Goals of care

The family confirmed that she was indeed a full code because she did not want to die of COVID.

The COVID-19 pandemic caused different emotions worldwide in a span of a few months, including exhaustion among clinicians. In the midst of this, I encountered a COVID case in May that presented an interesting dilemma.

An 84-year-old woman residing in a nursing home was brought to the ED due to altered mental status and hypoxia. Her hypoxia and workup were highly suspicious for COVID-19 infection. She was requiring a nonrebreather mask with 6-L nasal cannula, which our hospital used as an alternative due to limited supply of high-flow oxygen. Addressing goals of care was the first priority due to her critical condition. Her POLST form stated that she was full code, but the nurse informed me that she had previously been DNR/DNI and changed her mind because she did not want to die of COVID.

This is where the dilemma began: mixed information about her code status with minimal information from her due to her encephalopathy. There was also no clear explanation of her POLST form from the nursing home. Adding to this dilemma was the uncertainty of how the patient's family would react to our clinical status update and discussion regarding goals of care. The family confirmed that she was indeed a full code because she did not want to die of COVID. They also reported that she was cognitively intact up until a few days prior to her admission when she became altered and progressively hypoxic. They understood our update, including our high suspicion for COVID. They had a lot of questions, for which we had limited answers.

In an ideal situation, we want to respect the patient's wishes. However, we advised comfort measures due to her critical clinical status and mortality risk related to her age and the uncertainty of the disease course, especially in the nursing home population. Her family seemed very conflicted because they wanted to do what was best for her and to respect her wishes at the same time. Her family felt helpless and wanted to see how sick she was but could not due to the strict no-visitor policy. At the end of our discussion, they wanted to speak with other family members before making a decision. I silently prayed that the patient had time to allow that. I found later on that she was made “comfort measures only” and passed away comfortably.

This case was unique to me because it was my first goals-of-care discussion during the pandemic. It was filled with conflicting emotions. It is a case I will never forget.