As seniors and internists, we write this essay addressed only to retirees and other seniors.
The COVID-19 pandemic requires us to make decisions. And the decisions have to be made in light of what is, not what might have been.
Decision #1: What might have been and what should be...
What might have been is important though, and it should guide our first decision. For those of us who make it through the coming months, how will we make sure that the systemic failures of our health care system and economy do not happen again? We live and work in a society that structures medicine around profit, thereby denying care to millions. And it has only gotten worse in our lifetime. In 1975 the U.S. had nearly 7,200 hospitals with almost 1.5 million beds for a population of 220 million. For the one hundred million more Americans alive today we have 1700 fewer hospitals and more than 600,000 fewer beds.
"If we are among the lucky seniors to survive this epidemic then we will use our time, resources, networks, and votes to support those working for policies like Medicare For All plus guaranteed family and sick leave for every American."
84.2 million Americans—nearly half of all adults who do not qualify for Medicare by fact of their age—are uninsured or underinsured. This fact alone has tragically caused the deaths of so many who were denied care or put off treatment for fear of debt. It is an incubator for the preexisting conditions and comorbidities that are making this disease more fatal than it should be. We are chronically lacking in primary care specialists as medical school debt leads more and more physicians to choose careers in lucrative specialties rather than the kind of work most needed in a public health crisis like this one as well as in more normal times. Our lack of paid family and medical leave forced many people who were exhibiting symptoms to stay at work, thereby spreading this coronavirus quicker and farther. The world that could have been is important, and especially in light of the harrowing decisions we must make at this moment, we must first decide to help create this alternate world in every way we can with our time, resources, and votes.
Decision #2: If I get sick...
The need for sheltering-in-place with its restrictions of what we touch and how close we get to people is a clear imperative that we do not need to think much about.
Our next decision concerns whether or not we have caught the virus. Cold and influenza viruses are at least as likely to infect us and cause symptoms. What distinguishes COVID-19 from cold viruses? Two presentations may be clues. 1) COVID-19 infections do not tend to cause nasal symptoms like runny nose, sneezing and head congestion. And 2) COVID-19 infections tend to cause fevers and weakness or malaise very quickly. Still, influenza infections are similar in those two respects. Did you get your flu vaccination? If you did, that may tip the diagnosis toward a COVID-19 infection. In these days of rationed tests for COVID-19, we cannot simply run or drive in for a confirmatory test. No. The first decision is that, “Yes, I must assume this infection of rapid onset with fever and cough but no upper respiratory symptoms is actually COVID-19.” Then with that decided and no treatment for it, I then should decide to stay away from clinics and hospitals, and self-quarantine, letting everyone close to me know to stay away for at least two weeks. I can also use my phone to tell my clinic or physician if I have one.
Decision #3: Should I stay or go...
The next decision comes as I try to wait out the infection. What if it gets worse? Most of us reflexively go to the emergency room. But wait. I can decide not to. Hospital treatment is only supportive not curative: fluids, oxygen, support for failing organs, artificial ventilation. We have few data to know how many patients safely get off their ventilators. What we have suggests it’s likely that far fewer than half of patients put on ventilators can go off the ventilators and survive. In this time of severe shortage of hospital beds and ventilators, I need to balance at my age using those precious resources against the low likelihood that they will save my life. Another decision time.
If I have significant underlying health problems, I might fare better in the hospital. But if I don’t, can I stay home, drink liquids and ask for supplemental home oxygen and medicines to take away the panic of being unable to catch my breath? This decision can also be tilted by the knowledge that during the 1918 influenza pandemic, papers were written describing the healing benefits of sunlight and fresh air, even to the severely infected. Those are not available in the hospital. Maybe I should consider not going to the overloaded hospitals at all, given my age, how I feel about resuscitation measures and the likelihood that they wouldn’t work, and the needs of my society. Maybe I would rather the health system with its severe limitations focus on my children and grandchildren. Home hospice and palliative care should be available for oxygen and helpful medicines if needed. In time, patients who have recovered from this infection may be serving as volunteers to help infected people in their homes. Whether or not they’re available, I would be closer to my family and loved ones than isolated in the I.C.U. (It has not been recognized much about this advantage of “flattening the curve.” People who have been infected and now have antibodies with negative secretions are a valuable source to our health system, both for their ability to be around the very ill as well as for plasma donation.) Of course if I choose this option, I need to make or update my will, and update my trust if I have one.
So as I convalesce during this illness, I can decide that what I can give to my family and friends is the decision not to go to the hospital, even if it means I may die at home. Clearly this is not a decision to be taken lightly. My religious beliefs must enter in. Another factor, seldom discussed, is that end-of-life care decisions are not static. Under certain circumstances I may choose no resuscitation, but under different circumstances I may change that decision, consistent with my beliefs. This dynamic nature of decisions that need not be permanent can be very helpful when I talk with my friends and loved-ones. End-of-life care decisions are seldom made in a vacuum. Usually we’re influenced by those with whom we’re interdependent. We can also be influenced by wider social factors as now during a pandemic.
We cannot advise seniors and retirees what to do. We can highlight what goes into our own decisions. Both of us, as seniors and doctors of internal medicine, have decided that at this time we will be NoCoHo, no COVID-19 hospitalization, with no attempts at resuscitation. We have communicated that decision to our family, friends and care-givers. We know that decision may be reversed when other things change. For now, we feel this decision is best for us, our loved ones, and the country. We hope other seniors and/or retirees will think about this decision as well.
We also hope that readers will take seriously our first decision. If we are among the lucky seniors to survive this epidemic then we will use our time, resources, networks, and votes to support those working for policies like Medicare For All plus guaranteed family and sick leave for every American; policies that will help move us to a system that can keep us and our families from being forced to make these other decisions in a future epidemic.