ABSTRACT
CASE: This is a 68 year old female who presented to the emergency room with progressively worsening fatigue, malaise, fever, nonproductive cough, nausea, and vomiting after testing positive for COVID-19 the week prior. Her past medical history was significant for obesity, fibromyalgia, chronic pain, osteoarthritis, hypertension, lymphedema, hypothyroidism, and GERD. She was admitted and started on remdesivir, IV methylprednisolone, supplemental oxygen, and nebulizer treatments. The patient's respiratory status deteriorated and her SpO2 dropped to 60%. She was escalated to high flow nasal cannulaadministered oxygen and a goals of care discussion was held. She refused both BiPaP and intubation and elected to not escalate her care further, instead focusing on comfort. Her high flow oxygen was weaned to 4L via nasal cannula and she was started on a morphine infusion, with as needed morphine for comfort. She desaturated to 65% SpO2, but did not exhibit respiratory distress or tachypnea. After twelve hours, she remained relatively stable and requested to go home. After twenty-four hours she was discharged with home hospice with a fentanyl patch, liquid morphine, and a benzodiazepine as needed. After two weeks, she survived and was discharged from hospice care. IMPACT/DISCUSSION: This case raises two key points of discussion. First, one must acknowledge the silent hypoxia that this patient experienced when she elected to go hospice. This phenomenon has been seen in multiple COVID19 patients around the world at various points during their treatment course. Some of these patients have survived, while others did not. Tobin et al. explored possible mechanisms for this including, but not limited to: a change in the baseline CO2 causing a diminished response to hypoxia as well as a change in oxygen dissociation due to fever. Rahman et al. suggested an additional mechanism with interplay between the patient's hypoxia, hypoxia-induced factor-1 (HIF-1), and angiotensin-converting enzyme receptor creating and exacerbating a cycle of inflammation that is difficult for a patient to overcome. Second, one must review the role of opioids in this patient's recovery. Both ASCO and the ACP have made recommendations for offering systemic opioids for patients who are experiencing dyspnea at the end of life or in advanced lung disease. CONCLUSION: Given the positive outcome that this patient experienced, one would hope that there will be less reluctance to introduce patients to a palliative care team earlier in their care. The appropriate practice of palliative medicine should not be equated to denial of active treatment against the patient's wishes. Rather, it is an attempt to maintain the dignity of those with advanced disease and safely ameliorate somatic symptoms, including breathlessness and pain. In addition, further research is needed on the phenomenon of silent hypoxia and its implications for what is deemed a safe oxygen saturation range for patients who require supplemental oxygenation.