One issue is that many of these major anti-vax states do not have any statewide plan other than ignoring it. Refusing to treat a person based on their illness or how they got it is both unethical (violates the principles of autonomy, justice and beneficence) and illegal (violates federal law). Thus one can see how the hospitals’ hands are tied.
Regarding downstream level of care, again we run into the issue of care delivery based on the cause of illness and manner of getting ill is again unethical. Secondly, our healthcare is a reflection of societal mores. In general we are more aggressive with “futile healthcare theater” as I call it than others countries. Why? Because “Death Panels!!”. However, this is an interesting area of healthcare decision-making because it is clearly lawful for an attending physician to declare further care futile and thus not in the patients’ best interest. We can’t just ignore the family, because again of social norms. Thus there is a lot of counseling required to get family to agree to a do-not-resuscitate order. I have personally guided many families through this process and have noted several key points:
1. No one wants the patient to suffer.
2. The definition of suffering varies widely from person to person.
3. Most families look to the clinician for guidance on what is acceptable and unacceptable suffering for potential survival. They have little experience and cannot reasonably make an informed decision in the heat of the moment.
4. Everyone dies, and acknowledging this in a mature, timely fashion reduces the suffering of your survivors that make the unbelievably difficult decision to let your body die when the time comes.
As clinicians we can easily say that CPR in a given situation is futile. And we will not be successfully challenged in court unless it’s clearly malicious intent. But we do have the responsibility to thread extremely carefully and not allow our views of morality cloud these decisions, as that will expose us to legal jeopardy.
Everything above is the easy part. Now comes the hard part: ventilator dependence with a persistive vegetative state. Some information on this (from my trauma experience):
1. Brain death is easy to determine. There are well described, ethical, lawful procedures to determine this state. It’s a process but very straightforward in every state (slight variations of documentation from state to state).
2. The human body can keep a brain physiologically functioning at a very basic level after tremendous insult. There is a vast spectrum of functioning between fully awake/alert and brain death. Respiratory failure in particular makes this a long, painful slide because oxygen deprivation for short periods will permanently and irreversibly shut down the functions we associate with cognition, but not basic reflexes like breathing, blinking, coughing and heart function.
3. If we artificially support oxygenation, the ability to maintain this basic level can be preserved for very long periods of time (potentially years). Ultimately the cause of death in these cases is insufficient oxygen to the heart causing an irreversible irregular rhythm that interrupts blood flow (cardiac death). Hearts, especially in young people, are extremely resilient and will last for weeks even if the brain barely functions. (Brain death will eventually interrupt these reflexes and result in cardiac death as the body fails to keep itself warm and regulate electrolytes the heart needs). This is the state most covid patients find themselves in. It takes up a ventilator, clinicians’ time and emotions, and other services for critical care. Most covid patients’ families are in denial for various reasons and thus the process is drawn out for weeks in many cases.
Can I legally say this care is futile? Yes. I can say that the chance of recovery is almost zero and absent a clear advanced directive, determine it is in the patients’ best interest to stop ventilator support. What are the ethical implications? How do I define too much suffering? What did the patient think (when they could think)? Who is being hurt by keeping the patient alive? Who is being hurt by not ending the patient’s life? Is my decision to stop care for a patient because of my implicit or explicit biases?
When I was younger, I helped keep a patient alive for days because I found the way he was injured was so unjust that even now I think about it at night. In that time I thought I was being helpful, and it was reflected in his parents’ pleas to do everything. And we did literally everything that could be done. Emptied the blood bank. Clamped off major vessels with plans to amputate his legs at bedside. Emptied the blood that just got flown in (we used all of our reserves overnight). Opened his chest at bedside to restart his heart. Go back to the OR, clamp off his aorta. That did the trick, but it was obviously too late. Eventually he died from brain death, but he was dead even before I clamped off his aorta. It was all futile care and I should have known it.
It was only after he died (again, brain death is very simple to determine) that I thought to ask who were we treating. Not the patient, but the family and ourselves. After that I realized that emotion cannot be used to decide the way forward. The dying do not have that luxury for us to experiment on them to soothe our fear of letting go. But if we let go too soon, we are monsters in some people’s eyes. In that case, the parents also understood after time to grieve that their son was long gone. They said “we are only treating ourselves because we are cowards. Let him go.” That experience changed my life trajectory. I was going to be one thing, but became another. I thought that my patients should have the benefit of seeing the end coming, and planning for it. My patients still die, but with dignity because we help them prepare for it. It is still sad. But it is a different sadness when they say “thanks, but enough” and not their family saying “nothing is too much”.
Now if I had the same situation, but behaved callously because I thought the patient’s suffering was payback for their actions, I would be a monster. The one thing that made me a good at running trauma afterwards was learning from my mentors that we should acknowledge and subvert our implicit and explicit biases at every step. Why someone ended up in front of us, hemorrhaging to death did not matter. It was not our place to pass judgement. As a society we decided that everyone deserves to live, and doctors are not executioners. That’s the way it should be.
Hence the dilemma we face in our current predicament. If the quality (as our society defines it currently) of care we provide to unvaccinated covid patients is different from patients who had respiratory failure for some other reason (got shot during a robbery while closing their store, and bled out before they got to the hospital), we are complicit in their deaths. To say we need to rewrite the rules means we rewrite it for all of us. We can do what the UK does and uses a combination of age, co-morbid conditions and survival likelihood to decide on ICU vs palliative care. We can do what Japan does and as a society not accept “heroic measures” in most cases. We cannot let the reason for withholding care be based on our beliefs of who is a “good person” or “bad person”. If we had, the covid pandemic would’ve been a drop in the bucket of death from AIDS. We almost did cast “those people” aside. Do not repeat that mistake.
