Hi all, I wanted to get your thoughts on the feasibility / potential benefit vs. harm of adult primary care providers calling each patient individually at this time while we are still likely in the early stages of the pandemic.
There would be two potential points of discussion between the provider and patient:
1) Code status / desire to be hospitalized – discussion with primarily elderly patients (>80) and/or those with poor functional status
This call would provide an opportunity to discuss the patient's wishes in the setting of a COVID-19 infection prior to them becoming too ill to express themselves. Once they are too ill, they will likely be brought into the hospital without their explicit consent by caregivers who feel they have no choice. I suspect there are many patients over 80 and/or those with poor functional status who would choose to not be hospitalized and/or intubated in the setting of COVID-19 infection but the discussion has not been had with them. If these discussions occur beforehand and are documented this may reduce burden on the hospital systems.
I think a potential issue here is that patients will feel this is a 'death panel' type call where we are asking them to sacrifice themselves. It will be important that PCP makes the conversation feel educational and open-ended rather than coercive. If they are hesitating or unsure tell them you do not expect an answer right now. I believe that while some patients may take the call negatively, many patients will take it in a more positive light and mark themselves as DNR/DNI, do not send to ICU or even comfort care willfully.
It may be beneficial to have some data during these calls; can anyone comment if they know of any good papers on how elderly patients / poor functional status patient's do with intubation / ICU admissions with: survival, 3 months quality of life after d/c, 6 months quality of life after d/c? I found the following:
– https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.15361 – Prognosis after emergency department intubation to inform shared decision making – 33% mortality in those over age 65, with increasing mortality percentage as you go up in decade of life
– https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2875504/ – Quality of life in patients aged 80 or over after ICU discharge. Mortality was 40/106 (37%) at ICU discharge, 48/106 (45.2%) at hospital discharge, and 73/106 (68.9%) one year after ICU discharge. Those that survived however did not have a chance in their pre-admission self-sufficiency level.
2) What to do in setting of COVID-19-like symptoms – discussion with all patients
Building on the first point, physicians can form plans with all of their patients on what to do if they develop COVID-19 like symptoms. This will depend on the patient's baseline health / comorbidities. Many patients in good health can be told to avoid hospitals or clinics (aside from Drive-Through testing) and self-quarantine for 2 weeks as long as they don't have symptoms such as dyspnea. This would be another opportunity to lower hospital burden as many healthy patient's are misinformed and feel they have to come to the hospital or clinic for any COVID symptoms even though they can be managed at home with symptomatic treatment (for reference, please listen to the latest JAMA clinical reviews podcast titled "COVID-19 in Seattle: Clinical Features and Managing the Outbreak" where the physician discusses the influx of the 'worried well').
I realize that calling all patients in the panel will be time consuming but certain patients can be prioritized and the calls can be scheduled over a period of days.
Would love to hear everyone's thoughts if this is something that should be implemented on a wide scale.
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