Cardiopulmonary Resuscitation During the COVID-19 Pandemic

hen we entered cardiology training, we never expected to think of our own safety before initiating chest compressions on a pulseless patient.Yet, the novel coronavirus disease 2019 (COVID-19) pandemic has raised new questions, including issues of clinician safety during cardiopulmonary resuscitation (CPR).CPR and endotracheal intubation are aerosol-generating procedures.According to the Centers for Disease Control and Prevention, aerosolizing procedures should be performed with personal protective equipment (PPE) consisting of eye protection, N95 respirators, gloves, and gowns in airborne infection isolation rooms given the higher risk of viral transmission.1 In New York City, the need for intensive care unit capacity has surpassed the number of negative-pressure rooms.Most intubated patients are placed in non-negative-pressure rooms where CPR should, in theory, be avoided given the risks of dislodgement of the endotracheal tube and aerosolization of secretions.Furthermore, there are already dramatic PPE shortages.These resource constraints challenge our ability to comply with Centers for Disease Control and Prevention recommendations.Because of the complex realities of resuscitation in the COVID-19 era, we encourage a national conversation on the following 4 points.First, how can we better identify patients who would not want CPR?As clinicians, one of our priorities has been, and continues to be, to provide patients with care aligned with their values and preferences in the event that they become critically ill.Advanced care planning is more imperative now than ever, particularly among older adults with chronic, life-limiting illnesses who are at higher risk for severe infection.Ideally, these conversations should occur before patients become infected and present to the hospital.Primary care clinicians or specialists who have longitudinal relationships with patients can address advanced care planning during outpatient visits scheduled for other reasons or during dedicated telemedicine visits. 2 In addition, patients and families can be directed to online resources to guide these conversations and to facilitate completion of physician order for life-sustaining treatments forms. 2 At the time of hospital admission, all patients should have conversations with their clinicians about goals of care and preferences for resuscitation, regardless of their CO-VID-19 status; however, these conversations should be prioritized in older patients with multiple comorbidities who test positive.Some institutions have also created palliative care telehealth services to assist frontline clinicians with reaching out to family members beginning in the emergency room.These services can dedicate time to having these important family discussions via phone or video conference because most hospitals now restrict inpatient visitation.Whenever feasible, primary team members should also partake in these conversations and revisit goals of care as a patient's clinical status changes.