Another COVID-19 Medical Mystery: Patients Come Off Ventilator, But Linger In A Coma

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24 Авг 2020, 12:18

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A COVID-19 patient in the intensive care unit at the United Memorial Medical Center, Houston, Texas on July 28th, 2020.

Go Nakamura/Getty Images

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Go Nakamura/Getty Images

Frank and Leslie Cutitta at their home in Wayland where a banner still hangs for his return from the hospital.

Jesse Costa/WBUR

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Jesse Costa/WBUR

Frank Cutitta spent a month at Spaulding Rehabilitation Hospital. He’s back home now, in a Boston suburb, doing physical therapy to strengthen his arms and legs. He says he slurs words occasionally but has no other cognitive problems.

While in the ICU, Cutitta’s nurses would play recorded messages from his family, as well as some of his favorite music from the Beach Boys and Pavarotti. Frank Cutitta says he believes the flow of these inspiring sounds helped maintain his cognitive function.

The Cutittas say they feel incredibly lucky. Leslie Cutitta says one doctor told the family that during the worst of the pandemic in New York City, most patients in Frank’s condition died because hospitals couldn’t devote so much time and resources to one patient.

«If Frank had been anywhere else in the country but here, he would have not made it,» Leslie Cutitta says. «That’s a conversation I will never forget having, because I was stunned.»

Frank Cutitta credits the Mass General doctors and nurses, saying they became his advocates.

It «could have gone the other way,» he says, if clinicians had decided, «look, this guy’s just way too sick, and we’ve got other patients who need this equipment. Or we have an advocate who says, ‘throw the kitchen sink at him,'» Frank says, «And we happened to have the latter.»

Many hospitals use 72 hours, or 3 days, as the period for patients with a traumatic brain injury to regain consciousness before advising an end to life support. But as COVID-19 patients fill ICUs across the country, it’s not clear how long hospital staff will wait beyond that point for those patients who do not wake up after a ventilator tube is removed.

Joseph Giacino directs neuropsychology at Spaulding, and says he’s worried hospitals are using that 72-hour model now with COVID-19 patients, who may need more time. Even before the coronavirus pandemic, some neurologists were questioning that model. In 2018 the American Academy of Neurology updated its guidelines for treating prolonged «disorders of consciousness,» noting that some situations may require more time and assessment.

Some patients, like Frank Cutitta, do not appear to have any brain damage. Whatever caused his extended period of unconsciousness cleared.

Unless a patient has previously specified that she does not want aggressive treatment, «we need to really go slow,» says Giacino, «because we are not at a point where we have prognostic indicators that approach the level of certainty that is necessary before making a decision that we should stop treatment because there is no chance of meaningful recovery.»

Doctors interviewed for this story urged everyone to tell their loved ones what you expect a «meaningful recovery» to include. If confronted with this situation, family members should ask doctors about their levels of certainty for each possible outcome.

Some medical ethicists are also urging clinicians not to rush when it comes to decisions about how quickly COVID-19 patients may return to consciousness.

«A significant number of patients are going to have a prolonged recovery from the comatose state that they’re in,» says Dr. Joseph Fins, chief of medical ethics at Weill Cornell Medical College. «This is a time for prudence because what we don’t know can hurt us and can hurt patients.»

Leslie and Frank Cutitta have a final request: Wear a mask.

«This disease is nothing to be trifled with,» Leslie Cutitta says. «It’s a devastating experience.»

Frank Cutitta worries about all of the patients still suffering with COVID-19 and those who have survived but have lasting damage.

«I’m not considering myself one of those,» he says, «but there are many, many people who would rather be dead than left with what they have after this.»