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This article was first published in Westvic News on 8 April 2020 and has been slightly modified to suit the InSight+ audience. Read the original here.
IN the absence of any formal measures, I find that one of the best litmus tests for how I am travelling as a GP is how I treat my family, and in particular, how I treat my husband. Without going into detail, let’s just say that over the past 2 weeks I haven’t been an angel at home.
So, my question for health practitioners is this: how are you going with the new reality of general practice with coronavirus disease 2019 (COVID 19)? Or should I ask how is your nearest and dearest coping?
Every day, I’m swamped with a huge amount of information, news and updates about COVID-19. There are new ways of practising medicine, new ways to receive and exchange information and new ways to actually run the business of general practice. We then need to distil this changing landscape for our workplaces and patient community. Many patients are elderly and not IT-literate, and social media or email updates are not always the best way to get information to our community.
It’s been interesting to watch the evolution of how we are adapting our practices to deal with the pandemic situation. Many practices, including mine, are swabbing for the virus in our carparks to prevent the virus from entering our sacred space, and asking our patients to wait for us in their cars before they come in to see us.
With the new telehealth/teleconferencing item numbers, we are doing much of our consulting remotely through teleconferencing or over the phone. GPs have universally embraced this initiative and it has come a long way to keep us on board with the fight against this terribly contagious virus.
When you walk into our general practice at the moment, it is strangely quiet and calm. The usual tatty, out-of-date scandal magazines, unread health leaflets and broken kids’ toys are gone. But the strangest thing of all is there is no one there. The usual hubbub of people and their chatter is absent, and it feels kind of desolate, almost nothing like the general practice waiting rooms of old. It’s quite disconcerting arriving at work, but the hectic pace quickly resumes once I’m in my consulting room.
Many doctors have asked: is this the calm before the storm? As more people start to get acute respiratory distress syndrome from this virus – and they will – it will get more difficult to manage. Are we going to be trying to assess our older patients with comorbidities in a telephone consult to ascertain whether they should go to hospital? Should we be starting to talk to all our patients about what their plan is if they get the virus?
Absolutely, we should. Any patient being admitted to hospital may not survive and may not see their family again. Especially if they are elderly and/or with comorbidities.
Steve Carroll, a US emergency physician said last week: “Patients are arriving without family or friends. Now we make sure they call their family before we put them on a ventilator. Because they may never get to speak to them again.”
While it is overwhelming, and there is so much to get our head around, it is time to get serious about having end-of-life conversations with our high risk patients about the potential consequences of COVID-19 and what would they do if they became infected.
We know that elderly patients with comorbidities are unlikely to survive this illness if they deteriorate to the point where they require ventilation. Outcome data from UK critical care COVID-19 from 26 March 2020 tell us that for patients over 70 years of age who require ventilating, 73% will die in critical care.
Stepping people through these issues before the crisis occurs helps them make considered decisions. As GPs, we are in a position to start the conversation with patients about COVID-19, how it manifests and what options are available to patients and their families. Then the far more difficult conversation about their preferences can occur.
Good luck to everyone (and their partners) over the coming months.
Dr Anne Stephenson is a practising GP in Torquay, Victoria and the GP Liaison for the Epworth Geelong private hospital. She also teaches medical communication skills at Deakin University.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Thank you Anne–as a 72 yo, I’ve felt slightly ridiculous with a surgical tape/indelible marker message across my chest these past weeks: ‘comfort care only, no ventilator, no ICU’.
Thank you for your comments Emily. These conversations are so difficult when we are in the thick of a crisis and anxiety levels are high. I know GPs are well place to have these conversations, but GPs often feel overwhelmed by all the other things we need to achieve in consultations. I’m interested to find ways to support GPs to be able to do this. I think we need to practice doing it and find ways to do it sensitively with our patients.
Two things that are worrying.
1. The revision of the number of deaths in Wuhan increased them by 50%. Deaths occur in the community which are not always correctly counted.
2. On the US aircraft carrierU.S. aircraft carrier Theodore Roosevelt, roughly 60 percent of the over 600 sailors who tested positive so far have not shown symptoms of COVID-19, the potentially lethal respiratory disease caused by the coronavirus, the Navy says. “With regard to COVID-19, we’re learning that stealth in the form of asymptomatic transmission is this adversary’s secret power,”
We shall be very cautious!
” it is time to get serious about having end-of-life conversations with our high risk patients about the potential consequences of COVID-19 and what would they do if they became infected” absolutely. And I completely agree that GPs are in the best place to start these conversations. In my work as a medical registrar we tried to ensure each patient had a documented Acute Resus Plan at admission. It made the world of difference when the patient already had that documentation or had discussed this with their GP and thought about their answer. Once the patient is unwell in hospital, on oxygen, needing ventilatory support, those talks are so much more difficult and rushed.