[Dr. Wawa]

I think you can look up the statistics as to how what percentage of ventilated patients die. I have read 80%. But you a e correct that any such percentages would be largely determined by the initial diagnosis which required ventilation. Anyway, one should be able to find these numbers if they would help.

Meanwhile, heart and kidney transplantation is BIG BUSINESS in hospitals. Generally the patient considered beyond saving is already on a ventilator. That gives me pause. If the diagnosis leading to intubation and ventilation is sepsis, there seems to be controversy as to how best to treat it (with or without intravenous ascorbic acid?). The hospital doctor who may want to harvest an organ tend to inform the next of kin of the intubated person that the patient is “brain dead” as per electroencephalogram. However, there are rare but stirring accounts of patients who recover completely after being that ill, so “brain death” may be a tricky concept in any context where organ harvesting is an issue.

You probably want to find out how many people who get intubated (for instance, for sepsis) ever get the tube removed.

[IMA-HelenT]

Such an interesting questions, I do remember this being covered in a webinar, I will try and find a link.

[aaronaf]

I asked AI (GPT-5 mini) for some guidance on this question.

Here is its answer:

I can help you draft clear, specific language for an advance directive (living will) and suggest medical conditions and decision rules you can state. I’m not a lawyer or clinician — you should review any final wording with an attorney and discuss it with your primary care clinician to ensure it’s medically appropriate and valid where you live. Below are concise, actionable items you can copy, adapt, and discuss with professionals.

1) Core directive language (short, clear)

– “If I am hospitalized and diagnosed with COVID-19, I direct that a mechanical ventilator (invasive positive-pressure ventilation) not be used on me unless all of the following are true:

1. My treating physician reasonably expects that respiratory failure from COVID-19 is the primary, life‑threatening condition; and

2. All reasonable non‑invasive respiratory treatments (oxygen therapy, high‑flow nasal cannula, non‑invasive ventilation/BiPAP/CPAP when not contraindicated) and appropriate medical therapies have been attempted and documented as ineffective or unsuitable; and

3. There is a documented, reasonable expectation of meaningful recovery (defined as expected survival to hospital discharge with ability to perform at least basic activities of daily living), based on available clinical information; and

4. I have not previously expressed, in this directive or to my health care agent, a wish to forgo ventilation in these circumstances.”

2) Optional stricter refusal (if you want to forbid ventilator use in most COVID cases)

– “I refuse initiation of mechanical ventilation for treatment of COVID-19 acquired while hospitalized for another condition, unless initiation is the only reasonably available intervention to prevent imminent death and the criteria in items 1–3 above are met.”

3) Conditions to explicitly contraindicate ventilation (examples you can include)

– Irreversible terminal condition unrelated to COVID with expected life expectancy < 6 months despite treatment.

– Severe, permanent cognitive impairment or advanced neurodegenerative disease with loss of ability to perform basic self‑care.

– Multi‑organ failure where ventilator would only prolong dying, not restore meaningful function.

– Patient already on a ventilator prior to acquiring COVID where clinicians judge additional invasive ventilation would be futile.

4) How to authorize/limit other treatments (avoid unintentionally blocking beneficial care)

– Specify acceptance of non‑invasive respiratory support and standard COVID treatments you want (e.g., oxygen, remdesivir, monoclonal antibodies if indicated, steroids) unless you object. Example:

– “I consent to non‑invasive respiratory support (oxygen, high‑flow nasal cannula, BiPAP/CPAP), and to antiviral, anti‑inflammatory, and other standard-of-care medical treatments for COVID-19 as recommended by my treating clinicians, except as limited above.”

5) Naming a health care agent and decision rules

– Name a durable power of attorney for health care (agent) and grant them authority to interpret this directive and consent/refuse treatments consistent with it.

– Include: “If my agent believes a reasonable interpretation of my wishes is unclear, they should prioritize avoidance of invasive mechanical ventilation for COVID-19 acquired while hospitalized for another condition.”

6) Documentation and procedural requests

– Request that clinicians document in the chart any attempts at non‑invasive measures and the medical rationale if ventilation is initiated.

– Ask that your directive be followed even if treating clinicians disagree; require second opinion/ethics consult before initiating ventilation against this directive.

7) Practical tips for making it legally effective

– Use your state’s (or country’s) statutory advance directive form if available, and attach or incorporate the above wording.

– Sign and date it with the required witness/notary formalities in your jurisdiction.

– Give copies to your agent, primary care physician, and the hospital where you are treated; upload to any local advance directive registry if available.

– Discuss your wishes with your primary care clinician and agent, and include them in your medical record if possible.

8) Brief note on treatments and opinions you mentioned

– If you want to require or recommend specific off‑label or controversial therapies, name them explicitly and state whether you want them offered/attempted. Be aware clinicians may decline treatments they consider ineffective or unsafe; you can request transfer to another facility willing to provide them.

***

The following two statements had a chilling effect on me. They seem to be the offered advice that might have been produced by the thinking of influential groups of physicians who poo-poo the use of repurposed drugs and nutraceuticals.

(1) “Discuss it with your primary care clinician to ensure it’s medically appropriate and valid where you live.”

(2) “Be aware clinicians
may decline treatments they consider ineffective or unsafe; you can request
transfer to another facility willing to provide them.”

I thought whatever a patient has put into his advance directive would be preserved and protected, especially if has already been based on research-based methods, such as thoughtfully developed by the IMA.

I’d really like to see what others think of these two statements, as well as the answer provided by AI.

[IMA-HelenT]

The webinar where the doctors covered a bit about ventilation use: https://imahealth.org/hospital-covid-protocols-grace-schara-case/

The team mentioned that Doctor Varon has a new op ed coming out covering your topic too. Will send the link once its live

[aaronaf]

Thanks for posting this very important and useful article!

However, I would like to bring to your attention something that was overlooked in this article:

Near the beginning of “Hospital COVID Protocols: The Grace Schara Case,” it reads:

“DNR means when a person is dead… not to resuscitate them. That’s what it means. It doesn’t mean do not treat, do not manage. It’s only when a patient is actually dead, heart has stopped beating and they’re clinically dead, that you do cardiopulmonary resuscitation… the DNI part complicates the issue.”

There seems to be the omission of the word, “not,” which completely reverses the intended meaning of the statement by its authors.

Only much later on in the same article about the webinar, was DNR’s meaning accurately expressed:

Do Not Resuscitate (DNR):
Clearly specifies that if your heart stops beating (you are clinically dead), medical staff should not attempt CPR or other resuscitation efforts. It does not mean “do not treat.”

[IMA-HelenT]

Thanks you @AaronAF will pass this on to the team.

[aaronaf]

IMA-Helen, I am not sure you have noticed that I have already retracted my initial criticism of the linked article. So, there may be no need to bring it to the attention of the team – unless to mention that Dr. Marik’s quotation seems to contain an adverb that contributed to my initial misunderstanding. That word is “actually.” To the casual reader, the use of actually would strongly imply that the afflicted person was really, really, and truly dead, and therefore, not just clinically dead.

[IMA-HelenT]

👍

[aaronaf]

After rereading the article, I finally understand what was meant by when CPR would be applied. Normally, in the absence of a DNR, the doctor or nurse would try to bring the “clinically” dead patient back to life. If he were not dead as a door nail (that is, not beyond recovery), he would be revived.

[IMA-HelenT]

Morning @AaronAF promised to share Dr. Varon’s latest article

Reflections on Brain Death, Hope, and the Limits of Certainty https://brownstone.org/articles/reflections-on-brain-death-hope-and-the-limits-of-certainty/