Merle Tochor, 80, is being extremely cautious when it comes to the coronavirus.

She lives alone in a Winnipeg apartment complex that houses mostly seniors who are all isolating. She's avoided physical contact with anyone since the global pandemic was declared in early March. Her daughters buy her groceries.

If, however, she contracts COVID-19, her mind is made up.

"I don't want any kind of assistance to help me live," Tochor said.

Because of her existing health conditions — lung disease and autoimmune hepatitis — she already has a Do Not Resuscitate (DNR) order. She isn't sure if it covers intubation.

Not everyone is aware that refusing resuscitation isn't the same as refusing intubation. Some DNR policies include intubation, while others treat the two orders as separate.

Merle Tochor, 80, says she will refuse 'any kind of assistance,' including a ventilator, if she contracts COVID-19. (Submitted by Merle Tochor)

"Where they put the tube down the throat — I don't want that," said Tochor.

"If they have to make a decision on who lives, and apparently, it could come to that, I don't want it to be me. I would like someone, like 60 years old, to live on. I've lived a good life."

While Tochor's daughters know about her DNR, she says: "I haven't talked to them about this other thing."

Advanced care planning

End-of-life talks can be upsetting to some, creepy to others. But the increased risk for seniors of complications and death related to COVID-19 means they need to have honest discussions with their families, according to one of Canada's top geriatricians.

"Every older person in Canada should truly be compelled to do advance care planning now," said Dr. Samir Sinha, director of geriatrics at Mount Sinai Hospital in Toronto and the expert lead for Ontario's Seniors Care Strategy.

"Because, frankly, when we have a virus out there that's highly contagious, that has a predilection for older people … and a 30 per cent-plus 'kill-rate' for those living in long-term care homes, everybody should at least be having the conversation."

Dr. Samir Sinha, director of geriatrics at Mount Sinai Hospital in Toronto and the expert lead for Ontario’s Seniors Care Strategy, said the coronavirus pandemic should be spurring conversations about end-of-life care. (Taylor Simmons/CBC)

The extreme pressures on health care resources during the pandemic — specifically, a shortage of ventilators — is bringing advanced care planning questions to the fore.

Patients who suffer severe cases of COVID-19 have difficulty breathing, in which case the mechanical breathing machines may become crucial life-saving equipment.

But studies suggest ventilators, which involve an invasive procedure known as intubation to attach a patient to the machine, may fail to save many patients over the age of 65. Those who do survive may end up with a poor quality of life, such as permanent lung damage.

"If you're an older person and you end up on a ventilator, your chance of actually surviving is around 20 per cent range. When you know that information, you may very well choose to say, 'Well, I wouldn't want that sort of intervention,'" said Sinha.

Advance care plans are a process of anticipating some of these end-of-life medical decisions at a time of one's choosing, instead of during a crisis in a hospital emergency room.

Also known as living wills or medical directives, the plan should instruct what to do if a person becomes incapacitated because of a critical illness, by setting out whether he or she believes in letting nature take its course, or supports aggressive treatment, such as resuscitation, intubation, or IV hydration.

A ventilator is displayed during a news conference on March 24, 2020 at the New York City Emergency Management Warehouse. (Mark Lennihan/Associated Press)

Only one in five Canadians have written advanced care plans, according to a 2012 Ipsos-Reid poll. However, it also found about half of Canadians have designated a substitute decision-maker regarding future health care.

Negotiating 'your surrender'

In the coastal village of Port Joli, N.S., Joan Stephenson hopes the pandemic won't stop her and her 83-year-old husband Tom from celebrating their 60th anniversary this summer.

But they've also clearly communicated to their children they have no desire to be intubated if they contract COVID-19.

"They know we have a personal directive. They've known this since we had it made. We're very outspoken about these things," said Joan, 80.

Joan Stephenson, 80, tells Cross Country Checkup host Duncan McCue and Dr. Samir Sinha why she and her husband Tom, 83, have clearly communicated to their children they have no desire to be intubated if they contract COVID-19. 8:09

The time to have such informed end-of-life conversations is "yesterday," says Dr. Sinha, to avoid a situation where a patient is unable to communicate and the family doesn't know their wishes.

"Imagine the enormous guilt the families feel … when they're not sure what [is] the right answer," he said.

"In the end, our default is to stick a tube down mom's throat, knowing that there's an 80 per cent chance she will not survive that ventilator after a two-week stint on it."

Nevertheless, Sinha emphasizes no Canadian should be required to sign a DNR or "relinquish their right to access the ventilator."

Ultimately, he says advance care plans allow people to truly understand the risks — and opportunities — of medical intervention.

"The question then becomes, 'How would you like to negotiate your surrender?' What would you want your family to do?" said Dr. Sinha.

Interviews produced by Kirthana Sasitharan and Levi Garber.