As critical care and emergency physicians on the front lines of the COVID-19 pandemic we were saddened and frustrated to read of the recent court order requiring Mercy Hospital in Coon Rapids to keep a patient on life support after it appears medical teams had determined that continued treatment would not benefit the patient ("Judge: COVID patient must be kept on ventilator," Jan. 15).
Since the advent of critical care in the 1950s, cases have been common in which a patient has no chance of survival despite best efforts, and essentially is dead but for the machines and interventions that keep the patient in medical purgatory, awaiting an infection, stroke or other event that yields final closure. This can take weeks, months or even years, but the outcome is a foregone conclusion.
The U.S. is nearly unique in allowing families and courts to intervene in these situations, and to order that artificial life support must continue. During times when adequate resources are available, these circumstances pose difficult financial and ethical considerations. When resources are scarce, the community consequences of continued active treatment become more significant and urgent — because other community members' lives are often at stake.
Today, as for the past several months, hundreds of patients are waiting in emergency departments in Minnesota for beds that are not available due to sustained and severe demands on hospitals. Some of these patients are critically ill or injured; they need trained personnel, a critical care unit, ventilators, dialysis machines, specialized treatments and diagnostics to prevent complications and death. Unfortunately, many of these patients never get a critical care bed. Many nonetheless recover, but some get worse and some die.
The average stay in intensive care, whether for a severe infection, a heart problem, trauma or other emergency condition is three days. Even during the 30 days the judge ordered Mercy to continue to provide artificial support (the patient has since been transferred to a Texas hospital), the intensive care resources involved could have benefited an additional 10 patients needing help.
It is never easy for families and care providers when a care team arrives at the decision that a patient cannot be benefited by further active treatment. Multiple opinions are sought, every angle is considered. The decision could not be more important, and it is treated that way.
Currently, it is estimated that 5 to 10% of all of our Minnesota critical care beds are occupied by patients receiving non-beneficial care at their families' request. Given the severity of illness and limited resources across the region, there are often no places to send them, so we continue to support them, expending precious resources, and experiencing the anguish of declining request after request from outside hospitals with other patients who need and could benefit from our services.
This is not to say that we are lowering our threshold for stopping active treatment due to scarce resources, but that the current scarcity sharply defines the trade-offs in devoting limited resources to a patient who cannot benefit.
