TWiV 710 COVID-19 Clinical Update #46

This Week in Virology

Host: Vincent Racaniello

Guest: Daniel Griffin

Aired 23 January 2021

Vincent Racaniello: This Week in Virology, the podcast about viruses. The kind that make you sick.

From MicrobeTV, this is TWiV, This Week in Virology Episode 710 recorded on January 21st, 2021. I’m Vincent Racaniello, and you’re listening to the podcast all about viruses. Joining me today from New York, Daniel Griffin.

Daniel Griffin: Hello, everyone.

VR: Clinical update number 46 Daniel, I have a feeling we’re going to pass 50.

DG: Unfortunately, we are. We will not be through this in four weeks, but I am going to be positive today. Let me start off, we have a lot to cover, I want to make sure we hit it all. I know people are busy. You can listen to this at 1.5 or 2X if that helps, but two quotations by the same individual.

“The greatness of a community is most accurately measured by the compassionate action of its members.” The other, same person, “Struggle is a never-ending process. Freedom is never really won, you earn it and win it every generation.” This was by Coretta Scott King, the wife of Martin Luther King.

I bring these up as we go forward, you’ll see where I get with this. I think that we’ve been talking a lot about vaccinations, making sure that we are doing this in a compassionate manner. I don’t think people have tried to not do it that way, but there’s been a lot of really difficult issues. Particularly, for seniors driving long distances, struggling through a really difficult process to get appointments, ending up showing up and there’s no vaccines. We’ll get into that. I think the others also struggle as a never-ending process. I want to remind people as we get through this, as we’re right now in really difficult times, we need to be vigilant.

We need to continue to fight for that situation we are hoping to get to where we are free from this pandemic, so that this never happens again. I think we want to remember that. My three quotations, my rules I will call them, “Never miss an opportunity to vaccinate, never miss an opportunity to test, and never miss an opportunity to be nice.” These are difficult times. People’s tempers have been quite a little bit short. If we’re going to get through the next few months we have to work together, we have to be collegial, we have to communicate.

All right. This is where I say, “If you’re on the wrong airplane, if you’re headed to LA, and that’s not your final destination, get off I’m going to talk a lot about vaccination.” If you don’t want to hear about vaccination, turn it off now, switch. Go do something else. Okay, so as far as active vaccination, I want to say I try not to talk that much about vaccine hesitancy because I feel that’s what’s going to be the challenge in the future. I do think it’s critical that, as physicians, we take responsibility for answering questions about vaccinations. I think there has been a brilliant mistake at many healthcare systems to think that healthcare workers would not need their questions answered about vaccinations.

They should know already. We have seen really a significant difference in success based upon people taking the time to educate healthcare workers about vaccines. At UCSF, well over 80% when they first said, “Hey, we’ve got vaccines,” they said, “When can I get one?” Mass General, it was in the mid-70s, ProHealth I think I mentioned it was over 90% when the call came out, “Who wants to get vaccinated?” We’re hearing that some of the large healthcare systems here in New York, that less than half of their providers and staff are signing up to be vaccinated.

Just because someone’s in healthcare doesn’t mean they don’t have questions that need to be answered. I think if we don’t give the education, if we don’t answer the questions and the public starts seeing that healthcare providers are not getting vaccinated, that’s going to come back to haunt us down the road. Now, this is sort of an FAQ. I get so many questions about vaccines, so I’m going to start hitting them here because remember, this is my chance to answer the questions for all the curious ProHealth clinicians, and our listening audience. It saves me a ton of texts and emails a day.

One of the first questions, “Are we underselling the benefits of the vaccines?” There’s a really nice piece in the New York Times, Underselling the Vaccine by David Leonhardt. They quoted our buddy Paul Hotez. If you’re an anti-vaxxer, and you’re still tuning in, he’s the one that likes to get your messages. He draws a parallel, David does, between underselling the vaccines, and the early mask-wearing, we don’t quite know yet, et cetera. I don’t know if that holds completely true. We try not to get ahead of the science. I know that bothers people, but we as scientists, we as clinicians, the vaccines appear to be really effective.

We are really thinking that they’re going to have an impact on transmission, we don’t have the transmission data yet, but I’m going to talk a little about the advice. Because, “Why is everyone saying I still have to wear a mask?” We’re just saying that now, we are hoping we will be able to change.

“Should a person wait 90 days after acute infection before they get that vaccination?” Well, what does the CDC say? As per the CDC, there is no recommended minimal interval between infection and vaccination. Some physicians are recommending people wait months after infection to get vaccinated, but I have to say several people including Tom Frieden, Eleanor Murray up at Boston University– I’m going to jump in on this too. I’m concerned, we are concerned that when you tell people to wait 90 days, right now, they’re all excited. They want to get vaccinated. I don’t know how they’re going to feel in 90 days. You don’t want to feed the anti-vaxx movement, there’s no science that says you have to wait. Person feels fine, they’ve recovered from their infection, my answer is in line, I’ll say with the CDC, which is back. Welcome back CDC. “Never miss an opportunity to vaccinate.” If you say, “Wait three months,” you are missing that opportunity, let’s not do that.

“I have heard people who previously had COVID, and then had a bad reaction to the vaccine.” Right, feeds into that first one. “Should people who have had COVID still get vaccinated?” Again, the CDC is very clear here on encouraging all to get vaccinated. We’ve definitely seen people have reactogenicity, so significant reactions after the vaccine. Some of those people had COVID before, some of the people did not.

Only anecdotes, millions of people have been vaccinated, no clear science to support this fear. When you hear, “Oh, I had COVID, and I had a bad reaction,” there’s a matching person who never had COVID and had a rough reaction. People who are not vaccinated, we’re concerned they can get re-infected, we’re concerned that just because your first time with COVID wasn’t so bad, maybe the second time will be worse. I’ve certainly seen people who had COVID earlier on, and we’ve certainly seen many reports of re-infection. The vaccine protection is better than natural exposure.

“If a person had a severe reaction from the first vaccination, what should they expect from the second shot?” In general, and this is what the science suggested, when we had the early studies, this is what our experience is reinforcing. The first reaction, whatever you get, it’s usually a little bit more significant the second time. So, if you felt kind of achy, a little tired the first time, you will probably feel a little more achy, a little more tired the second time. If that reaction was rather severe, then I think it’s reasonable for that person to have a conversation with an educated person, a physician I’m going to say here, who is familiar with this situation. I’ve done several consultations, and I think this makes sense.

I mean a lot of people don’t want to be herded like cattle, they don’t want to be marched through the Javits Center. Particularly, I’ll say older individuals, they may want to sit down, they may want to have a conversation with their primary care physician, or an infectious disease specialist, someone familiar with vaccination. People want to talk to their doctors, that’s fine. Actually, I encourage that, and I think this feeds into what I talked upfront about. We haven’t tried to do this. We haven’t tried to be cruel. We haven’t tried to make this process difficult, but in a lot of ways, it has been difficult.

Particularly now as we’ve rolled it out to older individuals, I described the situation where my mom, unfortunately, had some challenges. Here she is in a strange situation, she’s not with a healthcare provider she trusts. I described an individual in his 80s who drove two and a half hours to Mount Sinai only to find out that the vaccines have been taken to the Javits Center. We need to do a better job, and I think that’s about to happen, that’s the optimism here. We are about to have a really good national plan, and that’s what I’m hearing.

“What about people that had multi-system inflammatory issues with COVID, should they get vaccinated?” I had a very interesting individual that I took care of this last weekend, it’s actually a physician that I know. We took care of him back in April when he actually developed what we believe was an autoimmune-mediated ataxia. He ended up with steroids IVIG then. He actually developed those symptoms about 14 days into his acute illness. Back in December, he got his vaccine, and about 14 days later, he noticed he was having trouble writing.

He noticed his eyes were wandering a little bit. Noticed a little bit of ataxia. Tried to set him up in the outpatient setting for steroids and IVIG. Welcome to the world of private insurance, pre-ops are required. He ended up requiring hospitalization to get that therapy. He is feeling better.

A person who has severe COVID the first time around or had what we think was an auto-antibody muted issue. That’s an individual who should consult with a physician, that makes sense. Consult with a physician, come up with a plan. I guess that’s a recurring theme. We saw a little bit of a disaster at Jones Beach where you had all these older individuals sitting for hours in this line of cars waiting for the herding cattle car approach to vaccination. That’s fine for some people, but a lot of other people need a different setting for them to have vaccination. A lot of people probably need something where there’s a home visit where someone can come to the home. There’s a lot of homebound individuals.

This is the big one, I get this all the time. I think I get this because people don’t like my answer, and they want to hear a new one. “Do I still need to wear a mask if all my friends have been vaccinated?”

Now, this really comes down to the issue as I talked about, we do not have the science yet to tell us about transmissibility. Let’s run through a couple scenarios, and I’m going to use my mom again, I think she likes that talk about her. Here’s a woman in her 80s. My youngest brother Ben, he has twins, and he just had a new baby over the last year, and my mother is dying to go down and see him. When she has gotten her second shot and two weeks go by, is it okay for her to go down to visit my younger brother, to hug her grandchildren?

From her perspective, she’s safe. I’m going to say, “Mom, you can go.” Now, my brother has to look at the fact that my mom, even though she’s vaccinated, she still potentially could get, transmit to him. I think we need to start looking at this. A lot of older individuals are not going to live forever. They’ve missed a lot of really important things that they want to get out of the house. They want to hug their kids, they want to have that human contact. The vaccine really protects them, they’re in the bulletproof car. The rest of the people that are not vaccinated, still at risk. Don’t think a vaccinated person is less at risk, and then also relates the same to quarantine issues.

If someone’s been vaccinated, and now they’re exposed to someone, all the quarantine stuff applies. We’re not so much worried about them, it’s again, worried about transmission risk. If you had a reaction to an mRNA vaccine, then is it fine to just go ahead with the J&J vaccine because everyone thinks that’s about to come out and get EUA in the coming weeks. Now, it’s not entirely clear that it’s safe to just go ahead with the J&J. One of the issues is that we think a lot of the allergic reactions are due to PEG, polyethylene glycol 2000. There’s a very similar polysorbate that is in the Adenovirus vaccine, so there may be some cross-reactivity.

We don’t know, just to say, we don’t know. We do think that the protein vaccine by Novavax will be safer because it’s not going to have it in there. One of the things I’m going to say, we’ll end up talking a lot about J&J. The J&J platform has been given to over 200,000 people. We are not seeing the significant level of the anaphylactic and allergic reactions we’re seeing with the mRNA vaccine, so I want to throw that in there. This will be a judgment call.

Again, you got a bad reaction with the first vaccine, you’re going to have to make a decision with someone knowledgeable. You want to probably consider getting that vaccine in a setting where you can have a longer observation period, and be treated if you have any issue.

Now, this is going to be an operational, in the weeds– “We are trying not to throw out additional doses. What happens?” I want to describe this for people. We’re going to be doing our second round of vaccinations for ProHealth. We did what we were supposed to, we got our 1,200 vaccines, and we immediately gave all those 1,200 vaccines to all our employees, and they’re gone.

We didn’t put any in the freezer. I don’t think that surprises any of our listeners, but I am a big fan of vaccines going into people’s arms, not into freezers. We are going to get our next shipment on Tuesday, it’s arriving. This is a change. We actually were told ahead of time yesterday. We actually were told, “Hey, by the way, just to confirm. You will be getting your second dose of vaccines coming next Tuesday.” When we did our first vaccines, what we saw several times was that instead of there being just 10 doses in the vial, there might be 11. You might actually have a vial with 12 doses. In certain circumstances, instead of doing just 10 people, we did that 11th person.

We’re now hoping that when we get our second 1,200 doses– do we have those extra few doses that we gave to people? Again, it’s the issue like let’s say, it’s the first night. I worked at one place, was down at Long Beach, and I was there for a couple hours. I did 31 vaccinations. That was three vials, one of the vials had an extra dose so we got the 31st person. I am hoping that things work in our favor. We also have 31, but what if we have a vial which has only 10, 10, 10? What do we do with that extra person? We don’t want to send them away. Do you open another vial? This is where we’re talking about coordination.

We’re actually going to set up a call center, so that people can say, “Okay, I don’t want to open a new vial for one person, but if you drive 15 minutes, our Freeport site will have a vaccine. People really need to be thinking through the logistics here, we do not want to throw vaccines in the trash. I’m going to quote George Benjamin, the president of the American Public Health Association, “Principle number one is don’t waste the vaccines.” I’m very excited, I have to say that Dr. Kessler is going to be the head of the Biden Taskforce. He’s been talking a lot about improving the operations of getting vaccines out there.

We are expected to have transparency on how many doses are produced, where those doses are, and at the end, we really want to increase the efficiency. He uses the analogy of the airplane. I feel like maybe we use that here. You find out we’ve got most of the people in first class boarded, but somebody’s running 15 minutes late. You start boarding the rest of the airplane and when that person who shows up 15 minutes late, you get them in as well. Let’s make things move forward, let’s make this efficient. Let’s move away from this threat of punishment when you do things wrong, to getting those doses in people’s arms, and the dialect being, “How can we help?”

All right, that’s it for active vaccines. Now, what about the pre-exposure period? Just want to hit a little bit on testing. There was a BinaxNOW antigen test sensitivity for culture positive specimens, showed a 92.6% and a 78.6% for those symptomatic and asymptomatic. Again, reinforcing that people who have a high level of virus, people who are in that infectious period, that the antigen is actually really a great way of picking those folks up. This was in the MMWR, so it’s nice to get a little more information. I don’t think we have as much information as we would like on asymptomatic persons using our testing technology, so great to have a little more information there.

Now, we get up to passive vaccination. So here we are, we’re at the period of detectable viral replication. A person has symptoms, it’s week one. What can we do during week one if the person meets criteria? This is when we jump in with our monoclonal antibody therapy. We heard a little bit about Bamlanivimab, the Mayo experience, greater than 2,000 patients, and then they’re suggesting an efficacy of 70% and a mortality benefit. I’m also going to talk a little bit, this is an exciting day, we’re recording this on the 21st of January, we actually got a little more information from Eli Lilly. They actually released some data where they were looking at giving this antibody, Bamlanivimab, to nursing homes.

Residents and staff at skilled nursing and assisted living facilities. What they did is, this was a study of 965 participants, start off with a baseline negative for SARS‐CoV‐2 virus. There were 299 residents, there were 666 staff, and basically, they’re following who gets infected, and does anyone die? Actually, in this– which, right now it’s still the press release stage. I’ll be excited when I see peer review, but the residents randomized to Bamlanivimab had an 80% lower risk of developing COVID-19. The individuals in the placebo group, there were four deaths. There were zero deaths in the residents that received the Bamlanivimab. Those were four deaths due to COVID.

Continuing to get more information on the Bamlanivimab, we have our trial up and running at United in Research. We’ve already been infusing people in-home, so we’re hoping to get more and more information. People go to United in Research, it’s the lead study there. They pre-register while they’re still healthy. Then if an individual develops COVID, the system is activated and we are giving in-home infusions, which, ideally, is when this therapy and how this therapy should be given.

All right, the early inflammatory phase. I’m going to hit on vitamin D again. Nice article, Vitamin D Status is Associated with In-hospital Mortality and Mechanical Ventilation: A Cohort of COVID-19 Hospitalized Patients. This was Mayo Clinic Proceedings. Retrospective observational cohort study, done to tertiary academic medical centers in Boston and New York. Eligible patients had to be hospitalized, and they basically broke them down into people that had very high vitamin D levels, who are greater than 30 nanograms per milliliter, and people that had very low say, less than 30 nanograms per milliliter.

People that had very high levels, 9.2% mortality. People that had low levels, 25.3% mortality. We’re actually seeing, again, at least when you come in, it’s very predictive, actually predictive for need for mechanical ventilation, so keep those vitamin D levels up. Again, we do not know. We’ve seen studies both ways on once you get into the hospital, but we’re trying to avoid that, and try to keep people out of the hospital. Again, we don’t know that if you prospectively brought people’s levels up, brought it down, or if this is more of a marker for something else, but just more information out there on vitamin D.

Anticoagulation. I know I talked a little bit last time about the full-dose anticoagulation was removed from some of the ACTIV trials. Now we actually saw, Intermediate-dose Anticoagulation, Aspirin, and In-hospital Mortality in COVID-19, A Propensity Score-matched Analysis. This came out as a preprint from some researchers and clinicians up at Yale. We know that clotting complications are common. We know that this is a major issue in COVID, and some degree of anticoagulation is standard. We’re still trying to clarify what dose, what agent? Nice to see a little data here, more data here on aspirin being thrown into the mix here.

They actually were looking, they were comparing intermediate, which is, we’ll say if you’re going to use low-molecular-weight heparin, clinicians who are listening in now, instead of the once a day, you might go up to twice a day, that’s our intermediate. We may go up to twice a day for weight-based dosing. The study actually suggested that there was a benefit to intermediate dosing, also a benefit to being on aspirin. Using intermediate, slightly higher dose anticoagulation, not full dose, and adding aspirin as well.

What about IL-6 receptor inhibition? I know it’s been a while since I’ve talked about tocilizumab, but we have some new data out. The REM-CAP Interleukin-6 Receptor Antagonist in Critically Ill Patients with COVID-19, a preliminary report. This was a randomized embedded, multifactorial, adaptive platform trial for community-acquired pneumonia. You get your REM-CAP, and adult patients with COVID-19, within 24 hours of commencing organ support in an ICU. We’re looking here at timing. We’re also looking at a background of steroids. Over 93% of these people had a background of steroids. We’re going to hit on that again, but it wasn’t being given to people in late stage.

It wasn’t given to people particularly early, it was given right when we saw an escalation of, I’m going to say, the cytokine storm, so the timing was what we talked about. People were either randomized to receive the tocilizumab or sarilumab, another IL-6 receptor antagonist, or standard of care, and the primary outcome was in-hospital mortality. Hospital mortality was 28% for people that got TOCI, 22% for people that got sarilumab, and 36% for controls. This gives us about a 22% to a 38% reduction in mortality statistically significant.

Again, the advantages of this trial background premedication with steroids tocilizumab is given, what most of us have said for a while here is the right stage during the early inflammatory stage. People that are progressing, and actually, about 30% of the folks got a second dose of tocilizumab. Just to recap here. We now have the EMPACTA trial with a 44% reduction in need for a mechanical intervention with use of TOCI and a background of steroids. The COVACTA trial demonstrating a reduction in hospital duration. Now the REM-CAP data showing a rather impressive mortality benefit if given after steroids with attention to timing. Now we’re waiting for the recovery trial.

Now on 1/11, January 11th, the ROCVERY trial independent Data Monitoring Committee recommended continuing recruitment to their tocilizumab treatment arm, so that’s encouraging. This is going to give us data on about 3,000 individuals with a background of steroids in COVID in the U.K. At least when they looked it over, they were not seeing any reason why they should stop. That will be helpful to really clarify the role and timing of tocilizumab.

The secondary infection phase. Another nice article, Prevalence of Coinfection at the Time of Hospital Admission in COVID-19 Patients, A Multicenter Study. This is an Open Forum Infectious Disease. Yes, that is a fine journal reporting they looked at over 1,000 patients, and at the time of admission, only about 1% had what they felt were bacterial respiratory coinfections. Reinforcing looking at this disease as far as timing. When people come in the door, it is really uncommon, less than 10%, maybe closer to 1%, that there’s a bacterial process going on. It’s the later stage. It’s week three when we really start seeing the infections. At that point, we see a combination. We see a lot of bacteremias. We see pneumonias. We see incidents of fungal.

Multisystem inflammatory phase comes at that. It’s important to keep reinforcing the bimodal aspect of the inflammatory process. We have the early inflammatory, and then we have the late or the multi-system inflammatory phase. We haven’t been hearing much about this. I don’t know if there’s any more new news as much as– now we appreciate this. We’re addressing it. Sometimes children. Sometimes adults. We don’t even see them in the hospital. Initially, they come in just during this late stage.

The tail phase. A number of more studies, actually really appreciate the attention here. One of the studies was the COVID-19 Post-Acute Care Study Group. Persistent Symptoms in Patients After Acute COVID-19, that was in JAMA. Looking at 143 Italian patients hospitalized for COVID-19, 83% continued to have at least one symptom 60 days post-discharge. Reinforcing, this isn’t you just get better. Another study, COVID-19 Symptoms: Longitudinal Evolution and Persistence in Outpatient Settings in the Annals of Internal Medicine. This was 669 Swiss patients with positive tests for COVID-19 mostly outpatients, 32% continued to have at least one symptom at a mean of 43 days after discharge.

Even your mild folks, even your outpatients continuing to see symptoms here. I just want to thank everyone for taking the time. We’re still doing our fundraiser, still trying to help the Peace Corps HIV and AIDS Program. Go to parasiteswithoutborders.com. Go to donate and help us continue to do what we’re doing as well as support the Peace Corps.

VR: Alright Daniel, a couple of questions. I had one that you partially answered, but let me just confirm. So, if someone is fully vaccinated, two doses, and they’re exposed to someone, you said they should still be quarantined but that is a nine-day, not a 14-day quarantine. Is that correct?

DG: Quarantine versus isolated. I try to make the distinction and it really only matters in certain states. The CDC has made it 10 and 10. They’ve lined them right up so if you’re infected, you wait 10 days. Actually, it was a really nice study showing that after nine days you’re really not seeing, they were not able to culture virus, so that was really good. On the isolator for the infected.

The quarantine. This has gotten a little bit– the CDC said, “Let’s just use the 10 days.” They’ve even talked about a seven-day test out, where you just quarantine for seven days. If you’re still feeling fine at day seven, you get a test. You can end your quarantine early. You could just wait for 10 if you don’t want to test and just do symptoms. This was analyzed. You will miss about 20%. About 20% of people will develop symptoms or turn positive if you use the seven-day test-out option.

VR: What about vaccinated people? Is there a day?

DG: We don’t treat them any differently yet just because we don’t know. It is tough. “Come on. I’ve been vaccinated. What am I doing?”

VR: Yes, sure.

DG: This is not about you. This is about transmission, but we just don’t know, but we will. We will know.

VR: All right, a couple of emails. Tarryn writes, “Hello, I work at a big academic medic hospital. I’m almost 14 days post-second Pfizer vaccine. Our hospital uses Abbott’s SARS-CoV-2 IgG assay. A couple of my coworkers have gone to get tested, come back negative. The results specifically state they can’t be used for vaccine efficacy verification. What can be used for that? Anything?”

DG: I’ve been telling people, just don’t check your serologies. Go ahead and trust the data, trust the science, trust the protection. Yes, there is a commercially available neutralizing antibody assay. Again, I don’t want to encourage you to do that. Yes, just go ahead. Get your vaccines. Stop doing all the blood work. Let’s focus our resources on the critical areas.

VR: All right. This is from Anthony. I do a live stream with Amy every Wednesday night, and he heard it last night, and the topic came up of taking NSAIDs after vaccination to reduce discomfort. “If memory serves me correctly, someone even suggested taking an over-the-counter pain killer before vaccination. Someone else thought NSAIDs, reduce the effect of this vaccination. What’s the correct thing to do? For years I used aspirin to reduce pain so I could exercise more. Then I read that this diminished the exercise effect.”

[laughter]

DG: I get this question a lot actually, and I’m thinking it might be like an anti-vaxxer thing. “If you feel crummy after the vaccine, don’t take anything. It won’t work.” They want everyone to suffer a little bit more. I got my second dose of vaccine on Tuesday morning. I had a few side effects. At one point I opened an email from my partner Anuja and felt a little annoyed for a couple of minutes. I’m sure it was the vaccine, not the content of the email. Then I had a meeting yesterday, was supposed to be at four. I thought it was at three. A little bit of a cognitive impact getting confused there. I felt a little achy, actually.

It wasn’t big. I took a couple of Aleve, I think that that’s fine. I don’t think there’s any– get Brianne Barker to jump in on this. If you take a couple ofAleve, take a couple of Advil, you take NSAIDs. I don’t think that that’s going to prevent your B cells and T cells from doing their job. Not a problem from my perspective.

VR: All right. One more from Karen whose mother in November contracted COVID-19. She’s in an assisted living facility. Had a hard time, has a lot of comorbidities. At one point she decided she didn’t want to eat anymore, which they took to determine was her will not to live. They asked that she be placed in hospice care rather than going to the hospital. She would like to know a little discussion of hospice or palliative care decisions in your clinical updates, Daniel.

DG: Sure. I appreciate that you bring this up. We don’t talk about this a lot or haven’t talked about this. On a daily basis, this is part of our day. We try to get a sense of where people are headed, how they’re going to do. There certainly are a lot of individuals where early on, we realized that their chance of coming out of this in a positive way is low. A little bit of hats off to Northwell. They, at Plainview Hospital, where I spend a lot of time, they recruited, and they have a full-time palliative care specialist, and she and I talk quite a bit. She’s a lovely, brilliant woman. She speaks more languages than I have fingers. We have specialists get involved, have conversations with the family.

“What are the goals of care? What would your loved one want?” Often, and it’s wonderful when the loved one can be part of that decision-making. Yes, this is a big part. You want to have this conversation before someone gets sick. You want to share your goals, your desires with your family. Talking to the individuals who might end up getting COVID here which is a lot of us, before so that when someone ends up in the hospital– I worked with an attending who was a physicist, and he used to refer to this as the fifth vital sign.

You want to know, on the admission, what would this person want? What are their goals of care? Often, people who I consult for, I will put my recommendations. I’ll also put a little tagline about, these should be consistent with goals of care. Particularly in the surge conditions, this would come up quite a bit. Does this individual really want to be here in the hospital? Or is this an individual– Is this a family context where they would prefer to be home? They’d prefer to be in a hospice setting. I will say my stepsister is a hospice nurse. Hospice is not, “Ooh, someone’s just about to die.” It is a change in the goals of care.

A lot of times, just to qualify prosperous, you’re saying, I think they’re less likely to live six months. The mistake people often make when they think about palliative care is they wait too long to make these decisions. They wait too long to have these conversations. I appreciate you bringing it up because I think this is critical. No one wants to talk about this, but everyone should talk about it so that when we get to this point, we know what you want us to be doing.

VR: That’s COVID-19 Clinical Update number 46 with Dr. Daniel Griffin. Thank you, Daniel.

DG: Thank you so much, Vincent. Everyone be safe.

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