COVID-19 presents alarming concerns for our country and for those who are terminally ill:
Initial symptoms include fever, dry cough, fatigue, loss of appetite and smell, and body ache. If the disease progresses, you may experience:
COVID-19 is a disease that progresses very quickly. Most people who get COVID-19 (97-98%), will survive. However, many who die are often dying lonely, isolated deaths. Planning in advance could help ensure that you get care consistent with your values and priorities.
There is no specific cure for COVID-19, but new therapies are being discovered and prevention is most important — vaccination matters.
Healthcare providers can also treat symptoms to make you more comfortable and may try a range of treatments from antibiotics to experimental drugs depending on your circumstances.
For some patients COVID-19 progresses, damaging the lungs and making it harder for oxygen to travel into the bloodstream and organs. You may hear this referred to as acute respiratory distress syndrome, or ARDS. There are several options for ARDS — non-invasive respiratory care, intubation with ventilation, and comfort care.
What is it?
Patients with milder symptoms may be given oxygen through facemasks, nasal masks or mouthpieces, which allow air to be pushed into the lungs. These devices still allow you to speak and eat, although some people report the masks are tight-fitting and uncomfortable. You may be given medicine to help you stay calm.
To receive oxygen, your doctor may ask you to go to the office, emergency room or urgent care to get your oxygen levels tested. Levels below 88% qualify for oxygen. If you require oxygen, you may be able to get it through home or hospice care.
Bottom line: Non-invasive respiratory care can provide oxygen to people who have mild to moderate symptoms. It sometimes can be provided at home allowing you to avoid a hospital stay. If your condition worsens, you will need to make a choice between intubation with ventilation (at the hospital) and comfort care.
What is it?
Intubation with ventilation is for people who are severely ill and not able to breathe well on their own. It is used when other methods of treatment are no longer working. The procedure is performed in the hospital. You’ll remain in the intensive care unit (ICU) throughout the ventilation process.
With intubation, a tube goes into your mouth or nose, down your throat and into your windpipe. It is connected to a machine called a ventilator. You cannot speak or swallow. You would be in a medically induced coma and given pain-relieving medications before and throughout the process.
Ventilation, sometimes called mechanical ventilation, is a life support treatment. It pushes oxygen into your lungs to help you breathe and sustain your heart and kidneys so they can work properly. It is the last line of defense for the coronavirus. However, it is not a cure. Ventilation helps keep you alive, giving the lungs a longer time to recover on their own. It essentially buys time.
Ventilation is a relatively common treatment. For example, it is given when a patient undergoes heart surgery and in severe cases of chronic obstructive pulmonary disease, pneumonia, congestive heart failure, sepsis, cardiac arrest, etc. In general, duration and recovery time are shorter and survival more likely for people receiving ventilation for reasons other than COVID-19.
What else should I consider?
Data on mechanical ventilation for COVID-19 patients continues to emerge. People with COVID-19 who receive ventilation have varying levels of recovery.
Bottom Line: Intubation with ventilation will sustain your life and may allow you to recover from COVID-19. However, it is an invasive procedure that has the potential to diminish the quality of life for those who do survive. People least likely to recover are those who are seriously ill from heart, lung, liver or kidney failure, who are over age 65, or who have a terminal illness like cancer or advanced dementia.
What is it?
For patients who are not able to eat or drink, the doctor might suggest a feeding tube. This is more common for patients with severe COVID disease admitted to the ICU.7 There are two types of feeding tubes:
Hand feeding by another person is often an alternative to tube feeding. But, patients with COVID-19 are often unable to have loved ones or aides nearby to help due to the possibility of transmission of the virus.
What else should I consider?
In the short-term, getting nutrition from a feeding tube can be helpful. However, they may cause discomfort and may lead to bleeding, infection, skin irritation, or leaking around the tube, as well as nausea, vomiting and diarrhea.
Bottom line: When it is likely the patient will get better, getting nutrition from a feeding tube can be helpful. However, when someone is in the last stage of an illness, tube feeding can be uncomfortable if not painful. Instead of feeding tubes, some patients choose to refuse food and water. The action of stopping food and drink is a natural part of the dying process and can be considered as one of the options for care.
For some people with COVID-19, despite ventilation, the heart stops beating. The primary treatment in this case is cardiopulmonary resuscitation (CPR). During CPR, you may receive compressions (pushing) on your chest, or electrical shock and drugs, to restart your heart.
CPR may also be necessary for people with COVID-19 who have not received ventilation. In those cases, once CPR has been given, ventilation will also be performed.
What should I consider?
Survival rates for people who receive CPR vary:
Bottom Line: In a small number of cases, CPR can save a patient's life and allow them to recover fully and leave the hospital. The likelihood of surviving resuscitation for chronically ill elderly patients is very low.
Comfort care focuses on symptom control, pain relief and quality of life. If you have COVID-19 and choose comfort care, you may receive pain relievers, oxygen to help you breathe, fever reducers, and medicine to reduce anxiety and fear. In many cases, you may be able to choose to stay at home, which will increase the likelihood that you will not die alone.
If you select this care option, you will not be given invasive treatments or be kept alive on a ventilation machine and you may decide you do not want to go to the hospital at all. It is a more common option for people who are already receiving hospice care or who already have terminal or worsening conditions, such as advanced dementia. However, it is an option for everyone.
If you choose this option, talk with your provider about how you will receive care, such as pain medication. If you have a caregiver in your home, they will be encouraged to remain in a separate part of the house with minimal interaction; however, it will not be as isolating as it will be in the hospital.
There are several things to consider if you are receiving or considering hospice care:
Bottom Line: With comfort treatment you are choosing not to have aggressive treatments like ventilation and CPR. Instead, you are choosing care to relieve your symptoms and keep you comfortable. This care will not extend your life, but it will increase the likelihood that you die at home.
From Compassion & Choices:
From Other Organizations:
From the Centers for Disease Control and Prevention (CDC):
1Centers for Disease Control and Prevention. 2021, January. U.S. COVID-19 Cases and Deaths. Available at: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html#2019coronavirus-summary.
2 Woolf SH, Chapman DA, Lee JH. December 17, 2020. COVID-19 as the Leading Cause of Death in the United States. JAMA Network. Available at: https://jamanetwork.com/journals/jama/fullarticle/277446.
3Centers for Disease Control and Prevention. 2021, January. U.S. COVID-19 Cases and Deaths. Available at: https://covid.cdc.gov/covid-data-tracker/#cases_casesper100klast7days.
4APM Research Lab, as of January 7, 2021. Available at: https://www.apmresearchlab.org/covid/deaths-by-race .
5Dreger, K. What You Should Know Before You Need a Ventilator . 2020 Apr. New York Times Opinion Piece.
6Auld, SC, Caridi-Scheible M, Blum JM, et al. Sept 2020. ICU and Ventilator Mortality Among Critically Ill Adults With Coronavirus Disease 2019. Crit Care Med. https://journals.lww.com/ccmjournal/fulltext/2020/09000/icu_and_ventilator_mortality_among_critically_ill.35.aspx.
7Nutrition of the COVID-19 patient in the intensive care unit (ICU): a practical guidance. Critical Care BMC. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369442/.
8Khullar, Dhruv. The CPR We Don’t See on TV. 2014. New York Times Well Blog.
9 Ouellette L, Puro A, Weatherhead J, Chassee T, Whalen D, Jones J. 2018, Octobero. Public knowledge and perceptions about cardiopulmonary resuscitation (CPR): Results of a multicenter study. American Journal of Emergency Medicine. 36(10): P1900-1901.