In the chaos of New York City, where coronavirus deaths are mounting so quickly that freezer trucks have been set up as makeshift morgues, several hospitals have taken the unprecedented step of allowing doctors not to resuscitate people with covid-19 to avoid exposing health-care workers to the highly contagious virus.
The shift is part of a flurry of changes besieged hospitals are making on an almost daily basis, from canceling all but the most urgent surgeries to foregoing isolation rooms and requiring infected health workers to show up to work before the end of the previously recommended 14-day self-isolation period if they no longer have a fever.
Last week, DNRs or do-not-resuscitate policies for coronavirus patients who stop breathing, or are in cardiac arrest, were being discussed as part of worst-case scenario planning - ideas dismissed late last week by Deborah Birx, the White House coronavirus coordinator, saying, "there is no situation in the United States right now that warrants that kind of discussion."
Over the past few days, however, as the city's death count topped 900, with 10,900 people hospitalized with the virus and 2,700 people in intensive care amid predictions the peak of the crisis is still two weeks off, some hospitals and medical centers activated those protocols.
Those decisions are a reflection of a grim reality in which thousands of health-care workers have fallen ill, ventilators are so scarce that some hospitals have put two patients on one machine, and protective equipment like masks and gowns are in such short supply that some workers are sewing their own. Such a policy was announced at St. Joseph’s University Medical Center in Paterson, New Jersey. A memo detailing similar changes was sent out Saturday at Elmhurst Hospital in Queens but rescinded Tuesday afternoon. Doctors at other hospitals are informally putting such protocols into practice.
Judy Sheridan-Gonzalez, an emergency nurse at Montefiore Medical Center in the Bronx and who heads the New York State Nurses Association, described the situation as "post-apocalyptic - like in one of those movies I used to watch."
"Everybody is exposed," said Diana Torres, 33, a nurse at Mount Sinai West in Manhattan. "People are dying by the minute."
Spokespeople for Montefiore, NYU Langone Health, and New York-Presbyterian's Brooklyn Methodist said no new systemwide resuscitation protocols have been adopted. But doctors and nurses at those facilities say some doctors have been informally allowed in recent days to override a covid-19 patient's "code status" - the part of their medical record that expresses their desire for lifesaving medical intervention.
Maimonides Medical Center in Brooklyn said the hospital is actively discussing the move with community and religious leaders, but has not adopted it yet.
New York State Gov. Andrew M. Cuomo on Monday announced the state's public and private hospitals would begin operating as one network to share staff and resources, and distribute patients, but the details are still being worked out. Ken Raske, president of the Greater New York Hospital Association, which represents more than 250 nonprofit hospitals, said he hoped ethical protocols for resuscitation and allocating ventilators would be standardized as part of that plan.
"It's under active consideration, I can tell you that," Raske said. He also said the timeline for such decisions would be short: "I'm not talking about months; it could be a week or days."
In communications with staff, New York City area hospital leaders have sought to emphasize the real danger of viral transmission posed by the standard "all-hands approach" to responding to such situations, as well as the low survival chances for patients. An all-hands response when a patient crashes or codes can be brutal. Staff rush in to perform chest compressions and pump oxygen into the lungs. Ribs might broken, veins punctured. Nearly all patients who are resuscitated will need a ventilator, and many will die within the first 24 to 48 hours, even if health-care workers do everything they can.
Alice Thornton Bell, an advanced practice registered nurse and a senior director at Advisory Board, a hospital consulting firm, said just under 17 percent of people who are resuscitated in a hospital survive long enough to leave it - and that is not based on patients with complex respiratory problems. "The chances of that working for a covid-19 patient are very slim," she said.
"We will see a lot of deaths," one doctor typed Saturday in a grim text explaining the shift in protocol, "but they will happen nevertheless earlier or later."
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In the United States, some patients, especially the elderly and terminally ill, sign papers called advance directives asking doctors not to resuscitate (DNR) or intubate (DNI) them, and to withhold other types of medical treatment. In the absence of such instructions, doctors typically do all they can to save a patient. In New York, legal experts have said they believe the law supports a physician's decision to withhold cardiopulmonary resuscitation or CPR, over the objection of a patient or family member, if it is medically futile. But the issue is hotly debated and until the pandemic hit, this power was rarely invoked.
Scott Halpern, a University of Pennsylvania bioethicist who drafted model guidelines regarding resuscitation and covid-19 that serve as the basis for many policies being considered by hospitals, said clear protocols are needed to ensure fair treatment of patients and relieve the moral distress of providers.
But the reality on the ground is much messier.
Embattled New York doctors and nurses say some hospitals have already informally changed how they deal with resuscitation, forcing them to make life-or-death decisions on the fly, with some colleagues openly defying such orders. Amid the pandemic, health-care workers say the Hippocratic oath to treat the sick to the best of one's ability has taken on new significance and some believe DNR orders without patient or family consent are antithetical to that and their training.
"If I have a patient and they crash, I'm going to try do my best to save them," Torres said. "I'm not sure what I would do if they told me to stop. I can't imagine making that choice."
One doctor at a major New York hospital described how he recently ended up trying to resuscitate a patient who stopped breathing despite an order not to do so from a senior physician.
The patient "was turning blue and we were literally watching him die," the doctor recalled. He said that he was thinking the man was young and had a family.
At Elmhurst, according to a protocol that was communicated to staff on Saturday and again on Sunday and was shared with The Washington Post, doctors would be able to unilaterally designate coronavirus patients as DNR and/or DNI - do not intubate - which means they will not be eligible for a ventilator, even if it goes against the wishes of the patient or family. Getting the agreement of a second doctor is "optimal," the guidance states, but is not required. The language of the ethical framework states that if the order is in effect, doctors have no "no obligation to offer or initiate" the treatment, allowing them to make decisions on a case-by-case basis.
Stephanie Guzman, a spokeswoman for NYC Health + Hospitals, which operates the city's public hospitals including Elmhurst, said the information about the new protocol had been sent out "prematurely" and was subsequently rescinded. She could not offer any specifics about when that occurred or what happened at the hospital during the time between the first communication on Saturday and the second on Sunday when workers received the new protocol and believed it to be policy. A hospital worker told The Post the policy was rescinded Tuesday afternoon.
St. Joseph's University Medical Center in Paterson, New Jersey, is taking a different approach. "As of now, all COVID-19 patients are to be designated as DNR B. This means no CPR," said a message from Mourad Ismail, the chief of critical care, to other doctors on Sunday. He added that the policy applies to all infected patients, as well as to those suspected of being infected. The message was shared with The Washington Post.
Pamela Garretson, a spokeswoman for St. Joseph's, said in a written statement the center had adopted a "crisis level of care." She said it conforms to the ethical and religious directives for Catholic health care services "which uphold the dignity of the human person."
"We recognize that even with supportive care (including ventilator support) many critically ill will succumb to multi-organ failure, sepsis and cardiac complications," she wrote. However, she said that it is "morally inappropriate to make universal decisions of DNR on patients who are COVID-19 positive" and that the hospital is continuing to "treat every patient as a unique individual."
At NYU Langone Health on Saturday, the head of the emergency medicine emailed other doctors urging them to "think more critically" about who gets ventilators, according to The Wall Street Journal. Robert Femia emphasized that doctors have "sole discretion" to put patients on ventilators and that they will be supported if they decide to "withhold futile intubation" for covid-19 patients.
NYU Langone said in a statement that these guidelines were in place before the current crisis but officials felt it was important to "reemphasize" them at this time to assure doctors "that the decisions they make at the bedside would be supported."
Arthur Caplan, a bioethicist at NYU Langone, said he could not discuss the medical center's policies but believes patients and family members must be part of the decision-making. It is acceptable in a crisis, he said, for hospitals to tell people their resuscitation and other efforts will not be as aggressive, and that teams may be unable to go into a room and treat a patient if they are not adequately protected. But Caplan is bothered by the idea of withholding treatment without their involvement.
"You can't do it unilaterally, even in a pandemic," he said.
Caplan said he also expects may doctors, nurses and first responders on the front lines will make their own decisions and "no prohibition, policies or laws" will change that.
At Montefiore, where over 1,000 covid-19 patients have being treated since March, Sheridan-Gonzalez and other nurses said doctors are choosing not to resuscitate some patients even as a formal policy is still in the works. A Montefiore spokeswoman said she was unable to respond to questions on Tuesday as "clinical teams are 100 percent focused on patient care."
A physician at New York-Presbyterian's Brooklyn Methodist said doctors have been told not to perform CPR except in rare cases where the patient is young, otherwise healthy and is judged to have a good chance of recovery. For some patients, he said, "we are pretty much doing nothing." The doctor spoke on the condition of anonymity because he was not authorized to speak to the media. A spokeswoman for New York-Presbyterian said, however, that "there has been no directive to withhold CPR from patients."
At Mount Sinai, John Puskas, chair of cardiovascular surgery, said the hospital was operating in "a domino sort of way," adapting one unit for covid-19 patients as another fills up. There have been no restrictions on care, such as CPR, he said.
"So far we are keeping our nose above water," Puskas said.
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In some of the hardest hit New York area hospitals, doctors and nurses described everything - and perhaps everyone - as potentially contaminated. They said even patients on floors for non-covid patients, who have been kept on separate, cordoned off wings, are getting infected.
Sheridan-Gonzalez, who heads the nurse's union at Montefiore, said that about 1,000 health-care workers from Montefiore have been out sick or in isolation at some time due to known or suspected exposure to covid-19. She said the stress has been especially devastating for people with infected family members, including one nurse whose elderly mother is in the ICU.
"I have had to talk nurses down from suicide," she said.
Another nurse said that three weeks ago, they were careful to isolate the covid-19 patients in one area, but there are too many to do that now. On Monday night, there were more than 100 patients in the emergency department and seven were so ill they had to be put on ventilators.
Nurses said they worried changes in self-isolation procedures for health-care workers may have accelerated the spread among staff and patients. A few weeks ago, any health-care worker suspected of exposure was sent home for 14 days. Then it changed to seven days, and now it's 72 hours if you have a positive test but no longer have a fever or other symptoms. The change mirrors updates to Centers for Disease Control and Prevention guidance that allow hospitals to make decisions about recalling those workers "in the context of local circumstances."
The overload of covid-19 patients, meanwhile, is leading to reduced medical care for patients who have other serious conditions.
Kamal Kalsi, an emergency room doctor who practices in New York and New Jersey, said he is aware of canceled surgeries for lumpectomies for breast cancer patients, gallbladder surgery and procedures to remove kidney stones.
"All these things are sort of ticking time bombs," he said. "If you don't take care of them, they could potentially become much, much worse. We're definitely doing a disservice to our patients."
A Mount Sinai spokeswoman said that hospital has put restrictions on major nonelective surgeries, including cancer surgeries.
"It's done on a case-by-case basis in consultation with their doctor," the spokesperson said. "We are doing all we can to schedule them as soon as possible."
One middle-aged New York architect said she was surprised to learn her lumpectomy, scheduled for March 30, would have to be postponed.
The architect, who declined to give her name citing extreme stress, was scheduled a week ago for surgery with breast surgeon Stephanie Bernik at Mount Sinai West, and said the extensive preoperative procedures were handled expeditiously.
"I told the doctor I would come in the next day if that was available to me," she said. By the time she left the office last Tuesday the surgery had been scheduled for the following Monday.
But on Friday, during a pre-op call with a nurse, she was put on hold and then told her surgery would have to be postponed.
The woman has had no luck scheduling surgery with other hospitals including Memorial Sloan Kettering in New York and MD Anderson, the cancer hospital in Houston.
“They just said no,” she said.