Unmasking the fear of death with Tolstoy

During this pandemic when we’re feeling the anxieties of infection and death, The Death of Evan Ilyich (1886), by Leo Tolstoy gives us the message of our capacities to respond to the fear of death in ways we never knew we could. It reminds us that, fear isn’t real. Human, as a species, is not defined by fear.

By Nayan Sayed Jibon

YES, we’re scared. We’re on the edge, unable to think properly. Our focus flutters and floats around flea-like from one update to the next. We follow the news, because we feel we should but soon we wish we hadn’t, because it’s sad.

The thought of dying alone with a respiratory sickness is so horrifying to hide under our masks. We are separated from one another but we can’t keep our distance from the fear of death. This led me to question, how can I accept my own mortality, so that I can live my life to the fullest during this terrifying situation?

Then I found a novella The Death of Evan Ilyich (1886), by Leo Tolstoy which helped me not only to understand the author’s philosophy towards death but also the psychology behind it. As a result, I could gather some emotional courage to embrace my fear of death during this COVID-19 pandemic situation.

Leo Tolstoy (1828-1910), a Russian writer, is regarded as one of the greatest authors of all time. He is best known for his novels like War and Peace (1869) and Anna Karenina (1877). But due to his unusual firsthand experiences of death and dying, he also wrote extensively about the inevitability of death for our understanding of life itself. Some of his most memorable meditations on this theme are found in his novella The Death of Ivan Ilyich. In the novella through the story of a dying Russian judge, Tolstoy successfully narrates the different episodes of ‘dying’ some eighty years before its discovery by Swiss-American psychiatrist Elizabeth Kubler Ross. In her book On Death and Dying (1969) Kubler Ross outlined five stages that a dying individual goes through.

The Death of Ivan Ilyich, as its title suggests, depicts the death of an ordinary middle-aged Russian judge, but it is also about a man who overcame it. Like everyone in his social circle, Ivan Ilyich lives a superficial life and dedicates his life to climbing the social ladder and seeking the bliss which he believes is found at the top. Initially he was contented with his life but gradually he becomes unhappy as his marriage deteriorates so he starts ignoring his family life and focuses on becoming a magistrate. 

One day he falls awkwardly upon hanging curtains for his new home and becomes ill. Doctors offer all kinds of diagnoses and medicines but he cannot recover and within some weeks, Ivan Ilyich could see that he is a bedridden dying man. In his death bed Ivan’s main source of comfort becomes his servant Gerasim. He is the only person in the house who does not fear death, and the only one other than his own son who seems to show compassion for him.

As Ivan’s interaction with Gerasim becomes deeper, Ivan begins to question the how can he accept death without being unhappy? Gerasim guides Ivan in his last days, and allowed him to realise the difference between a superficial and an authentic life and how to accept death with ease. He says, ‘We shall all of us die, so why should I grudge a little trouble?’ Apart from the philosophical thought, Tolstoy also shows the psychological stages of a dying person.

According to Ross, denial is the initial emotional response to the knowledge of death. In this stage people often say, ‘No, not me. It can’t be!’ From chapter five we find Ivan Ilych gets the idea that he is going to die but he could not get used to the idea and immediately denies it. In chapter six he says, ‘It can’t be me having to die. That would be too horrible.’ After a while, he entered the stage of anger, blaming god for imposing this kind of misery and pain to him, and expecting an answer, ‘Why hast Thou done all this? Why hast Thou brought me here? Why, why dost Thou torment me so terribly?’

Then he started talking to god asking for the meaning of his life. During this ‘bargaining’ period he started to look back and after much argumentation with himself he realises that he may not have done anything meaningful during his whole life. Consequently he enters into the ‘black hole’ of depression. He learns that it is impossible to turn back and fight against the forces, now he can only wait for the moment.

Finally, the door of acceptance was opening in his scared mind, with his understanding of the inevitability of death. Ivan Ilyich during this stage realises that he has not lived his life in the best way and he was dead long before he was called to die. He was materialistically driven and blinded most of his life by shallow pleasures. He eventually finds solace from the selfless love and kindness from his family and servants and embraces death. ‘Death is finished,’ he said to himself. ‘It is no more!’ 

Therefore, The Death of Ivan Ilych is Tolstoy’s parable representing the mystery that living well is the best way to die well. Tolstoy tells us that we don’t fear death, we fear life because we feel that we don’t live our destined time on earth as we were supposed to. It also echoes with the Stoic philosopher Marcus Aurelius who told us that ‘it is not death that a man should fear, but he should fear never beginning to live’.

During this pandemic when we’re feeling the anxieties of infection and death, this story gives us the message of our capacities to respond to the fear of death in ways we never knew we could. It reminds us that, fear isn’t real. It is like wearing the uncomfortable personal protective suit around our mind and feeling we’re being protected.

In doing so, we have allowed this fear into our house, our head, and our heart. It’s circulating like the ghostly virus — looking for prey in every thought and every action. But we must remember that human is not defined by fear. We are a hope and a faith-driven species that seeks to live life to the fullest and not die.

Complete Article HERE!

How to prepare for death

By Peter J. Adams

The main challenge in reflecting on one’s own death is the way the various aspects of death and dying are intertwined which make it difficult to discern personal mortality.

First there is the prospect of me dying; of me entering whatever is in store at the end of my life. How long will it last? Will there be pain? What will I leave behind? How do I say goodbye? Next there is the prospect of other people dying, particularly the death of loved-ones and the painful absence their loss leaves behind. How would I cope with the death of a close friend, a partner, a child? But thinking about my dying and other people’s deaths are different. Dying is an event in life, admittedly an important event, but still one that happens within the course of life. Similarly, coming to terms with the loss of a loved-one is an important process, but it belongs to a different domain than my death.

Another temptation is to think of my death as though it is like the death of others. I imagine myself in the shoes of someone as they approach their death. Maybe it would be my soul that is absorbed into a zone of endless tranquility. Maybe it would be my body lying motionless in the coffin. I conjure up images of love-ones with shocked expressions as they are told about my death, I visualize their forlorn looks as they watch my coffin descending into the grave and I picture their reactions to constantly interacting with the spaces I now no longer occupy.

But thinking about my death in terms of what happens when others die does not fully capture what happens when I think about my own death. When I die, looking at myself from the outside, my brain will stop working, my senses will cease to operate, I will no longer have any voluntary control of my muscles, and my body will lie limp and lifeless. This is undeniably what will happen.

Looking at this from the inside is more complicated. If my brain and my body cease to function, then it makes sense to consider my emotions, my consciousness and all those aspects that make up my subjective world, as ceasing to operate as well. My consciousness surely relies on input from my senses plus the processing power of my brain, so without them it is hard to think of how consciousness might persist. I might reassure myself that my consciousness will continue in some form in another realm, but I can’t be sure. It makes more sense to say that when all the conditions for consciousness are no longer present then my consciousness will no longer be able to function.

But this is a terrible thought; a horrifying realization with alarming consequences. My consciousness is always present whenever I look out at anything in the world. I never experience anything around me without being conscious. When I am unconscious, such as when I am asleep or knocked out, I assume the world continues under its own steam, but this is an assumption which I can never fully trust. What I can be surer about is that the world and my consciousness are always paired; they are always together, each interacting with and enabling the other, and participating together in allowing what is going on around me to continue to take place.

What this throws up is the possibility that without my mind the world, and all that it contains—objects, animals, people, loved ones—will cease to exist. In other words, from the standpoint of how I experience things, when I die the conditions that enable the existence of both my consciousness and the world around me will, most likely, no longer be present. In this way, the prospect of my own death highlights the possibility of the end of everything.

The unthinkable and unspeakable nature of my death forces me to walk repeatedly down a conceptual dead-end; a dead-end which discourages any further attempts to think along the same track. Even if we were to consider it important to form some sort of relationship to my death, there is no identifiable object to connect with, there is nothing to cling on to; it stands there as a conceptual black-hole; an emptiness which we can only approach with insecurity and foreboding.

Here lies the true challenge of reflecting on my death; the idea of it as an unthinkable, unspeakable nothingness. But, despite this, thinkers, poets, and artists have, over the centuries, still had a lot to say about personal mortality. It is just too big a part of the rhythm and structure of life to be ignored.

It is, similarly, important for each of us not to turn our backs on death and, despite its unintelligibility, to seek out ways of engaging with it. What is needed is some sort of provisional handhold that allows each of us to reach out and grasp onto something that can enable us to pursue a lifelong relationship with personal mortality.

Complete Article HERE!

Now more than ever we need to talk about how we want to die

Whilst our primary goal is to support patients to recovery, we must also ensure that patients who are no longer benefiting from intensive care are supported too.

By Dr Anushka Aubeelack

The coronavirus pandemic has brought death and dying to the forefront of the public’s consciousness.

As an anaesthetist working in a London intensive care unit, it is part of my daily life. Within a matter of weeks it has become everyone’s business.

Throughout my career I have been involved in the care of critically-unwell patients. All intensive care doctors accept that in spite of our best efforts, some people will not survive.

Whilst our primary goal is to support patients to recovery, we must also ensure that patients who are no longer benefiting from intensive care are supported too, so they may die without discomfort. This is true of any intensive care ward, at any time, but Covid-19 has further highlighted the importance of good end of life care, as we are seeing record numbers of very unwell people admitted to the hospital.

When the intensive care team is called to admit a patient, we try our best to establish their wishes with regards to treatments.

Have they thought about intensive care and life support? If their heart or breathing was to stop, have they thought about whether they would want the medical team to attempt cardiopulmonary resuscitation, for instance?

Whenever we can, we explain clearly what the treatment options are and the risks and benefits of each; we ask them what their own priorities are and answer any questions they may have. Then we adjust the treatment goals to best suit that individual patient.

But sadly, there are times where this communication is not possible and both the team and patient are robbed of that opportunity. That is why I am so passionate about what is known as advance or anticipatory care planning, or what I prefer to call advance life planning.

This is where people are given the opportunity to talk through their priorities and concerns for the end of life and translate them into a plan for their future care and treatment. This may include a Living Will (a legally-binding document also known as an Advance Decision or Directive) to refuse certain treatments and an Advance Statement to record other preferences for care.

People may also wish to nominate a trusted person to make healthcare decisions for them if they become unable to, using a Lasting Power of Attorney for Health and Welfare. These documents are then shared with healthcare professionals and loved ones.

I appreciate that in these uncertain times people can feel powerless and voiceless, but advance care planning can empower you and ensure your voice is heard clearly

All intensivists can recount a story in which, acting in good faith, a patient was put on to full life support, only to subsequently learn from loved ones that this action was against that patient’s end of life wishes.

This is not only heart-breaking for all involved, going against our core belief to ‘do no harm’, but it also denies that person the chance to be kept comfortable in a place of their choosing to say a meaningful goodbye.

This pandemic means we can no longer shy away from death. It is an inevitability of life and conversations about death should no longer be taboo.

It is now more essential than ever to talk to our loved ones about what a good death would mean to us as an individual.

For some, the most important thing might be remaining as pain-free as possible. For others, the priority might be to remain as lucid as possible until the end, or dying in a place of their choosing, whether that is at home or at a hospice, surrounded by their loved ones.

Some may want to accept all efforts to keep them alive as long as possible in spite of the risks. An Advance Statement can record information like this, and while it is not legally-binding like a Living Will, it should be taken into account if decisions need to be made on your behalf about your care and treatment. 

I appreciate that in these uncertain times people can feel powerless and voiceless, but advance care planning can empower you and ensure your voice is heard clearly. It also assists medical professionals like myself to continue to act in the best interests of our patients by respecting their wishes.

By recording them as clearly as possible now and sharing them with your family and your GP, you will be far more likely to get the care and treatment that’s right for you when the time comes.

Know that if you do want to put plans in place, you are not alone.

The charity Compassion in Dying – for which I am clinical ambassador – aims to help people prepare for the end of life; how to talk about it, plan for it and record their wishes.

The MyDecisions.org.uk free site, which guides people through different scenarios so they can record their wishes for future care and treatment, has seen the number of completed Living Wills in the last month surge 160 per cent compared to the same period last year, and completed Advance Statements are up 226 per cent.

One might therefore conclude that the coronavirus is prompting people to consider and record their wishes for the end of their lives – some for the first time – and that is to be welcomed.

These are unsettling times, but know that healthcare teams in hospitals will continue to work hard to care for our patients, whether that means supporting them to a full or partial recovery or enabling them to have a dignified death.

For those who have already taken the time to document their wishes for the end of life, I am thankful. To those who are thinking about it, I appeal to you to do so.

Complete Article HERE!

Dying old, dying young

– death and ageism in the times of Greek myth and coronavirus

By

The loss of life from the spread of coronavirus has been on an enormous scale. In the USA more Americans have now died from COVID-19 than in the entire Vietnam war.

Notwithstanding some poignant and passionate speeches by particular individuals (notably New York Governor Andrew Cuomo), much of the discourse has focused on the economic, political and policy division, rather than grief for the victims.

This broadly sanguine response might be due to perceptions that it is mostly older people dying from coronavirus, although experts warn younger people can die too. Witness the relief at new reports that children under 10 have not accounted for a single transmission of the virus. The deaths of older people have been comparatively discounted, not the least because many were socially isolated even before the pandemic.

The Greeks of antiquity reflected on the death of the young and the old in some very creative mythical narratives. Greek myth reflects on and reminds us of some of the less attractive characteristics of human life and society, such as sickness, old age, death and war. In the ancient Greek world this made it harder to put old age and death into a corner and forget about it, which we tend to do.

Choosing when

Achilles, the hero of Homer’s Iliad, actually has a choice in the timing of his life and death.

He can have a long life without heroic glory, back on the farm, or he can have a short life with undying fame and renown from his fighting at Troy. The fact that he chooses the latter makes him different from ordinary people like us.

Achilles’ heroism is fundamentally linked to his own personal choice of an early death. But it also means his desperate mother, the goddess Thetis, will have to mourn him eternally after seeing him for such a short time in life. Such is the pain for the loss of a child in war.

A play by the master Athenian dramatist Euripides is even more focused on young and old death. The play Alcestis was produced in Athens in 438 BC, making it the earliest surviving Euripidean play (about ten years before the plague at Athens).

In the play, the king of Thessaly – an appallingly self-interested person called Admetus – has previously done the god Apollo a favour, and so Apollo does Admetus a favour in return. He arranges for him to extend his life and avoid death in the short term, if he can find someone to take his place and die in his stead.

Admetus immediately asks his father or mother to die for him, based on the assumption that they are old and will presumably die soon anyway. But the father, Pheres, and his wife turn down Admetus, and so he has to prevail on his own wife, Alcestis, to die for him, which she agrees to do.

The story of the play is based around the day of her death and descent to the Underworld, with some rather comic twists and turns along the way. Death (Greek Thanatos) is a character in the play, and he is delighted to have a young victim, in Alcestis, rather than an old one. “They who die young yield me a greater prize,” he says.

The light of day

There is a particularly spiteful encounter between Admetus and his father on the subject of young and old death:

Admetus:

Yet it would have been a beautiful deed for you to die for your son, and short indeed was the time left for you to live. My wife and I would have lived out our lives, and I should not now be here alone lamenting my misery.

Father:

I indeed begot you, and bred you up to be lord of this land, but I am not bound to die for you. It is not a law of our ancestors or of Hellas that fathers should die for their children! … You love to look upon the light of day – do you think your father hates it? I tell myself that we are a long time underground and that life is short, but sweet.

The Alcestis of Euripides, and other Greek myths, remind us, should we ever forget, that love of looking upon the light of day is a characteristic of human existence, both for the young and the very old.

Complete Article HERE!

Some Ways That I’m O.K. Dying

By

This is the first time I have spent long stretches imagining my own death. Usually, the death pass is a perfect thirty-yard spiral. This death daydream takes place in a blinding blizzard in a game that I lose. In this one, I imagine being sick for a while and then developing a hacking cough and then getting pneumonia and then dying. This is an awful death simulation.

I feel like I am O.K. with some versions of my own death. Like, maybe I go for a nice long walk, then I have dinner with my wife and daughter, maybe a phone call with an old college friend, and then a meteor hits the earth. Sign me up for that death. Or maybe this: I take a guitar lesson with Paul Simon. He teaches me “The Boxer” and then, for no justifiable reason, I play the song perfectly—like, better than Simon & Garfunkel in Central Park in ’81—and after I play the final note Paul looks over at me and says, “That was really good, Mike.” And then the building explodes. So obviously, in that scenario, we both die instantly and the headline reads, “Paul Simon and Unknown Comedian Die After Perfect Jam Session.”

There is one last death scenario I’d be O.K. with. To recap, so far it’s:

1. Dinner with my family and then a meteor.

2. Simon & Birbiglia followed by explosion.

The third and final death scenario I’m O.K. with is my wife and daughter and I go to the beach and have a bonfire, which is prepared by bonfire professionals who make sure it’s not too hot but perfect for s’mores. And we make s’mores—no, wait, that’s after we make a bonfire pizza, with dough flown in from Frank Pepe’s, in New Haven. So we do pizza then s’mores and then my wife leans over to me—privately, because our daughter is only five—and she says, “If anything ever happened to you, I want you to know that we would be O.K. and that you’ve given us more than we could hope for in three lifetimes. So, God forbid anything happens—we will be fine.”

And then I say, “I love you both.”

And I walk into the water and am eaten by a shark. Quickly. The key there is “quickly.” And the headline reads, “Unknown Comedian Killed by Shark After He Kills with Thousands of Audience Members.”

Those are the ways I’m O.K. dying. But, these days, it’s much grimmer than that. It’s hacking coughs and scorching fevers and ventilators and intubations and people sharing their final words with their families through a bad connection on a cell phone.

So my only remaining hope in this terrible simulation is that, if I find myself in a hospital, hooked up to a ventilator that is about to be taken from me—that I will be aided by an adequate amount of medical delirium to actually believe that the last thing I see is Paul Simon, leaning over to say, “Mike, you played that final note perfectly.”

Complete Article HERE!

Coronavirus Disrupts Hard Decisions About End-Of-Life Treatment

The coronavirus means more people are dying alone in ICUs. Families are having to make abrupt decisions at a distance about terminal care. Palliative care specialists try to adapt.

By Will Stone

TRANSCRIPT

Palliative care is a specialized branch of medicine that focuses on relieving pain and symptoms in seriously ill patients and those who are dying. Will Stone reports that the coronavirus pandemic has disrupted this kind of care at a time when families are facing abrupt decisions about end-of-life treatment.

WILL STONE, BYLINE: Before coronavirus, Darrell Owens rarely worked in the emergency room. Now he’s there daily. Owens is a nurse practitioner and directs the palliative care program at a hospital run by the University of Washington in Seattle. Owens used to visit with families in quiet conference rooms or at the bedside.

DARRELL OWENS: Cancer patients, stroke – regular routine palliative care patients.

STONE: Back then, he could grab a chair and scoot up right next to the patient and take his time. Palliative medicine focuses on patients’ quality of life and relieving symptoms of serious illness, like pain and anxiety.

OWENS: We are obligated – as much as we are to try to save people’s lives, we are as obligated to save their deaths.

STONE: Across the country, coronavirus has disrupted this sacred task. Owens is adapting. The ER now calls him a lot. He sees every coronavirus patient who’s older or at risk for complications.

OWENS: The conversations are more abbreviated than they would be because, one, you’re behind a mask. You’re in a loud room, completely gowned up, and so you want to limit your exposure.

STONE: All that makes it harder to talk through a patient’s chance of survival and big questions, like do you want to be resuscitated? Do you want to be put on a ventilator? Because of the pandemic, relatives are usually barred from the hospital.

OWENS: You cannot underestimate the stress on family members who cannot visit and now, in a crisis mode, trying to talk this through over the phone.

STONE: It’s this painful new reality that Rich and Rob Mar and their sister Angie Okumoto faced when they lost both of their parents to coronavirus last month. Their mother Elizabeth was in her early 70s, still running a Hawaiian restaurant with her daughter. Rich says she liked to give out hugs.

RICH MAR: One of those people that just quickly made friends and made an impression on everyone.

STONE: They say their mother was in good health before contracting the coronavirus. They brought her to the ER when her breathing got worse. She was asked, did she want to be resuscitated, if necessary, and put on life support? Angie says they didn’t hesitate to say yes.

ANGIE OKUMOTO: You know, yeah, of course. We just had no idea what this virus was going to do.

STONE: They just assumed she would pull through.

MAR: I didn’t know that was the last time I was ever going to talk with her.

STONE: Before they knew it, she was sent to the ICU.

OKUMOTO: For 14 days on the ventilator, she was alone.

MAR: Right. Right.

OKUMOTO: Alone for 14 days.

MAR: That’s the part that hurts the most and what will haunt me forever.

STONE: Near the end, they did get to see her, but she was sedated.

MAR: We were all gowned up. And so we’re, like, trying to talk to her and let her hear our voices.

STONE: Meanwhile, their father Robert was also getting sick. He was 78, an engineer.

MAR: My dad was more of the analytical type. He can give you a practical solution for everything.

STONE: They took him to the same hospital as his wife, where he made his wishes very clear.

OKUMOTO: My dad, from Day 1, he said he did not want to be on life support.

STONE: So Darrell Owens, the palliative care director, started managing Robert’s care.

MAR: He was super compassionate, telling us the facts and being straightforward with us.

STONE: Because Robert had decided against aggressive treatment, he was never moved to the ICU. He was able to have a few visits with his kids, and he wasn’t on a ventilator, so they could talk to him and text. Their father died on March 27, not long after their mother.

MAR: The way he wanted to.

OKUMOTO: With dignity.

MAR: With dignity, yeah. That was very important to him.

STONE: The family is grateful to the nurses and doctors. Still, they grieve those visits they never had. Angie never got to say goodbye before her mom was intubated.

OKUMOTO: If I got to be bedside to my mom earlier, holding her hand and just being present – and that we’ll never know, right? Like, that’s what sucks.

STONE: It’s an experience of death that more families are coming to know – loved ones dying alone and out of reach from a new and poorly understood virus. In New York City, Dr. Diane Meier works in palliative care at Mt. Sinai School of Medicine. During the worst of the surge, the hospital set up a palliative care hotline for families.

DIANE MEIER: So this is completely unprecedented. All the cues you normally get with face-to-face are very hard to pick up over the phone.

STONE: Mt. Sinai doctors are even calling elderly patients at home to learn their wishes just in case they do get infected.

MEIER: Many of our patients had been thinking about it a lot, incredibly relieved that we had reached out to them.

STONE: Meier says it’s a new way of doing palliative care when faced with a virus that moves so fast. For NPR News, I’m Will Stone in Seattle.

Complete Article HERE!

Do You Want to Die in an I.C.U.?

Pandemic Makes Question All Too Real

Cheryl Goldman of Valley Stream, N.Y., has emphysema and relies on supplemental oxygen. She told her son that if she contracted Covid-19 and needed a ventilator that she would refuse treatment.

Sobering statistics for older patients sharpen the need to draw up advanced directives for treatment and share them with their families.

By

Earlier this month, Cheryl Goldman, a retired high school teacher living on Long Island, called her son, Edo Banach, in Maryland. It seemed a routine chat until Ms. Goldman announced that if she became ill with Covid-19, she would decline a ventilator.

“I’m her health care proxy,” said Mr. Banach, who happens to be the president of the National Hospice and Palliative Care Organization. “Her perspective was, what’s the point? In all likelihood it’s not going to help, and she’d be taking a vent away from someone else.”

At 69, Ms. Goldman has emphysema and already relies on supplemental oxygen. She told me that she’d been following the news, including the grim statistics for older adults with chronic illnesses who require ventilators during extended stays in intensive care.

In such cases, “the number who leave the hospital is low, and it’s lower for someone with health problems like me,” she said. She also feared being separated from her family during a hospitalization and wanted, instead, to remain at home with hospice care. “It’s a pragmatic decision.”

Mr. Banach, leading the response of about a thousand hospices nationwide that are facing heightened demand and bracing for worse, appreciated her forthrightness. “It’s the kind of conversation everyone should be having with their loved ones,” he said.

In the best of times, it can be tough to get Americans to discuss and document their end-of-life wishes. Depending on the study, a third to two-thirds of adults haven’t drafted advance directives, the documents that outline which medical treatments they would accept or refuse and designate a decision maker to act on their behalf if they’re incapacitated.

“People think, I’ll deal with it in the future,” Mr. Banach said. But for thousands of older adults, the future may have arrived.

To date, there’s no clear evidence that older people are more apt to contract the new coronavirus, said Dr. Douglas White, a critical care specialist and the director of the Program on Ethics and Decision Making at the University of Pittsburgh School of Medicine.

“What we do know is that older individuals are more likely to experience very severe disease if they do become infected,” he said. “The data are sobering.”

That’s partly because most older adults have chronic conditions — heart or lung disease, diabetes, high blood pressure — known to intensify the virus’s effects. And they have less physiologic reserve — “less ability to rebound from an overwhelming illness,” Dr. White explained.

When seniors and their families engage in what’s called advance-care planning, they often focus on the D.N.R. question — whether patients would want to be resuscitated after cardiac arrest.

But because Covid-19 is a respiratory disease, the more pressing question will likely be whether a hospitalized patient who’s seriously ill will accept intubation and ventilation.

That initially involves a tube inserted down the throat, connected to a ventilator that pushes air into the lungs. When a patient has spent two weeks on a vent, doctors commonly perform a tracheostomy, creating a surgical opening in the windpipe that replaces the swallowed tube.

Long before the virus erupted, among people over 66 who spent 14 days in an I.C.U. on a ventilator, 40 percent died within a year of discharge. Now, “those numbers are too rosy for Covid,” Dr. White said, citing findings from Italy and Britain, where more than half of older patients on prolonged ventilation died.

A just-published JAMA article looked at coronavirus patients admitted to Northwell Health hospitals in and around New York City. Excluding those still hospitalized after the monthlong study, the mortality rate among patients over age 65 exceeded 26 percent, and almost all patients over 65 who needed mechanical ventilation during that period died.

That data can prompt frank exchanges. “If a patient is elderly and has significant medical issues, I’ll explain that a large proportion of people who become ill with Covid-19 and need a ventilator unfortunately will not survive,” said Dr. Kosha Thakore, the director of palliative care at Newton-Wellesley Hospital in Massachusetts.

Moreover, longevity is not the only priority, and sometimes not the primary one, for older people considering medical options. What will life look like if they do survive?

“After elderly people have been on a ventilator, they’ve often already developed physical debilitation, difficulty swallowing, bedsores,” Dr. Thakore explained. They frequently cycle in and out of hospitals with complications. Their deficits can be physical or cognitive or both, and are often permanent.

Even pre-Covid, after 14 days on a ventilator in an I.C.U., only about one in five older discharged patients went home. “The others end up in nursing homes,” Mr. Banach said. “Some may later go home, and some will die in the nursing home.”

Though older adults with Covid-19 may not require hospitalization or ventilation, the decisions they face if they do highlight the importance of reviewing advance directives.

A new study in JAMA Internal Medicine questioned 180 patients over age 60 with serious illnesses; most said they would trade a year of life if that meant they could avoid dying in an I.C.U. on life support.

But that kind of aggressive care is exactly what they might receive. “If you don’t let the system know your wishes, the system takes over,” Mr. Banach pointed out. Family members can feel lingering trauma if they’re forced to make life-or-death decisions for loved ones who never discussed what they wanted.

“Many older patients we’ve encountered with Covid-19 have opted not to undergo ventilation and an I.C.U.,” Dr. White said. “No one should impose that on a patient, though if there’s true scarcity, that may arise. But patients might choose it for themselves.”

If older people have paperwork stashed in a drawer or safe, now is the time to unearth it and see if their instructions still reflect their values. If so, scan the document and send it to family members and doctors, Mr. Banach advised.

But for those who never got around to drawing up advance directives, appointing a decision maker — and telling that person what’s acceptable and what’s not — is ultimately more crucial. In emergencies, doctors probably won’t flip through documents to learn patients’ wishes; they’ll ask family or friends.

Mr. Banach’s counsel: “Take out your phone and do a video selfie: ‘This is who I am. This is the date. This is what I want.’ Send it to your friends and relatives. That’s enough.”

Many hospitals and health systems have developed workarounds when documents require signatures or witnesses; some are also doing palliative-care visits via telemedicine.

Dr. Gregg VandeKieft, a palliative care specialist with Providence Health on the West Coast, recently spent half an hour on Zoom talking with a patient’s sons about her end-of-life care. Dr. VandeKieft and a nurse were in Olympia, Wash.; one son was in Alaska and two elsewhere in Washington. “It felt not all that different than if we’d been in the same room,” Dr. VandeKieft said.

The coronavirus pandemic may spur more such conversations. In Los Angeles recently, Brie Loskota and her husband contacted close family friends, a couple in their 70s, asking about their well-being, offering to FaceTime, and then inquired: “If you got sick, is there anything we should know?”

The older couple, one of whom has a neurodegenerative disease and has already experienced mechanical ventilation, responded that they both wanted to avoid hospitalization and to die at home.

“It was a relief to be told,” said Ms. Loskota. “It’s not less heartbreaking, but it lets us make a decision with them in mind. It led my husband and me to talk about it for ourselves.” They’re in their 40s and have not yet drafted advance directives.

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