Death due to pulmonary dysfunction common in COVID-19
Pulmonary dysfunction and septic shock were the most common causes of death in a cohort of patients hospitalized with COVID-19, according to a new study published in the Annals of the American Thoracic Society.
The retrospective cohort study evaluated specific causes of death, the prevalence of lung failure and end-of-life ICU care among 82 adults (median age, 71 years; 33% women) hospitalized with COVID-19 at Michigan Medicine who died. Researchers obtained data on organ system dysfunction, septic shock, primary cause of death and withdrawal of life support from each patient. Causes of death were compared with those of a prior cohort of 385 patients hospitalized with acute hypoxemic respiratory failure who died in hospital.
Before death, the most common organ dysfunction was pulmonary (81.7%), neurologic (57.3%) and renal (39%). Mechanical ventilation was used in 74.4% of patients during hospitalization. Sixty-seven percent of patients had multiple organ failure and 41.5% had coinfection. Septic shock occurred in 40% of patients, of whom 24.3% had coinfection.
Pulmonary dysfunction (56.1%) and septic shock (26.8%) were the most common primary cause of death. Patients with COVID-19 were more likely to die of pulmonary dysfunction (56.1% vs. 21.6%; P < .01) and were less likely to die of cardiac (7.3% vs. 16.1%; P = .04) or neurologic (6.1% vs. 19.5%; P < .01) dysfunction compared with the cohort of patients with non-COVID-19-related respiratory failure.
Withdrawal or limitation of life-sustaining interventions occurred in more than 76% of patients. At time of death, 25.6% of patients were receiving invasive mechanical ventilation.
Discussion of goals of care was documented for 97.6% of patients with COVID-19 who died in hospital. Within 72 hours after first ICU admission, 59.7% of patients treated in an ICU had goals-of-care discussions by telephone (91.3%), in person (43.8%) or by videoconference (2.5%). For family and friends visits within 24 hours of death, 34.1% of patients had in-person visits, 15.9% had virtual visits, 4.9% had both in-person and virtual visits and 54.9% had neither.
In the first months of the pandemic, the ability of friends and family to connect in-person or virtually with critically ill patients with COVID-19 had been limited across the country and, even if permitted in-person visits, family members have chosen not to come in fear for their own safety, according to a press release.
“The medical therapies we use to treat COVID-19 patients are important, but it’s also important to remember to care for, not just treat, these patients,” Scott W. Ketcham, MD, internal medicine resident in the department of internal medicine at the University of Michigan, Ann Arbor, said in the release. “We need to think about the individual as a whole, emotionally, spiritually and socially. We need to look at what we gain from visitation policies, in terms of transmission, and how we can use technology to connect providers to families and patients to families and friends.”
The researchers noted several limitations of the study, including the small sample size, conduct at a single center and potential changes in the cause of death.
“These findings underscore the importance of trying to deliver evidence-based interventions for respiratory failure in COVID-19 patients as the pandemic continues, especially as professionals who don’t normally treat this condition or work in an ICU are pulled into service,” Ketcham said in the release. “This means prone positioning, a good working knowledge of mechanical ventilation, appropriate selection of patients to receive heated high-flow oxygen and early recognition and treatment of infection. In other words, following guidelines developed before by those who specialize in treating respiratory failure like acute respiratory distress syndrome and sepsis.”