Wednesday, April 8, 2020

End-of-Life Decisions and Technology, Especially Ventilators

At Dickinson Law, in the last third of the Spring 2020 Semester, my Elder Law students are doing a module on End-of-Life Decisions.  I had planned this module more than a year in advance; certainly the timing has proven to be uniquely relevant.  Originally, my plan was for an in-depth discussion about choices related to assisted death, sometimes known as the Death with Dignity or Physician-Assisted Death.  And we are considering comparative studies and positions on legislation intended to support this choice, starting with a review of Oregon's more than 20 years of experience in providing this option.  

The COVID-19 pandemic, however, is triggering new focal points on end-of-life decisions.  Consider for example the statement by an emergency room chief in a San Francisco hospital, as quoted recently in the Los Angeles Times, "You have an 80-year-old and a 20-year-old and both need a vent and you only have one.  What do you do?"  Individuals may have thoughtfully made advance decisions about whether they want mechanical assistance in breathing during life-or-death circumstances.  They may have appointed an agent to speak for them or created written directions via living wills, DNR orders, or POLST documents.  But it is one thing to make you own decision; it is another to have the "decision" made because of lack of what is arguably baseline equipment.  

I've been particularly interested in the history behind ventilator shortages as reported by The New York Times.  

Thirteen years ago, a group of U.S. public health officials came up with a plan to address what they regarded as one of the medical system’s crucial vulnerabilities: a shortage of ventilators. The breathing-assistance machines tended to be bulky, expensive and limited in number. The plan was to build a large fleet of inexpensive portable devices to deploy in a flu pandemic or another crisis.


Money was budgeted. A federal contract was signed. Work got underway.


And then things suddenly veered off course. A multibillion-dollar maker of medical devices bought the small California company that had been hired to design the new machines. The project ultimately produced zero ventilators.

The rest of the story reads like a detective tale.  The small California-based company was proposing a new generation of easy-to-use, more cost effective, mobile ventilators.  By 2012, the partners were on schedule to file for market approval in September 2013, paving the path for production.  However, in May 2012, a much large medical device manufacturer bought the California-based company for just over $100 million.  Good news? That larger company might have especially strong resources for speedy production, right?

The new owner, Covidien, already made ventilators -- at a higher cost -- and in 2014, reportedly told federal officials they wanted to get out of the new ventilator contract.  The federal government agreed to cancel the contract. Covidien was sold to an even larger international company in 2015.

Why?  For more, read "The U.S. Tried to Build a New Fleet of Ventilators.  The Mission Failed," by Nicholas Kulish, Sarah Kliff and Jessica Silver-Greenberg, published in the NY Times on March 29 2020 and updated on March 31, 2020.  Or catch a NY Times podcast that looks further into shortages of hospital rooms, COVID-19 testing supplies and ventilator availability.  All interesting -- especially if you are talking about "end-of- life decisions."

Advance Directives/End-of-Life, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, International, Statistics | Permalink


I’m 73. Should the worse-case situation arise, I’ve been thinking about how to best convey to any medical decisionmakers that it would be okay by me if a scarce ventilator was assigned to a younger person who has dependents or a lot of good years ahead of them. I’ve had a full life. If it comes to a dire situation, I don’t think there would be time to go through my paper files... I’m thinking about handwriting a legible note with my directive and taping it to my upper chest if I were to get really sick. However, there is a moral dilemma for me: If more than one younger person needs one of these precious medical breathing devices, my note would stipulate that it go to a non-smoker. I figure a non-smoker is “on their own team,” whereas a smoker, not so much.
Speaking of smoking and the COVID-19 stress on lungs -- I’ve wondered about the medical stats of people who are succumbing – what percentage were smokers? That is one characteristic that is controllable on the part of an individual, whereas race, gender, and age are not. If the numbers so indicate, maybe one long term effect and “new normal” for society would be a huge decrease in smokers. Also, when people hear the phrase “Save for a rainy day,” they’ll now know what a rainy day is and defer the purchase of a new car or a bigger flat screen TV, etc. Put money they would have spent on cigarettes in that rainy day fund.

Posted by: Jennifer Young | Apr 9, 2020 5:27:37 AM

Times of crisis bring life and death issues to the fore. I am old now, 83 years old. I remember the life and death stories of World War II, a time when heroism abounded. I, too, once was young with a full future ahead and dreams of how the human condition might advance through ingenuity and decisive execution.

Recently, the question came up among a group of my contemporaries about how we might respond if we were stricken by COVID-19 and needed respiratory assistance in a time of equipment shortage. We all know that our time is limited by the inevitabilities of age.

As you can imagine, the discussion was heated. Some people, even of advanced age, remain fearful of life’s end. Others, while not welcoming that end, still accept philosophically its inevitability. Whether that philosophical detachment will persist when faced with the percipient reality of impending death is hard to discern until the time comes. Still others, dread the artificial continuation of a life that is ending and would embrace an affordable right to die option.

After everyone had voiced their views, and as emotions began to give way to the consideration that, with the potentialities of the COVID-19 disease, some of us might soon be faced with the question of whether we should choose intubation even if that meant the death of someone younger, a consensus emerged. That consensus was that we would, if asked, instruct the physician to save the life of the younger person and to ameliorate our suffering with a quick passage facilitated by morphine.

I’m trying to imagine how the young people in your classes are likely to respond to these questions. The response might be one way if held in the lecture and seminar rooms of the university. It might go a different way if held in one of the gathering rooms of a senior living residence. Of course, that latter option would have to wait until after these Zoom days are behind us unless you bring those seniors into the discussion by Zoom alongside the students.

I’d love to be a fly on the wall for that discussion.

Posted by: Jack Cumming | Apr 9, 2020 9:31:22 AM

Post a comment