Coding the COVID patient: Is it futile?

It is perhaps an understatement to say that the coronavirus disease 2019 (COVID‐19) pandemic has irrevocably altered the landscape of medicine and public health in the 21st century. With hundreds of millions of cases globally, the COVID‐19 pandemic has changed almost every facet of health care and with it brought waves of mortality, especially for elderly patients and those with comorbidities. Notably, patients with cardiovascular disease are more likely to suffer serious complications of COVID‐19 infection, and in turn, patients who are COVID‐19 positive are more likely to die from cardiovascular conditions, such as ST‐elevation myocardial infarctions (STEMI). Indeed, cardiovascular emergencies seem to be just one of many diagnoses for which a concomitant COVID‐19 infection portends a significantly worse prognosis.

In particular, cardiac arrest is associated with high mortality rates. Despite significant advances in the care of patients with cardiac emergencies over the past several decades, the survival rate to hospital discharge for patients who suffer an out‐of‐hospital cardiac arrest (OHCA) in the United States remains dismally low at approximately 11%, with an even lower rate of neurologically intact survival. While much important work is being carried out on a global scale to improve outcomes in patients with OHCA, attention must also be focused on patients who experience an in‐hospital cardiac arrest (IHCA). Despite an incidence of almost 300,000 cases each year in the United States, proportionally little research involves cardiac arrests that occur within the walls of the hospital, despite an overall higher survival rate and demonstrated improvement in outcomes over the past several decades. ,

In this issue of CCI, Mir and colleagues present data on outcomes for COVID‐19 patients who suffer an IHCA. Via a pooled proportional meta‐analysis, the authors evaluated several observational studies that focused on IHCA for COVID‐19 patients over the past 2 years. They identified four pertinent studies that comprised 7891 COVID‐19‐positive hospitalized patients, of which 943 experienced an IHCA; only 621 of these patients underwent cardiopulmonary resuscitation (CPR). The average age of a COVID‐19 patient experiencing an IHCA was 62 years old, and the majority of patients were male. The presenting rhythm for most patients was either PEA or asystole. A shockable rhythm was present only 8% of the time, which is almost half the standard average rate of shockable rhythm in IHCA. Return of spontaneous circulation (ROSC) was achieved 33% of the time in patients undergoing CPR (21% of all patients who arrested)—and in a relatively timely fashion with an average time to ROSC of 7.7 min—but ultimately only 8% of patients for whom CPR was attempted survived to discharge. In total, nearly 95% of COVID‐19 IHCA patients did not survive. This is significantly higher than the average mortality rate for IHCA in non‐COVID patients. Functional status at discharge for the few survivors was not able to be evaluated.

As noted above, there is a relative paucity of research regarding IHCA, and those with COVID‐19 even more so, reflective of the recent onset of the pandemic. While the cohorts of the individual studies did have some disparate baseline features which possibly limit generalizability, a common thread emerges: Most of the COVID‐19 IHCA patients were older, sicker, with multiple comorbidities, arrested with a nonshockable rhythm—and very few left the hospital alive.

Where does this leave us? Certainly, more research into improving outcomes for both in‐ and out‐of‐hospital cardiac arrests is necessary. While OHCA remains a challenge, some improvement has been seen in the past several decades for the survival rate for IHCA, attributed primarily to a focus on early high‐quality CPR, early defibrillation, and aggressive post‐ROSC care. Indeed, survival to hospital discharge from IHCA has increased from an average of around 15% in the early 2000s to over 25% in some of the most recent registry reports. , What makes COVID‐19 patients' outcomes for IHCA so much worse than historical averages? While some of the resuscitation factors that portend a higher likelihood of a better outcome were present—such as a short duration to ROSC and in‐hospital CPR—the proportional lack of shockable rhythms likely explains some of the increased mortality. The authors question whether potential delays to the onset of resuscitation efforts could be attributable to the donning of personal protective equipment or the relative inexperience of staff members stretched thin during the pandemic. These factors, paired with what we know about a concomitant COVID‐19 diagnosis increasing the morbidity associated with other common presenting conditions such as acute coronary syndrome, could explain some of the staggering mortality rates presented here. It is notable that for 34% of patients, CPR was not even attempted. Clearly, more information on the complex interplay between the physiology of COVID‐19, other comorbidities, and the logistics of resuscitation is needed.

With such a high mortality rate for COVID‐19 patients who experience IHCA, an ethical dilemma emerges: Should resuscitation be attempted across the board on this patient population? This study reported a high number of COVID‐19 patients who did not have CPR even attempted, with no data reported as to why. While this may represent patients with an active do‐not‐resuscitate order, it is unclear if resuscitation attempts for some patients were curtailed due to expected clinical outcomes or concerns regarding staff safety. Ethicists have written on this issue, making recommendations for the provision of CPR and other resuscitative efforts in the COVID‐19 era, with a focus on balancing staff safety and available resources with a duty to act. There is certainly no basis to suggest a carte blanche denial of resuscitative efforts based on any given diagnosis, including COVID‐19. However, recognizing the remarkably high mortality associated with IHCA in patients with COVID‐19 may help guide active, upfront provider‐family discussions regarding goals of care for critically ill COVID‐19 patients as we work to navigate this challenging pandemic.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.