End-of-Life at the Time of COVID-19

In a time of concern about end-of-life (EOL) care, the news that many deaths caused by Coronavirus (Covid-19) outbreaks occur in people older than 80 is not so reassuring. In fact, old patients with Covid-19 and preexisting comorbidities are more likely to die from bilateral interstitial pneumonia. This is also the case for complex neurological patients suffering from new-onset cerebrovascular events or with preexisting neurodegenerative diseases like dementia and Parkinson’s disease. The same may occur for long-term bedridden patients like those with persistent vegetative state or minimally conscious state who are completely dependent on others.^1,2

Following precautionary social distancing measures, most frail patients are at risk of dying relatively quickly in isolation and loneliness in the local hospital or in nursing homes. Dying in this way is the denial of the principles of good EOL assistance, according to which every patient should be accompanied along the path of suffering leading him to death, no matter how short or long or dangerous this path may be.³ However, as it happens when we are faced with sudden and unknown outbreaks, the most urgent need lies in solving the immediate problem and in preventing it from reoccurring, and perhaps neglecting not so stringent ethical and social issues. The psychological burden for patients and doctors and the discomfort experienced by everyone have been brilliantly reported by Camus in his The Plague and by Manzoni in The Betrothed.

The moral distress experienced by health-care professionals is coupled with the solitary confinement of the affected patients and with the sense of helplessness of caregivers, who are precluded from assisting their loved ones. The evolutionary advantage of social distancing measures in order to slow the spread of the virus is in conflict with the ethical concerns raised by the forced confinement of those who suffer or are about to die.

To date, intensive care units (ICU) and nursing homes are completely confined. At the same time, the demand for ICU beds is increasing sharply and intensivists may be forced to identify which lives are more noteworthy to be preserved: a first-come, first-served approach is at risk of being replaced with a strategy based on triage thresholds, where ceiling-of-care decisions are detrimental for the oldest patients.

While utilitarian measures for public health and safety are necessary, we should not forget basic deontological values such as not abandoning frail people. The events that have recently occurred worldwide following the coronavirus outbreak must induce us not only to reflect on the conflict between utilitarian measures and ethically correct measures but also to take these measures into account in formulating adequate international emergency rules matching ethical needs and implications.