| COVID-19 Outpatient Conversation Guide |
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“Alice”
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A 76-year-old woman with diabetes, hypertension, asthma, and well-managed schizophrenia with full decision-making capacity. She has confirmed coronavirus with five days of fever and intermittent wheezing and is managing at home.
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The conversation occurs via telemedicine with her daughter and family medicine physician.
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During the discussion, the family medicine physician learns that staying home and “feeling like herself” are most important to her. She fears going to the hospital because of visitor restrictions and doesn't want to be alone. Her best-case scenario is being managed at home. She did say that she would go to the hospital if needed to get more supportive care. Her sister died on a ventilator, and she does not want to be intubated or resuscitated under any circumstances.
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Recommendation: Increase home services, which included a safety check, pulse oximetry, and supplemental oxygen; code status updated in the electronic health record to DNR/DNI, and the discussion was documented in an advance care planning module in the EHR.
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“Derek”
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A 48-year-old man with advanced sarcoma on third-line chemotherapy. He lives at home with his wife and two teenage sons. He does not have any symptoms or exposures to coronavirus.
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Derek had a conversation with his oncology nurse practitioner via telemedicine.
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During the conversation, they discussed protective measures to prevent infection, given his compromised immune system and underlying cancer. He had a lot of questions about COVID-19 and its effects on his cancer treatment plan, which were his primary concerns. He was very anxious during the conversation and said that “anything besides living was not OK” when asked what was important to him. He didn't want to think about what would be important if he were to get very sick. His oncology nurse practitioner responded to emotion and answered his questions. She did not discuss the patient's values or preferences should he become sick with COVID-19.
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Recommendation: Connect with a social worker for a behavioral health visit; schedule their next oncology check-in within one week.
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| COVID-19 Inpatient Conversation Guide |
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“Angela”
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An 86-year-old frail elderly woman with dementia and heart failure requiring full-time care. She lives in a skilled nursing facility.
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Admitted to the hospital with fever, labored breathing (RR = 30) on 6L nasal canula, and delirium. Coronavirus positive. Patient's daughter is her surrogate decision-maker.
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The conversation occurs by phone with the patient's daughter, Anne, and the hospitalist.
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During the conversation when asked about worries, Anne expressed anger about her perceptions of the lack of communication in the nursing home. She was worried about her mother's care. The hospitalist acknowledged her frustrations and assured her that her mother would be given the best care possible. When asked about what is important, Anne shared that her mother's quality of life before the admission was declining for months and that it was most important that her mother not suffer and that she be well taken care of.
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Recommendation: Given the patient's underlying conditions and the daughter's wishes, the hospitalist recommended intensive comfort measures and best supportive care, which would not include the use of CPR or ventilation. The patient's daughter agreed. They arranged a video call so she could see her mother.
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“Allan”
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A 69-year-old male with advanced COPD (2L home oxygen, multiple admissions for COPD exacerbation), congestive heart failure, insulin-dependent diabetes, chronic kidney disease. The patient lives alone.
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He is admitted with COVID-19. A conversation occurred with his hospitalist on day 2.
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During the conversation, Allan shared his strong faith and belief that God would help him get through this. He said that it is important for him to be able to go to church and continue all of the activities they do when he recovers. He had never thought about life-sustaining treatments and wasn't ready to discuss it.
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Recommendation: Given the patient's goal and lack of readiness to discuss specifics of life-sustaining treatments, the hospitalist recommended the standard of carethat they would use resuscitation and ventilation if he got sicker and also continue best supportive care to help him recover. The patient agreed.
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On hospital day 6, Allan developed worsening hypoxemia, dyspnea, and acute kidney injury. The hospitalist revisited the discussion. Allan was scared and tearful. He said that he wanted to live and also shared worries that he wouldn't be able to get out of the hospital. He asked to see his pastor. The hospitalist responded to the patient's emotion and set up a video call with the pastor.
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Recommendation: Given what's important to the patient and worries that his underlying condition put him at higher risk of a prolonged ventilator course, the patient, his pastor, and the hospitalist agreed to a trial of intubation if needed and to revisit that decision if there was a worry that the treatments were not going to work. The patient also identified the pastor as his health care proxy. The hospitalist documented the code status, the proxy, and the discussion in the ACP template.
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