The New England Journal of Medicine ** released an article yesterday on how scarce medical resources could ethicically be allocated when our hospital systems get overwhelmed with COVID19 cases at the end of the week:
These ethical values — maximizing benefits, treating equally, promoting and rewarding instrumental value, and giving priority to the worst off — yield six specific recommendations for allocating medical resources in the Covid-19 pandemic: maximize benefits; prioritize health workers; do not allocate on a first-come, first-served basis; be responsive to evidence; recognize research participation; and apply the same principles to all Covid-19 and non–Covid-19 patients…..
However, encouraging all patients, especially those facing the prospect of intensive care, to document in an advance care directive what future quality of life they would regard as acceptable and when they would refuse ventilators or other life-sustaining interventions can be appropriate.
Operationalizing the value of maximizing benefits means that people who are sick but could recover if treated are given priority over those who are unlikely to recover even if treated and those who are likely to recover without treatment. Because young, severely ill patients will often comprise many of those who are sick but could recover with treatment, this operationalization also has the effect of giving priority to those who are worst off in the sense of being at risk of dying young and not having a full life
This article is merely recommendations. It is not operational guidance nor a legal document. But as hospitals are gearing up to face a wave of high need patients who were infected before we started to physically distance from each other, it is guidance that many hospitals and their clinicians will be consulting in the coming weeks.
One of the most important things that we can do as individuals is to update our end of life wishes. Update our wills. Make sure that our medical proxies are able, willing and have at least one back-up. We should also make sure that our kids will have someone to take them in with appropriate back-ups. The medical system is preparing for the worst, and we should do so as well in our personal life.
** DOI: 10.1056/NEJMsb2005114
Have the signatures on my durable power of attorney; need to plot out how to get it notarized.
My advanced directive is inadequate, and I’ll revisit that this week.
I’m 67, and an ex-smoker. I probably should decline a ventilator.
A bit late for rewriting wills and such, since responsible attorneys have gone home to shelter in place.
I wish Kay still came around here.
New Deal democrat
I am beyond myself with rage and despair. Because (1j lockdowns work, see, e.g., San Francisco and China; and (2) we only need lockdowns for a few weeks to bring the number of infections down, while we ramp up production of testing kits and necessary medical supplies, after which we can implement a system of very aggressive testing and quarantine like South Korea.
But nobody cares. Nobody is listening.
And while most of the blue States of the Eastern megalopolis and the West Coast and Southwest have moved towards lockdowns, they have not followed up by coordinated incoming traveler quarantines.
West of the Rockies
Ford, GM, Tesla gearing up to produce ventilators. Don’t abandon hope.
I’ll put this here and in the thread below: Fox News dot com is positively livid at all the things Nancy Smash managed to get into the COVID-19 relief bill that’s about to pass.
Which means, as usual, that we should all drop to our knees and praise the FSM that she is Speaker.
West of the Rockies
I am genuflecting now.
Twenty years ago, when my wife was on a ventilator and losing the battle, I had a long discussion with our friend (who happened to be the hospital Chaplain, and had written one of the textbooks on end-of-life issues) about the ethics of life-support withdrawal, aka “pulling the plug”. It was the most painful, fraught, and challenging conversations I’ve ever had.
Who’d’ve imagined we’d be having that conversation about entire populations?
@Jeffro: Nancy Smash! I will take any good news we can get.
@Salty Sam: What book was that? We all probably need to read a version of it.
Some states are passing emergency legislation to provide for online notarization. Can you email your attorney? Find out if this is a possibility- otherwise most banks have notaries and they may be able to do this for you through the drive thru window
Nancy SMASH is currently our Lincoln.
We need a Thaddeus Stevens, but Schumer is not up to the role (closer than Leahy would be, though)
Just think: we _could_ have had Seth Moulton as Speaker.
If it comes to that, I’m pretty sure that the hospital always has a notary .. but I’ll check.
The local notary is the UPS office, and that may be a vital business within the meaning of the act.
Because Ohio Son has autism, Ohio Dad and I got our affairs in order years ago — it’s really important that anyone relying on SSI and Medicaid not directly inherit anything (special needs trusts, and some other asset sheltering vehicles must be used).
All the documents, including advanced directives, are in a nice binder the attorney put together. I ocassionally allow myself to feel smug about this.
But who would take over as Ohio Son’s immediate family, on that I draw a blank. It takes a lot longer to launch a young adult with a disability, we’re working on it but we have years to go.
And now I am worried that the social service safety net, which would be one of Son’s main supports when we are no longer, will be in shreds.
Just heard that Governor DeWine is cutting all DD Boards by twenty-percent. Is this some sort of temporary stop-gap, or is this part of a larger, long-term GOP quest to shrink all social services?
DeWine has already used this crisis as an excuse to shutter Ohio’s abortion clinics, I don’t put anything past him.
Didn’t read the NEJM article. I’m assuming the guidelines are:
This is based on the sort-of Golden Rule: You are to be treated as you would or do treat others.
Since this removes about 57 million people from the potential care pool, the rest of us should be OK. Not great, but OK. Solves a lot of other problems, too.
Sorry, I don’t remember. But he (the Chaplain) was an adviser to Bill Moyers on Moyers’ excellent “On Our Own Terms: On Dying” series on PBS. That show is worth watching, especially now.
@Ohio Mom: What is a DD board?
@Salty Sam: Possibly “How we die” by Sherwin B. Nuland?
If Fox is a-gin it, I’m a-for it.
Thanks, Madame Speaker.
Salty Sam, I am so sorry, even if I am twenty years after the fact.
Developmentally disabled? California has a system of regional centers supporting that community. Sounds like maybe Ohio once did.
No, but that was a good one too. Thanks, you spurred me to look it up, this is it:
We moved to a new state so just got our new wills notarized and a copy to our son (the executor). Quite relieved to get that done. But my husband has a nearly impenetrable system for our financial system and was resistant to giving the methods of it to my son. I finally made a document and gave it to him, though it isn’t actually current – he constantly fiddles with it. But at least my son can see the patterns and has the passkeys (passwords) to the system. There still seems to be the expectation that we will be around to explain things (as in denial of the real effects of death).
Ventilators are a last resort, the survival rates for ARDS patients isn’t great, and surviving makes for long term health issues:
Water Girl: The County Board of Developmental Disabilities, the agency formerly known as MR/DD (we don’t use the word “Retarded” anymore), is the agency that provides social work services to disabled individuals.
When Ohio Dad and I have shuffled off this mortal coil, Son’s DD caseworker will be his point person.
@Ohio Mom: I like a lot of what deWine is doing lately, but he is insane on abortion. My very Catholic nieces used to be also, until they talked to their very Catholic cousin who is a pediatric icu nurse. She faces couples making horrible decisions almost daily.
I am not Catholic. It has been interesting to watch these girls deal with the real world over the last ten to twenty years.
@L85NJGT: The source for that quote appears to be here:
Trollhattan: Every State sets up their DD services somewhat differently, though all must be within general guidelines set by Medicaid, which partially finds them.
We still have a County Board system in Ohio, it’s just about to be cut a fair amount by our governor.
I suppose a lot of state programs and services are going to be cut as a result of CV-19’s economic fallout. I mostly wonder with how much glee my Republican Governor is going to do the slashing. He surely enjoyed closing the abortion providers down.
@Ohio Mom: Thank you for the info.
@Ohio Mom: I am kind of freaking out about my granddaighter’s prospects. She is six and autistic. Her mother smokes. My husband is sending her (mother) out to shop. I think he has lost his mind.
They are in Ohio lockdown ( Yay!!) so they texted for art supplies. I have lots, since used to be artistic until life intervened. Sent them on. It was a wrench, because I have been cherishing some of those items for decades, and now pre-schoolers are chewing on them.
Life in a time of pandemic. Makes you focus and rethink.
God damn that fucking sociopath. WaPo:
@dmsilev: Ain’t gonna happen. We are a federal country. Governors have a lot of power.
@dmsilev: The psychopath is doubling down.
Sab: I agree, DeWine deserves props for making us all stay at home. That was quite a bold and daring action for a run of the mill Republican such as he. I do feel safer this way.
But I remain royally passed off about not knowing when I am going to be able to vote in the primary. I get that he was In a tight spot but illegally cancelling Election Day is huge to me. A big red flag.
To Mr. Hanes, re comment #12
The essential parts of the New Jersey economy:
“The following businesses are considered essential and will remain open, but customers and employees must practice social distancing:
The UPS store is probably included under the last.
Meself, have usually gone to my bank, asked for their notary to seal whatever needed.
He can ‘want’ it all he wants. He has no authority to make states open up.
@Elizabelle: He’s actually retreating a bit. Yesterday, it was “we’ll think about reopening on March 30”, and today it’s Easter which is April 12. Given how things are going, and assuming we follow similar trends as Italy and Spain, that’s going to be close to the peak so I kind of doubt he’d have much headway with any governor at that point.
@dmsilev: Good to know. I hope people remember this well when it comes time to vote.
Chief Oshkosh: I think you need to add to your to rubric to include never-Trumpers.
i live among them, my pretty solidly Republican suburban subdivision went for Hillary. It was historic.
But they also continue to vote for Senator Rob Portman. It’s Congressmen like him who could have booted Trump out but declined to do so. I afraid that the Never-Trumpers are not willing or able to connect those dots.
@dmsilev: He seems to be moving the goal post though. The original 15 days were to end April 1, Easter is April 12.
@Ohio Mom: I disagree with you on the primary. My sister was in CA intending to fly back that Monday, then couldn’t or wouldn’t because corona virus. My niece expected to vote but couldn’t because in hospital because corona virus.
Lots of voters wanted to vote but couldn’t because corona virus. Everyone else shouldn’t because it was already here and we shouldn’t be congregating.
I early voted. Kind of wish I had waited. Who knows who will still be aound.
I am afraid for the metroparks levy, when everyone has lost their job.
West of the Rockies
If as predicted a week from now the figures illness and death rates have risen, there will be minimal appetite to churn forward in a Mission Accomplished mode.
JAFD: that list from New Jersey is similar to Ohio’s. I can see the logic behind each item but it’s a pretty long list. Those are a lot of businesses still in operation. I wonder if we are doing enough.
@JAFD: My bank ain’t open now, so no notary. Drive-through window only.
The news isn’t all bad today:
NRA to cut salaries, brace for layoffs as coronavirus disrupts fundraising, internal memo states
I’m sorry to hear this is occurring. California saw our first round of dismantling direct state support and housing of the mentally ill and developmentally disabled all the way back in Governor Ronny Reagan’s day. The same Governor Reagan who began defunding state universities. There remains a support network, however. But a good chunk of the visible homeless population are folks who would once have been in the state system.
And here we are.
@Ohio Mom: I do agree with your concern about a governor postponing an election. But these are weird times, and I knew a lot of people disenfranchised because of travel restrictions who will now be able to vote absentee. I am on both sides on this issue.
@dmsilev: One of the WaPost reader comments on the NRA story:
@Elizabelle: There may be more truth to that than you think. Chicago had fewer shootings overall last weekend and only one shooting fatality. Don’t know if there is a correlation but would be interesting to see crime figures across the country.
Our regional air quality folks are quite chuffed at the excellent air we’ve had lately.
Good practice for when we have an all-electric vehicle fleet.
ETA it’s also instructive how far down the electricity demand is now. Lots of idle generation.
@Elizabelle: Sick and sad but quite possibly true.8
IF we don’t listen, he’s going to declare martial law. He’s that dumb.
Dorothy A. Winsor
So is kill-the-olds the R version of OK Boomer? Seems a little extreme to me.
Orange is the New Red
@Ohio Mom: if you don’t have someone to serve to be there for your son, I can volunteer. Also an autism mom. Retired special educator, now advocate. I am old and asthmatic, so may not survive the current circumstances.
Pilot friend just sent pics of Delta’s fleet parked in the desert near Victorville. Eerie.
Jim, Foolish Literalist
sounds like he went pretty nutso during his Fox News ‘town hall’
@Jim, Foolish Literalist: At what point are even Republicans going to get sick of Trump’s “I Will Be Treated Fairly OR ELSE You All Will GET IT!” psychosis? Ever? How many people will have to be dead before any of them start to question Dear Leader?
Goku (aka Amerikan Baka)
I guess abortion is being considered as “elective surgery” by the Ohio state government.
As for your question, I’m not sure. I hope not
DeWine was asked about Trump’s utterings about opening up the economy in the next few weeks and loosening restrictions. He claimed he and Trump were aligned!
I don’t get it. I mean, I do. I guess DeWine doesn’t want to piss off Trump or something, but that in and of itself is abhorrent
Goku (aka Amerikan Baka)
@Jim, Foolish Literalist:
None of this fucking matters when hospitals are overwhelmed. That mortality rate will shoot up far above 1%. “Bunch of lies”. I want to scream.
I am pissed.
Got my mail today and there was a mailer from the CDC titled PRESIDENT TRUMP’S CORONAVIRUS GUIDELINES FOR AMERICA. As if he came up with the guidelines. It is, in effect, a campaign flyer.
I let the CDC know my displeasure, not that it will mean anything.
BTW, all the guidelines were standard issue that we have been hearing.
Orange is the new red: I’m old and asthmatic too, we also have that in common.
How old is your kid, does he/she live at home, how do they occupy their days?
Ohio Son is 22, on the higher-functioning side, taking classes at the community college (with the help of a tutor and his parents), had a job as a supermarket shopper but I won’t let him sign up for shifts anymore. That’s all we need, a vector in the house.
My long range plan is to sell this suburban ranch (now that we are done with the superb school district) and buy something in Cincinnati proper, on a bus line, and along the lines of a fourplex. Install Ohio Son in one of the apartments and eventually leave the building to one of the local disabled housing nonprofits., with the stipulation he stays.
I used to have a day dream that when Hillary was president and all was running well and we Juicers did not have so many pressing issues to discuss, we’d have a thread about supporting our disabled family members. There are a lot of us here.
West of the Rockies
There is an end to his support. Not sure where yet, but it is there. If someone is slapping you in the face nonstop, you might for “reasons” take it for ten seconds, a minute, ten… But at some point you leave and/or hit back. His supporters aren’t domestic violence victims who for psychological or economic reasons put up with it.
We may at last see the end of his 42% approval.
WaPost breaking news:
@West of the Rockies:
Have… have you seen the “Mr. Trump, my wife is dying of cancer, please give her the cure that you in your infinite wisdom are hiding from the American people” tweet?
Jim, Foolish Literalist
Goku: I think DeWine knows which side his bread is buttered on. He’s not going to badmouth Trump, the people who elected him also in large part are Trump supporters.
He’s not that different in this respect than a lot of other Republicans. I assume Portman thinks Trump is awful but he has no pride or ethics, just goes along to get along.
@Elizabelle: Damn. : (
@Miss Bianca: He was very popular in DC. I remember “Master Class.” Had a lot more plays …
@Elizabelle: And Trump is surely thinking “One down, just 2 million more to go!”
James E Powell
@West of the Rockies:
Not so sure of that. Their love for Trump might wane, but their hatred of us never dies.