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NAChristakis's profile
Nicholas A. Christakis
Nicholas A. Christakis
Nicholas A. Christakis
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@NAChristakis

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Nicholas A. ChristakisVerified account

@NAChristakis

Sterling Professor of Social and Natural Science at Yale. Physician. Author of Apollo's Arrow; Blueprint; and Connected. Luckily wed @ErikaChristakis

Vermont, USA
humannaturelab.net
Joined August 2012

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    Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

    People who are dying of COVID19 will need first-rate palliative (hospice) care. This is going to be especially the case for people who are denied ventilators or who are taken off of them (i.e., who are “extubated”). Let’s talk about this painful and poignant fact. 1/

    2:24 PM - 4 Apr 2020
    • 2,057 Retweets
    • 4,895 Likes
    • Maggie Snow Marie Kevin Sorbo's Conscience TIA JOHNSON BunRab skyblue Negawatts are best #Rashford #Saka #Sancho #GTTO #FBPA #Keir4PM #3.5% Nabil H The Peacemaker ⚛️☮️
    179 replies 2,057 retweets 4,895 likes
      1. New conversation
      2. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        It’s not just a question of “optimal” triage polices for access to ventilators or ICU beds (now tragically being promulgated in hospitals around the USA). Rather, it's a question regarding how will we care for the COVID19 patients whom we triage to allow to die. 2/

        8 replies 113 retweets 631 likes
        Show this thread
      3. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Especially if we resort to battlefield triage as in Italy, we will need to plan for palliative care. This will involve drugs to relieve pain, dyspnea, anxiety, and other symptoms near death. This means we need opioids and benzodiazepines (e.g., morphine and midazolam). 3/

        11 replies 122 retweets 785 likes
        Show this thread
      4. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        I was a practicing hospice doctor from 1995 to 2010. I was able, as a result of this privileged opportunity, to observe very many people near death, and to do my best to help them. I practiced at @HorizonHospice & @UChicago and later at @MassGeneralNews & @MountAuburnHosp 4/

        4 replies 81 retweets 697 likes
        Show this thread
      5. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        I am very worried we will not have the medications (and personnel) we need in the USA to properly treat symptoms of dyspnea (shortness of breath), air hunger, pain, thirst, and anxiety near the end of life for COVID19 patients denied ventilators. @NHPCO_news 5/

        10 replies 242 retweets 935 likes
        Show this thread
      6. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        And I am worried we are not adequately prepared to cope with the psychological aspects of often unusual COVID19 deaths (sudden, alone, or as a result of triage, etc.) either — for the patients themselves (if they are conscious) and their families. 6/

        6 replies 137 retweets 796 likes
        Show this thread
      7. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Nicholas A. Christakis Retweeted Nicholas A. Christakis

        We need to plan now for this, as I noted on March 22: https://twitter.com/NAChristakis/status/1241864708744937472?s=20 … 7/

        Nicholas A. Christakis added,

        Nicholas A. ChristakisVerified account @NAChristakis
        People are focused on ventilators & anti-virals, but, sadly, as a former hospice doctor, I'm worried we may not have enough opioids & anxiolytics to treat people we cannot give ventilators to, to ease suffering. I hope we are planning, though I fervently hope none of this happens
        Show this thread
        8 replies 130 retweets 709 likes
        Show this thread
      8. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        There is wide agreement among patients, families, and doctors in the USA about what is important at the end of life. http://jamanetwork.com/journals/jama/fullarticle/193279 … Unsurprisingly, 93% of Americans feel that being free of pain and other symptoms (such as dyspnea) is “very important.” 8/pic.twitter.com/uEF3wyl3Tb

        8 replies 155 retweets 788 likes
        Show this thread
      9. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Dyspnea and air hunger at the end of life are truly awful. These symptoms are often worse than pain, and often harder to treat. Like other hospice doctors (and nurses), I have seen this up close. 9/

        3 replies 143 retweets 754 likes
        Show this thread
      10. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Also important to patients: 81% of Americans rate having family present at death as “very important” when they die. The great majority of people do not wish to die alone. http://jamanetwork.com/journals/jama/fullarticle/193279 … 10/

        7 replies 121 retweets 653 likes
        Show this thread
      11. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        The use of opioids in medical care is high in the USA compared to most other countries, at baseline, for a variety of reasons, including our wealth. 11/pic.twitter.com/2D9me8CvCY

        1 reply 61 retweets 365 likes
        Show this thread
      12. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Opioids (e.g., morphine, fentanyl) are the mainstay of treatment for dyspnea, though benzodiazepines which relieve anxiety (e.g., valium, midazolam) help a lot. And there are other tricks that sometimes help (like inhaled furosemide). 12/

        7 replies 68 retweets 462 likes
        Show this thread
      13. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Positioning of patients on their bellies or sides can help with air hunger, but only a bit, if we are really talking about extubating critically ill patients to free up ventilators. Such patients are extremely sick. They require expert palliative care. 13/

        3 replies 69 retweets 475 likes
        Show this thread
      14. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Death is not immediate after disconnection from a ventilator (extubation). For instance, in one study of 12 patients in a community hospital in Taiwan, death ensued from 20 minutes to 97 hours after extubation. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4396346/ … 14/

        5 replies 102 retweets 490 likes
        Show this thread
      15. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Here is a nice review regarding treating dyspnea at the end of life, e.g., in extubated patients: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3304253/ … The pharmacological tools at our disposal are powerful, if limited. 15/pic.twitter.com/wQ5FvagbKy

        3 replies 64 retweets 354 likes
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      16. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Where do we stand in terms of our preparation to care for COVID19 patients, not just in terms of beds and palliative medicine personnel, but also the crucial drugs for treating such patients, if they have been triaged away from ventilators? 16/

        1 reply 71 retweets 378 likes
        Show this thread
      17. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        In many cases, the sedative and other drugs needed to treat COVID19 patients triaged to not get ventilators are the same as those necessary to care for patients on ventilators! 17/

        2 replies 66 retweets 368 likes
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      18. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        There has been a 51% increase in demand already in March in the USA for various sedatives and anesthetics: propofol, dexmedetomidine, etomidate, ketamine, lorazepam, and midazolam. https://www.statnews.com/pharmalot/2020/03/31/a-new-covid-19-problem-shortages-of-medicines-needed-for-placing-patients-on-ventilators/ … 18/

        2 replies 100 retweets 374 likes
        Show this thread
      19. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Similarly, the demand for three analgesics — hydromorphone, fentanyl, and morphine — rose 67% so far in March in the USA. https://www.statnews.com/pharmalot/2020/03/31/a-new-covid-19-problem-shortages-of-medicines-needed-for-placing-patients-on-ventilators/ … 19/

        7 replies 84 retweets 341 likes
        Show this thread
      20. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        You can use this @US_FDA website to check which drugs are “currently in shortage." https://www.accessdata.fda.gov/scripts/drugshortages/ … 20/

        3 replies 75 retweets 313 likes
        Show this thread
      21. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        And midazolam is already in shortage! It’s hard to emphasize how important a drug it is, both for treating ICU patients and for palliative care — though, in palliative care, we could switch to longer-acting agents, like valium, which would relieve shortage for ICU patients. 21/pic.twitter.com/fQppKBpcd7

        1 reply 64 retweets 336 likes
        Show this thread
      22. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Using such drugs to palliate symptoms in patients taken off ventilators might accelerate death, some will say. But what is the alternative, since, without a ventilator, the patients are slated to die anyway? Shall we let them suffer? 22/

        3 replies 60 retweets 399 likes
        Show this thread
      23. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Of course, we also need these agents to actually treat patients with COVID19 who are *not* expected to die! These drugs are essential to keep patients sedated while they are on a ventilator. Otherwise, they often thrash and pull out their life-saving tubes. 23/

        1 reply 61 retweets 363 likes
        Show this thread
      24. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        But the drug supply chain is one of just-in-time production and distribution. Nobody has 2 times, let alone 10 times, the amount of drugs on hand that are going to be needed for the surge in COVID19 patients. We need more drugs now. 24/

        7 replies 90 retweets 402 likes
        Show this thread
      25. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        The supply chain for many drugs goes through India and China, and this pandemic has highlighted how, when catastrophe strikes, each country looks to its own needs. This is not just with respect to PPE or ventilators, but basic and crucial drugs. [thread continues...] 25/

        6 replies 83 retweets 405 likes
        Show this thread
      26. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        We will have many thousands of people in this predicament. In the USA as a whole, we are estimated to reach peak resource demands for COVID19 patients on April 15. We will need 31,782 ventilators, and we are short. https://covid19.healthdata.org/projections  26/pic.twitter.com/MdqvkK3Nel

        3 replies 71 retweets 304 likes
        Show this thread
      27. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        In New York state (as of today, April 4), we are 5 days from peak demand. Yet we estimate a rough shortfall of 11,064 ICU beds and 9,427 ventilators. That is a lot of patients who will be triaged away from ventilators and who will need palliative care! https://covid19.healthdata.org/projections  27/pic.twitter.com/OZyQjTPSLX

        3 replies 84 retweets 321 likes
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      28. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        As a hospice doctor, I used to say: “While we cannot stop your disease, there is much that we can do to care for you. And I promise I will not abandon you.” But how can we provide care without basic medicines? 28/

        9 replies 73 retweets 493 likes
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      29. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        Dying alone is also awful. This can happen to COVID19 patients for a number of reasons, including hospital policies related to reducing transmission to family members (given the lack of PPE to spare for them) and the frequent suddenness of death in this condition. 29/

        6 replies 65 retweets 373 likes
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      30. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        In the case of COVID19, stories are emerging of people saying goodbye via video link, and dying alone! As a hospice doctor, this makes me weep. https://www.cnn.com/2020/03/29/world/funerals-dying-alone-coronavirus/index.html … 30/

        13 replies 114 retweets 535 likes
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      31. Nicholas A. Christakis‏Verified account @NAChristakis 4 Apr 2020

        All of this will be so much worse in the poor countries of the world. There, people will die without any medical care at all, as they do even in the best of times. But just look at poor Ecuador facing COVID19 now: https://www.cnn.com/2020/04/03/americas/guayaquil-ecuador-overwhelmed-coronavirus-intl/index.html … 31/

        22 replies 117 retweets 411 likes
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      32. Show replies

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