which as of Monday had killed more than 22,000 Americans – 33 of them in Delaware.

The guiding considerations include the possibility that CPR would not benefit certain COVID-19 patients, particularly those with:

• Advanced age.
• Comorbidities, which is the simultaneous presence of two chronic diseases or conditions in a person.
• Severe respiratory disease, such as acute respiratory distress syndrome.
• Sepsis with multi-organ failure.
• Progressive clinical decline despite maximal life-supportive measures.

Another guide a doctor must consider is the probability that performing CPR on patients with coronavirus will increase transmission to health care workers, threatening their well-being and reducing their availability to treat future patients. 

ChristianaCare recommends another physician agree with the attending physician's do-not-resuscitate order. 

"Patient or representative assent should be sought but is not required," the document states. "The attending physician should document in the record the basis for the decision and, if applicable, the agreement of the other physician."

Physicians who decide not to offer CPR should inform the patient or their representative of the decision and the reason why and assure them that the patient will continue to receive all other forms of care.

An appeal of the do-not-resuscitate order may be initiated by asking for an expedited ethics consultant, the document said. 

Other Delaware hospitals were asked about their do-not-resuscitate guidances. Only Saint Frances responded:

"At Saint Francis Healthcare, we are committed to faithful care for our patients and their families and we provide support in making end of life choices," Ann D'Antonio, a spokeswoman for Saint Francis' parent company Trinity Health Mid-Atlantic, said in a statement. 

D'Antonio said they ask patients if they have an advance health care directive or living will, indicating their health care wishes. 

"If these documents do not exist, we hold discussions with the patients and their families to determine their wishes, including their wishes for end of life care," she said. "We continue to follow this process during the COVID-19 pandemic."

The Delaware Healthcare Association issued a statement Friday on behalf of hospitals that did not respond. The statement said they regularly communicate with colleagues in other states and are aware of the "hot spot" locations where health care providers have been forced to make difficult decisions regarding resource allocation, due to an extreme surge of COVID-19 patients that outpaces the ability to meet patient need. 

"Delaware hospital ethics committees, along with the state, are developing a crisis standard of care framework to be implemented in the event that available resources are less than patient need in a peak demand environment," Wayne Smith, president and CEO of the Delaware Healthcare Association, said in the statement. 

The best way to ensure there are enough hospital beds, ventilators, health care providers and personal protective equipment to care for hospitalized COVID-19 patients in Delaware is for Delawareans to stay at home and practice social distancing to continue to help “flatten the curve” and slow the spread of coronavirus disease, Smith said. 

Contact Esteban Parra at (302) 324-2299, eparra@delawareonline.com or Twitter @eparra3.