Just what kills a person with COVID-19?
How do these deaths differ from the deaths of people whose lungs fail quickly due to other diseases or injuries?
And what can hospital crews pressed into service on COVID-19 wards that have been donated to try to keep patients from dying, despite a difficult situation?
All of these questions have sparked debate – and even conspiracy theories – since the beginning of the pandemic. Now, two studies from Michigan Medicine may help answer that.
Bottom line: COVID-19 deaths are actually different from other lung failure deaths. However, the researchers conclude, the type of care needed to help keep people through the worst cases of each type of lung failure is very likely. It just needs to be well-adjusted to focus on the damage that COVID-19 does to the lungs.
Both studies rely on a routine in-depth examination of the medical records of people who died at Michigan Medicine, an academic medical center of the University of Michigan. For each death, the researchers determined which organ system disorder directly caused the person’s death, or the decision to remove the patient from life support.
In 82 people with COVID-19 who died in the spring and early summer of 2020, that study of records found that 56% died mostly from lung failure.
That means they died as a result of the damage done by the coronavirus, even though they had other problems and complications with COVID-19 at the time of death. The results are published in the Biography of the American Thoracic Society.
That’s more than double the amount researchers saw in the other study, which is based on more than 380 people with similar lung failure who died at the same hospital in years before a stroke. COVID-19.
In that study, published last summer in Critical Care (DOI: 10.1186 / s13054-020-03108-w), only 22% of people died of lung failure due to lung damage and disorder.
In all groups, sepsis was the leading cause of death for 26% of patients – demonstrating the importance of prevention and treatment of this complication that can result from infection and blockage of organs throughout the body. bodies. Sepsis was the leading cause of death in the non-COVID group, with lung dysfunction and near brain / zero dysfunction behind it.
“These findings reinforce the importance of attempting to deliver evidence-based interventions for respiratory failure in COVID-19 patients during the course of the pandemic, especially since Professionals who do not typically treat this condition or work in an ICU are drawn into service, “said Scott Ketcham, MD, the in-house medical resident who led both studies. this means prone positioning, good working knowledge of mechanical ventilation, appropriate selection of patients to warm up high-pressure oxygen, and early detection and treatment of infections. In other words, following guidelines previously developed by those who specifically treat respiratory failure such as severe respiratory distress syndrome and sepsis. “
Support for those drawn into COVID-19 emergency care
The COVID-19 patients in the new study were treated before evidence of the effects of dexamethasone and remdesivir on the actual progression of cases of the disease emerged, said Hallie Prescott, MD, M.Sc., associate professor to lung care and diagnostic treatment which is the lead author of the paper. These options seem to have survived in that time.
“There was a lot of talk at the beginning of the pandemic that this was new, and that the best supportive care principles already used in ICUs were not true,” she says. more we realized that everything we have learned in the last 20 years may save people with COVID-19, and the more we learn about it, the more it becomes consistent with ARDS in general. Specific treatments for which the respiratory part of this disease will definitely improve survival. “
Prescott and her colleagues have offered several webinars and online resources to help providers who are not familiar with caring for respiratory failure and sepsis. For example, placing patients in a prone position is not enough – it is also important to move them frequently so that they do not develop wounds that may be entry points for secondary infections.
They include the webinars offered by the Mi-COVID19 consortium that are researching and working to improve COVID-19 care in hospitals across Michigan, posts on the Life blog in the Fastlane for emergency education and care with Jack Iwashyna, MD, Ph.D., from UM and VA Ann Arbor, and a seminar hosted by Prescott and Iwashyna through the UM Institute for Healthcare Policy and Innovation.
Near death situation
In addition to looking at the cause of death and related medical measures, Ketcham and his colleagues looked at the support patients and families received in the last days of patients ’lives.
In each group, more than two-thirds of patients were on ventilators or other important respiratory supports at death, and more than three-quarters of patients died after withdrawal of life support.
But among COVID-19 patients, the study finds that less than a third had prior guidance, stating their wishes if they became seriously ill or needed someone to make medical decisions for them.
During the COVID-19 hospitalization, approximately 80% of patients had a care-focused conversation with providers enrolled in their register – typically, one provider had a telephone call with a family member.
Such conversations take into account the patient’s current situation, as well as prior instructions or informal conversations with the family that they may have had before they became ill. They are important for informing later discussions about the treatment or removal of life support.
About 80% of patients received a visit from a member of the spiritual care team while in hospital – but of those who were fitted with an air conditioner, only 10% had the opportunity to see a spiritual care provider before introduction, when they would be able to interact more fully.
Ketcham notes that in the first months of the pandemic in particular, but even in the months since, friends and family have the ability to connect in person or almost exclusively with critically ill COVID patients -19 has been widespread across the country. And even when hospital policies have allowed people to visit, such as at the end of their lives at Michigan Medicine, family members have not always wanted to come in with fear for their own health.
As a result, only a third of the patients in the study had family or friends with them at the time of death, and 55% had not had a meaningful visit with friends or family within 24 hours of death. them, or anyone but the care team who were present when they died.
“The medical treatments we use to treat COVID-19 patients are important, but it’s also important that you remember to take care, not just treatment, of those patients,” Ketcham says. “We need to think about the person as a whole, emotionally, spiritually and socially. We need to look at what we get from visiting policies on distribution, and how we can use technology to connect providers to families, and patients to families. and his friends. ”
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