DNR Orders and Prognosis for COVID-19 Patients with Pneumonia

A family member has tested positive for COVID-19 and has a history of chronic pneumonia?

An elderly family member (68 years old) tested positive for COVID-19.
The clinic physician prescribed the antiviral medication Paxlovid.
After three days of treatment, the patient was urgently hospitalized due to a blood oxygen saturation level below 90%.
The emergency physician reviewed the X-ray and informed the family that the patient had extensive pulmonary infiltrates, with a very high mortality rate, and immediate admission to the intensive care unit was necessary for resuscitation.
After admission, the physician prescribed a 5-day course of Remdesivir along with a 14-day course of antibiotics, in conjunction with mechanical ventilation.
Two days into the treatment, the current blood oxygen saturation level is 98%; however, the physician requested the family to sign a Do Not Resuscitate (DNR) consent form.

What circumstances would lead a physician to ask the family to sign a DNR consent form? What is the likelihood of recovery for a patient undergoing a 5-day course of Remdesivir, a 14-day course of antibiotics, and mechanical ventilation? What is the mortality rate associated with pulmonary infiltrates?

Qian, 30~39 year old female. Ask Date: 2023/07/11

Dr. Shen Bochan reply Pulmonology

Hello, regarding your question, it involves too many professional and medical ethics considerations to answer online.
The mortality rate of severe COVID-19 in the elderly is not low, and it is appropriate for the physician to explain this to you and your family.
The treatment process you described aligns with current medical consensus.
You should be grateful that your family member has recovered, and it is not as severe as previously indicated by the physician, who aimed to make you aware of the seriousness of the illness to prevent excessive optimism that could lead to unmet expectations.
This reflects the current state of medical practice, and I hope for mutual understanding.
Do Not Resuscitate (DNR) orders can be established in advance and can be signed at any time.
The chances of recovery vary for each individual, making it difficult to provide a definitive answer.
At least your family member has returned.
"Pulmonary infiltration" is a general term, and I cannot analyze the mortality rate for you, as there are varying degrees of severity.
I hope this information helps you.

Reply Date: 2023/07/11

More Info

Understanding DNR (Do Not Resuscitate) orders and the prognosis for COVID-19 patients with pneumonia is a critical topic, especially in the context of severe illness and the complexities of treatment decisions.

DNR Orders
A DNR order is a medical directive that indicates that a patient does not wish to receive cardiopulmonary resuscitation (CPR) in the event of cardiac arrest or respiratory failure. Physicians may recommend a DNR order based on several factors, including the patient's overall prognosis, the severity of their condition, and the likelihood of recovery. In the case of your family member, the physician's recommendation for a DNR may stem from the following considerations:
1. Severity of Illness: The patient has been diagnosed with severe pneumonia due to COVID-19, which can lead to significant complications, including acute respiratory distress syndrome (ARDS). The presence of extensive lung infiltrates suggests a serious condition that may not respond well to treatment.

2. Prognosis: If the medical team assesses that the likelihood of recovery is low, especially given the patient's age and comorbidities, they may suggest a DNR order. This is often done to prevent unnecessary suffering and to respect the patient's wishes regarding end-of-life care.

3. Patient's Wishes: If the patient has previously expressed a desire not to undergo aggressive resuscitation efforts, this would also be a factor in the decision to sign a DNR.

Treatment and Prognosis
Regarding the treatment regimen of remdesivir and antibiotics, along with mechanical ventilation, the prognosis can vary widely based on several factors:
1. Response to Treatment: The fact that the patient's oxygen saturation improved to 98% after two days of treatment is a positive sign. It indicates that the treatment may be effective in managing the pneumonia and improving respiratory function.

2. Underlying Health Conditions: The overall health of the patient prior to contracting COVID-19 plays a significant role in recovery. Older adults and those with pre-existing health conditions are at a higher risk for severe outcomes.

3. Extent of Lung Damage: The degree of lung involvement and the presence of any complications, such as secondary infections or organ failure, will significantly influence the prognosis.

Mortality Rates
The mortality rate for patients with COVID-19 pneumonia can be quite high, particularly among older adults and those with significant comorbidities. Studies have shown that the mortality rate for hospitalized patients with severe COVID-19 can range from 20% to over 50%, depending on various factors, including age, underlying health conditions, and the timing and effectiveness of treatment.

Conclusion
In summary, the recommendation for a DNR order in your family member's case likely reflects the severity of their condition and the medical team's assessment of their prognosis. While the treatment regimen of remdesivir and antibiotics, along with mechanical ventilation, offers a chance for recovery, the overall outlook depends on numerous factors, including the patient's response to treatment and any underlying health issues. It is essential to maintain open communication with the healthcare team to understand the patient's condition and make informed decisions regarding their care.

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