The Curve Is Not Flat Enough

As of Friday afternoon, Thomas’s county was up to 110 confirmed cases. “Winter is coming,” as he put it. But Thomas maintains hope that a blanket DNR policy will not be necessary. “Assess, make decisions, reassess, make another decision. Repeat” is how he described the coronavirus-treatment playbook to me. “We can do this … as long as we have PPE and vents.”

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Although explicit, widespread rationing by health-care providers is unprecedented in the modern history of the United States, it is constantly happening around the world. “Our doctors face moral dilemmas and impossible choices every day,” said Doctors Without Borders’ Avril Benoit. “Even while COVID-19 is requiring reallocation of resources, we still have women who need emergency C-sections and children with malnutrition. We are converting trauma and burn clinics to care for the disease. You do the best you can with what you have. And many of our locations will not be able to do more than isolate people and provide palliative care.”

Patients, too, make rationing decisions. Every time we weigh whether or not to go to the doctor or to take medication, we’re balancing costs and benefits. Many people—an estimated third of U.S. adults—also make decisions about what they want should they become very ill. In the form of advance directives, they give instructions about when medical professionals should extend their lives with so-called extraordinary measures, and when they shouldn’t.

The directives can be elaborate or spare, but generally land on a spectrum between prioritizing comfort and prolonging life, should the two become mutually exclusive. The most common designations are “full code” and “DNR,” but directives can also get very specific. The options are not binary, care or none. A person who voluntarily designates as “DNR” wouldn’t be abandoned—he or she would still get IV fluids, oxygen, and medication, especially for pain.

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After determining advance directives, you should share them with family members or friends who might be communicating with medical professionals on your behalf. Have nuanced conversations with people close to you about what you do or don’t want in various dire scenarios. This eases the burden on them.

It eases the burden on medical providers as well. Too often, Lindsey said, a person is found unconscious by paramedics, then shocked back to life and brought to the hospital, or put on a ventilator, and only hours later a family member shows up with an advance directive that indicates that this was not what the patient wanted. “This was a tragic and challenging scenario pre-COVID, particularly if an individual’s directives weren’t followed during that period of resuscitation,” he said. But in the midst of this pandemic, the delay puts “all the providers in the chain of care” at unnecessary risk of exposure. And it takes a ventilator out of use for someone who might have wanted it.

As straightforward as it is to establish an advance directive and talk through what kind of care you want with your family, many of us avoid doing precisely that. Who wants to talk about the possibility of getting sick and dying? Thomas does. “I’m still a relatively young person, and my wife and I have that discussion relatively often,” he told me. “It should be had frequently, but especially now.”

James Hamblin, M.D., is a staff writer at The Atlantic. He is also a lecturer at Yale School of Public Health and author of the forthcoming book Clean.