Clients have been asking if they need to change their Living Will in the new age of Covid-19. There is a simple answer and more nuanced answer to this question, and it raises some very important issues.
The simple answer: You do not need to make changes to your advanced directive for coronavirus. A living will takes effect only if you are in an end stage condition, persistent vegetative state, or terminal condition. Covid-19 is not, in and of itself, any of those conditions. Therefore, a living will does not preclude treatment for Covid-19, including ventilator care.
The more nuanced answer raises another question: Is ventilator care a good choice? I do not know the answer to that question, even for myself. I read a great deal about this pandemic. As far as I can tell, there is not enough data to assess whether ventilators (or ECMO – extracorporeal membrane oxygenation, a type of heart-lung bypass) save lives, prolong death, or doom the patient to a miserable life with severely damaged lungs or hypoxic (reduced oxygen) brain injury. Some reports from health care providers say that most people die despite ventilator care. Some reports also include stories of people who survive despite weeks on a ventilator or ECMO. What I don’t see are stories from survivors about the quality of their lives after prolonged ventilator or ECMO treatment.
Then there is the issue of treatments for Covid-19. There are anecdotal reports about all kinds of possible treatments. Some kinds of treatment may work for an individual patient. Thus – how to know in advance whether prolonging life can allow treatment to work? How to know if a startling breakthrough will occur any day now?
Personally, I don’t think there is an easy answer to this dilemma. If you know you don’t want a ventilator under any circumstances, then you should execute a DNR. That is a physician’s order and, of course, must be signed by a physician. It is a form printed on yellow paper that is posted on the refrigerator (and, in this environment, I would execute 2 of them with one to be carried to a hospital). A DNR is not the same as a Living Will.
The next best suggestion is to discuss with your health care surrogate how aggressive you want to be in preserving life. What are the milestones you want your surrogate to consider if you cannot speak for yourself?
Do you want ventilator care if you arrive in an ER in respiratory distress (before diagnostic testing)?
Do you want to continue ventilator care after a given number of days?
Do you want to continue ventilator care long enough to try some kind of treatment? If so, how long do you want to try the treatment? And, how many do you want to try?
If your lungs are overwhelmed (a condition physicians often call “white out”), do you want ECMO, if it is available?
Do you want to preserve life in all instances, at any cost?
If want your surrogate to discontinue the ventilator, do you want aggressive comfort measures? Do you want this managed by a palliative care or Hospice physician? Is palliative care or Hospice even available in your hospital?
The ultimate question I think we all need to ask ourselves is have we made peace with this life? Is there anything left to do? Or anything left to say? If there is more to do, then my suggestion is get on with it, now. If there is more to say, then my suggestion is say it, now – no matter how difficult that may seem. The adage “live each day as if it were your last” seems especially poignant right now.
