NB: this note was posted and updated March 20-26 2020. Big changes will no doubt occur to make much of what I’m saying simply wrong in the near future.

Sounds like the title of ER doctor Dan Kalla’s thriller published in 2005 – and the origin of the much nastier bug in that story is the same as that of our own COVID 19. But the virus that starts in China doesn’t have to be as much of a killer as Dan’s fictional one to have monstrous consequences, as we are finding out.

The media talk of nothing else, borders and schools are closed, non-democratic countries have literally shut their societies down (with probably better epidemic results than we are seeing and will see around here), stores are raided for toilet paper, food, and hand sanitizers, untold millions of ordinary people are stuck at home or stuck in a foreign country and many are out of work and may not be able to meet rent and nutrition costs, a corporate credit crunch threatens, stock markets have crashed like it was 1929, and governments have promised vast billions to shore up the economy. Health professionals, hospitals, and nursing homes are locking down and getting ready (if they haven’t already experienced it) for a tsunami of critical respiratory failure and deaths.

This in response to a virus infection with symptoms often undetectable or not much worse than the common cold and generally less disabling than the flu, with a test-positive rate of somewhere around 1% in heavily-affected areas, and a death rate effectively zero in kids and around 15% in people over 80, average 1-2%. The trouble of course is it’s a brand-new bug and on the day it appeared nobody was immune. A vaccine is probably well over a year away, there are shameful runs on antivirals and other medications imagined to be effective at treatment, none of them proven so far.

But the often-repeated publicly-available and alarmingly advancing statistics may not be completely reliable. Death rate (it’s already been pointed out) is the number of people who have died divided by the number of people who have the disease. The deaths can’t be minimized (you’re either dead or you’re not), but that number may be inflated because people who either test positive or clearly have symptoms of COVID (especially the elderly and most especially the frail who die all the time) may die of entirely different causes (heart attack, pulmonary embolism, stroke, bacterial sepsis) and yet have their death attributed to COVID. On the “denominator” side (the number of people who have the disease) there is a huge probability of minimization: we only report test-positive cases. Millions of children are probably infected and just have common-cold symptoms and millions of older people with the virus have just a suggestion of symptoms (chills, sore throat, runny nose, or something else) and don’t meet criteria for testing. So the death rate must be exaggerated (at around 10% at the moment, for example, in New York City). I’m guessing it’s a fraction of 1%.

How much permanent damage will this virus do before it settles down into a childhood illness with everyone else immune? Unfortunately only time will tell.

I’m a family doc who has nothing but frail homebound patients: people unable to get out to see a doctor, average age high 80s, nearly all unable to get around and/or remember much. I’ve done decades of residential care. From that point of view I worry there’s a big and theoretically preventable problem looming, which I don’t think so far we are doing enough about.

The Canadian Institute for Health Information (CIHI) found in a 2016 study that about 7% of care home residents had a do-not-hospitalize (DNH, also known as MOST 2) directive on their charts. Ten times that proportion were not to be resuscitated from a cardiac arrest (DNR), but that apparently encouraging statistic doesn’t mean much when very few cardiac arrests in care homes are witnessed. Would, in other words, have any chance at all of surviving.

Care-home residents – along with my frail elderly patients living at home – are the people most likely to die of anything that afflicts them, and among the enlightened physicians and families of that DNH 7% a carefully-considered decision has been made to favour comfort over allegedly life-saving trips to hospital critical care, if the flu for example results in respiratory failure, heart failure, or a semblance of septic shock. These people, that is, experience the benefit of a comfortable (medicated if necessary) death in a familiar surrounding with the possibility of near and dear folks close by, as opposed to death a little later in a chilly, busy, businesslike hospital ward where (certainly in this pandemic setting) nobody they’ve ever met before is around to hold their hand.

But worse in a way, we now risk having in hospital many of the 93% of non-DNH care home folks whose family and physician haven’t understood what hospital nearly always means for such a person: complications and a good chance of dying. Anyone with a serious problem that could benefit from being in the hospital may in this strangely disruptive COVID pandemic find no room at the inn. Heart attack, stroke, overwhelming infection, serious accident, catastrophe in the abdomen, lung clot – the list goes on: relatively healthy younger people may not get the aggressive likely successful care they badly need.

I think we are lucky in Canada. My limited experience of the United States (mostly from talking to colleagues there and reading) suggests that the US society’s adulation of its healthcare system (and willingness to pay a world-record price for it) results in overuse of critical care: hospitals and specialist doctors. I was stunned reading Dr. Paul Kalanithi’s amazing book When Breath Becomes Air to understand that this brilliant neurosurgeon dying of brain cancer was rushed to hospital and taken into the intensive care unit on the day he died. If that kind of response to end-stage obviously irremediable disease is usual, no wonder New York City is screaming that it needs 90,000 respirators!

We all must wash our hands, self-isolate, maintain social distance, stay away from work if we are sick, and go to the hospital only if we are really in trouble. But I think we should be considering carefully and humanely very elderly and frail people in care homes and elsewhere for whom we’ve been afraid to make and document a comfort-first decision. I believe frail elderly people and our hospitals are one another’s worst enemies. But never so much, I’m afraid, as in the next few months.

This website gets very few visitors. My opinions are well-known but right now most people are preoccupied thinking about other things. I’m keeping my fingers crossed that a few trusted voices in the community understand this situation and will do something about it, so we can make changes in frail people’s care plans in time to make a difference.

About John Sloan

John Sloan is a senior academic physician in the Department of Family Practice at the University of British Columbia, and has spent most of his 40 years' practice caring for the frail elderly in Vancouver. He is the author of "A Bitter Pill: How the Medical System is Failing the Elderly", published in 2009 by Greystone Books. His innovative primary care practice for the frail elderly has been adopted by Vancouver Coastal Health and is expanding. Dr. Sloan lectures throughout North America on care of the elderly.
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