# Is anyone considering refusing intubation? **URL:** \ **Category:** The Quarantine Zone\ **Tags:** covid-quarantine\ **Created:** [April 7, 2020, 2:09am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243 "2020-04-07T02:09:07Z")\ **Posts on this page:** 20\ **Page:** 1
**Author:** ![squeegee](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/squeegee/32/14537_2.png) [@squeegee](https://boards.straightdope.com/u/squeegee)\ **Post date:** [April 7, 2020, 2:09am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/1 "2020-04-07T02:09:07Z")
I had no idea until this crisis that being intubated for a prolonged time was such a horrible, neverending nightmare for the patient. It sounds like the most horrid situation imaginable (unless you’re the caregiver of many people on ventilators these next two weeks). My father died of pulmonary fibrosis - he didn’t suffer at the end, but I’m not eager to follow his path because I was on a ventilator and damaged my lungs irreparably, _after_ going through gasping horror day after day and somehow coming out the other side. I don’t know that I’d have the courage to refuse the ventilator, but it never _ever_ would have occurred to me until now to weigh that option. ---
**Author:** ![nearwildheaven](https://avatars.discourse-cdn.com/v4/letter/n/90db22/32.png) [@nearwildheaven](https://boards.straightdope.com/u/nearwildheaven)\ **Post date:** [April 7, 2020, 2:23am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/2 "2020-04-07T02:23:02Z")
People who are sick enough to be intubated are not going to be able to make that decision on their own. They need to make their wishes known before they’re ever sick. As for me, it would depend. If I was in a situation where it was very unlikely that I would come off it (a terrible car accident, that kind of thing), I would not want it unless I was a candidate for organ donation. However, if I was really sick and the odds were better than even that I would come off it and make some degree of recovery? You bet I would want to be intubated. There are people on this board who have experienced long-term intubations, so they’ll probably have some interesting perspectives on it. In short, people go on life support all the time (if you have ever had general anesthesia, you have been on life support) and the overwhelming majority of the time, they come off it alive and make a decent recovery. p.s. I remember the story a couple weeks ago about the elderly priest who refused mechanical ventilation so a younger person could have it, but I suspect that wasn’t the whole story. Maybe he found out the week before that he was terminally ill and didn’t want to suffer? ---
**Author:** ![squeegee](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/squeegee/32/14537_2.png) [@squeegee](https://boards.straightdope.com/u/squeegee)\ **Post date:** [April 7, 2020, 2:24am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/3 "2020-04-07T02:24:48Z")
> [@nearwildheaven](#): > > People who are sick enough to be intubated are not going to be able to make that decision on their own. They need to make their wishes known before they’re ever sick. Yeah, there’s the rub. I’ve never filed an advance directive. Is there some way to do so now? I guess I need a witness or something. ---
**Author:** ![nearwildheaven](https://avatars.discourse-cdn.com/v4/letter/n/90db22/32.png) [@nearwildheaven](https://boards.straightdope.com/u/nearwildheaven)\ **Post date:** [April 7, 2020, 2:27am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/4 "2020-04-07T02:27:38Z")
I’m pretty sure you can download the forms. ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [April 7, 2020, 2:38am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/5 "2020-04-07T02:38:09Z")
I plan to die alone in my apartment if I get it and get extremely sick. They can come find my body when the neighbors complain about the smell. ---
**Author:** ![squeegee](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/squeegee/32/14537_2.png) [@squeegee](https://boards.straightdope.com/u/squeegee)\ **Post date:** [April 7, 2020, 2:38am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/6 "2020-04-07T02:38:40Z")
Yup, found the form for CA. Now I need _two_ witnesses. And some time to wring my hands and decide if I want to make that choice. Yes, I’ve been through major surgery (twice!) so I guess I’ve already been on a ventilator. That makes me feel a bit better, thank you. ---
**Author:** ![squeegee](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/squeegee/32/14537_2.png) [@squeegee](https://boards.straightdope.com/u/squeegee)\ **Post date:** [April 7, 2020, 2:41am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/7 "2020-04-07T02:41:51Z")
> [@Wesley\_Clark](#): > > I plan to die alone in my apartment if I get it and get extremely sick. They can come find my body when the neighbors complain about the smell. Ugh, I’m not going to do that to my college aged son. I hope you have nobody you know who would find your corpse. ---
**Author:** ![psychobunny](https://avatars.discourse-cdn.com/v4/letter/p/54ee81/32.png) [@psychobunny](https://boards.straightdope.com/u/psychobunny)\ **Post date:** [April 7, 2020, 2:44am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/8 "2020-04-07T02:44:13Z")
N/M ---
**Author:** ![Wesley\_Clark](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/wesley_clark/32/20581_2.png) [@Wesley\_Clark](https://boards.straightdope.com/u/Wesley_Clark)\ **Post date:** [April 7, 2020, 2:51am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/9 "2020-04-07T02:51:32Z")
> [@squeegee](#): > > Ugh, I’m not going to do that to my college aged son. I hope you have nobody you know who would find your corpse. On the plus side, someone can have the couch for free. it’ll probably need a good scrubbing. ---
**Author:** ![Darren\_Garrison](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/darren_garrison/32/92_2.png) [@Darren\_Garrison](https://boards.straightdope.com/u/Darren_Garrison)\ **Post date:** [April 7, 2020, 3:16am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/10 "2020-04-07T03:16:10Z")
Yes. I’m a private person and like my personal space. The idea of being hospitalized for _any_ condition (which I never have) is a nightmare situation for me. I’m pretty sure I would rather die at home than be hospitalized for this, if it comes to it. ---
**Author:** ![Duckster](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/duckster/32/1244_2.png) [@Duckster](https://boards.straightdope.com/u/Duckster)\ **Post date:** [April 7, 2020, 3:25am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/11 "2020-04-07T03:25:58Z")
From this past Sunday’s [**Face the Nation**](https://www.cbsnews.com/news/full-transcript-of-face-the-nation-on-april-5-2020/) on CBS: > [@](#): > > “Well, what we’re seeing, and I think it’s across all areas, all of-- all facilities, that **if you go on a ventilator, there is about a twenty-percent chance that you will survive**. We have had, obviously, patients survive off ventilators, but it’s about a twenty-percent chance. And, as you know, people are on the ventilators a long period of time. But we’ve had successes. And the other thing I’d just like to mention here, because I think the public sometimes gets-- can get not always the right information. We’ve had lots of people discharged from the hospital successfully after they have been treated, many after they have been on a ventilator.” – \*\*Michael Dowling, \*\*President & CEO, Northwell Health **Bolding** mine. ---
**Author:** ![Beckdawrek](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/beckdawrek/32/3647_2.png) [@Beckdawrek](https://boards.straightdope.com/u/Beckdawrek)\ **Post date:** [April 7, 2020, 3:37am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/12 "2020-04-07T03:37:45Z")
I’ve been on a prolonged intubation. It was horrible. I was fighting it the whole time. I came off got out of the hospital and healed. I have nightmares about that tube. I never ever want that again. If it’s for surgery and I wake up w/o it, that’s fine. But long term ‘NOPE’ I’ve told anyone pertinent this is my wish. ---
**Author:** ![Darren\_Garrison](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/darren_garrison/32/92_2.png) [@Darren\_Garrison](https://boards.straightdope.com/u/Darren_Garrison)\ **Post date:** [April 7, 2020, 3:44am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/13 "2020-04-07T03:44:17Z")
A point to consider–soon people might to enjoy ventilation [without drugs](https://www.vox.com/2020/4/6/21209589/coronavirus-medicine-ventilators-drug-shortage-sedatives-covid-19). ---
**Author:** ![squeegee](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/squeegee/32/14537_2.png) [@squeegee](https://boards.straightdope.com/u/squeegee)\ **Post date:** [April 7, 2020, 4:43am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/14 "2020-04-07T04:43:35Z")
It sounds like I should fill out that directive appropriately. And have a difficult conversation with my son. ---
**Author:** ![crowmanyclouds](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/crowmanyclouds/32/19884_2.png) [@crowmanyclouds](https://boards.straightdope.com/u/crowmanyclouds)\ **Post date:** [April 7, 2020, 4:53am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/15 "2020-04-07T04:53:51Z")
> [@Darren\_Garrison](#): > > A point to consider–soon people might to enjoy ventilation [without drugs](https://www.vox.com/2020/4/6/21209589/coronavirus-medicine-ventilators-drug-shortage-sedatives-covid-19). From that article, > [@](#): > > {…} Fox says that her hospital system in Utah {Erin Fox, who manages drug information and monitors supplies at University of Utah Health Care’s four hospitals} normally has 80 patients a day, and is ramping up to take care of more than 200 critically ill people a day. “It’s more than double,” she says. But most of the drug wholesalers are trying to limit hoarding, and many of these medications are controlled substances, meaning “the Drug Enforcement Administration has rules about how much a hospital is allowed to buy,” she says. “You can’t just order double.” {…} Oh, the DEA has ‘rules’? Does this cluster fuck ever stop getting worse? If only there was someone with the authority to tell the DEA not to enforce stupid rules! CMC fnord! ---
**Author:** ![Thylacine](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/thylacine/32/1143_2.png) [@Thylacine](https://boards.straightdope.com/u/Thylacine)\ **Post date:** [April 7, 2020, 6:06am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/16 "2020-04-07T06:06:23Z")
I have written instructions that I am not to be given such treatment, I have severe COPD and my life was very low quality until I got seriously fit, to come off a machine to find myself back stuck in a chair feeling like I’m drowning, my mood unliftable is my worst nightmare. My psychiatrist who has known me 25 years agrees that I don’t ever need return there, death is preferable. My partner and my friend who has agreed to advocate for me are both on board though I don’t for a minute think they’d find it easy. They know where I was and what it takes each day to not be back there. My partner on the other hand wants all possible treatment . ---
**Author:** ![AK84](https://avatars.discourse-cdn.com/v4/letter/a/85e7bf/32.png) [@AK84](https://boards.straightdope.com/u/AK84)\ **Post date:** [April 7, 2020, 6:46am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/17 "2020-04-07T06:46:59Z")
Its apparently[not that bad…](https://www.quora.com/What-does-it-feel-like-for-a-patient-to-be-on-a-ventilator-Is-it-worth-the-suffering) ---
**Author:** ![Broomstick](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/broomstick/32/246_2.png) [@Broomstick](https://boards.straightdope.com/u/Broomstick)\ **Post date:** [April 7, 2020, 10:03am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/18 "2020-04-07T10:03:09Z")
> [@Thylacine](#): > > My partner and my friend who has agreed to advocate for me are both on board though I don’t for a minute think they’d find it easy. Speaking as someone who has had to make treatment decisions for a loved one… Having you state your preferences in advance and clearly doesn’t make the decisions “easy”, but it does make them easiER. It helps. ---
**Author:** ![Ulfreida](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/ulfreida/32/8014_2.png) [@Ulfreida](https://boards.straightdope.com/u/Ulfreida)\ **Post date:** [April 7, 2020, 10:45am UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/19 "2020-04-07T10:45:13Z")
The rate of survival of Covid 19 once you are bad enough off to need a ventilator is very low. And the rate of survival without significant lung and/or other organ damage is lower than that. Ventilators work best for people without pre-existing lung damage who have stopped breathing on their own for some other reason, which isn’t what happens with this virus. I’m looking for an advance directive. ---
**Author:** ![susan](https://sea3.discourse-cdn.com/straightdope/user_avatar/boards.straightdope.com/susan/32/17537_2.png) [@susan](https://boards.straightdope.com/u/susan)\ **Post date:** [April 7, 2020, 4:34pm UTC](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243/20 "2020-04-07T16:34:53Z")
This article was free on Medscape this morning: [Is Protocol-Driven COVID-19 Ventilation Doing More Harm Than Good?](https://www.medscape.com/viewarticle/928236?nlid=134910_5402&src=wnl_dne_200407_mscpedit&uac=140598EY&impID=2338028&faf=1) Sharon Worcester April 06, 2020 > [@](#): > > Physicians in the COVID-19 trenches are beginning to question whether standard respiratory therapy protocols for Acute Respiratory Distress Syndrome (ARDS) are the best approach for treating patients with COVID-19 pneumonia. > > At issue is the standard use of ventilators for a virus whose presentation has not followed the standard for ARDS, but is looking more like high-altitude pulmonary edema (HAPE) in some patients. > > In a letter to the editor published in the American Journal of Respiratory and Critical Care Medicine on March 30, and in an editorial accepted for publication in Intensive Care Medicine, Luciano Gattinoni, MD, of the Medical University of Göttingen in Germany, and his colleagues make the case that protocol-driven ventilator use for patients with COVID-19 could be doing more harm than good. > > Dr. Gattinoni noted that COVID-19 patients in intensive care units in northern Italy had an atypical ARDS presentation with severe hypoxemia and well-preserved lung gas volume. He and his colleagues suggested that instead of high positive end-expiratory pressure (PEEP), physicians should consider the lowest possible PEEP and gentle ventilation-practicing patience to “buy time with minimum additional damage.” > > Similar observations were made by Cameron Kyle-Sidell, MD, a critical care physician working in New York City, who has been speaking out about this issue on Twitter and who shared his own experiences in this video interview with WebMD chief medical officer John Whyte, MD. > > The bottom line, as Dr. Kyle-Sidell and Dr. Gattinoni agree, is that protocol-driven ventilator use may be causing lung injury in COVID-19 patients. > > Consider Disease Phenotype > In the editorial, Dr. Gattinoni and his colleagues explained further that ventilator settings should be based on physiological findings — with different respiratory treatment based on disease phenotype rather than using standard protocols. > > “This, of course, is a conceptual model, but based on the observations we have this far, I don’t know of any model which is better,” he said in an interview. > > Anecdotal evidence is increasingly demonstrating that this proposed physiological approach is associated with much lower mortality rates among COVID-19 patients, he said. > > While not willing to name the hospitals at this time, he said that one center in Europe has had a 0% mortality rate among COVID-19 patients in the intensive care unit when using this approach, compared with a 60% mortality rate at a nearby hospital using a protocol-driven approach. > > In his editorial, Dr. Gattinoni disputed the recently published recommendation from the Surviving Sepsis Campaign that “mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.” > > “Yet, COVID-19 pneumonia, despite falling in most of the circumstances under the Berlin definition of ARDS, is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance,” Dr. Gattinoni and colleagues wrote, noting that this was true for more than half of the 150 patients he and his colleagues had assessed, and that several other colleagues in Northern Italy reported similar findings. “This remarkable combination is almost never seen in severe ARDS.” > > Dr. Gattinoni and his colleagues hypothesized that COVID-19 patterns at patient presentation depend on interaction between three sets of factors: 1) disease severity, host response, physiological reserve and comorbidities; 2) ventilatory responsiveness of the patient to hypoxemia; and 3) time elapsed between disease onset and hospitalization. > > They identified two primary phenotypes based on the interaction of these factors: Type L, characterized by low elastance, low ventilator perfusion ratio, low lung weight, and low recruitability; and Type H, characterized by high elastance, high right-to-left shunt, high lung weight, and high recruitability. > > “Given this conceptual model, it follows that the respiratory treatment offered to Type L and Type H patients must be different,” Dr. Gattinoni said. > > Patients may transition between phenotypes as their disease evolves. “If you start with the wrong protocol, at the end they become similar,” he said. > > Rather, it is important to identify the phenotype at presentation to understand the pathophysiology and treat accordingly, he advised. > > The phenotypes are best identified by computed tomography scan, but signs implicit in each of the phenotypes, including respiratory system elastance and recruitability, can be used as surrogates if CT is unavailable, he noted. > > “This is a kind of disease in which you don’t have to follow the protocol – you have to follow the physiology,” he said. “Unfortunately, many, many doctors around the world cannot think outside the protocol.” > > In his interview with Dr. Whyte, Dr. Kyle-Sidell stressed that doctors must begin to consider other approaches. “We are desperate now, in the sense that everything we are doing does not seem to be working,” Dr. Kyle-Sidell said, noting that the first step toward improving outcomes is admitting that “this is something new.” > > “I think it all starts from there, and I think we have the kind of scientific technology and the human capital in this country to solve this or at least have a very good shot at it,” he said. > > Proposed Treatment Model > Dr. Gattinoni and his colleagues offered a proposed treatment model based on their conceptualization: > > 1. Reverse hypoxemia through an increase in FiO2 to a level at which the Type L patient responds well, particularly for Type L patients who are not experiencing dyspnea. > > 2. In Type L patients with dyspnea, try noninvasive options such as high-flow nasal cannula, continuous positive airway pressure, or noninvasive ventilation, and be sure to measure inspiratory esophageal pressure using esophageal manometry or surrogate measures. In intubated patients, determine P0.1 and P occlusion. High PEEP may decrease pleural pressure swings “and stop the vicious cycle that exacerbates lung injury,” but may be associated with high failure rates and delayed intubation. > > 3. Intubate as soon as possible for esophageal pressure swings that increase from 5-10 cmH2O to above 15 cmH2O, which marks a transition from Type L to Type H phenotype and represents the level at which lung injury risk increases. > > 4. For intubated and deeply sedated Type L patients who are hypercapnic, ventilate with volumes greater than 6 mL/kg up to 8-9 mL/kg as this high compliance results in tolerable strain without risk of ventilator-associated lung injury. Prone positioning should be used only as a rescue maneuver. Reduce PEEP to 8-10 cmH2O, given that the recruitability is low and the risk of hemodynamic failure increases at higher levels. Early intubation may avert the transition to Type H phenotype. > > 5. Treat Type H phenotype like severe ARDS, including with higher PEEP if compatible with hemodynamics, and with prone positioning and extracorporeal support. > > Dr. Gattinoni reports having no financial disclosures. > > This story originally appeared on [MDedge.com](http://MDedge.com). [Next page](https://boards.straightdope.com/t/is-anyone-considering-refusing-intubation/851243.md?page=2)