Death in the time of COVID-19
Death is just another path, one that we all must take. The grey-rain curtain of this world rolls back, and all turns to silver glass, and then you see it…White shores, and beyond, a far green country under a swift sunrise.
-Gandalf, Lord of the Rings, J.R.R. Tolkein
Several weeks ago, when our main acute-care hospital was overflowing with patients, I had an ill patient at the rehab hospital whom I needed to transfer for evaluation and treatment of his disease. I called the Transfer Center to arrange this, only to be told the hospital was full and on “divert,” which means that even ambulances cannot bring patients to the emergency room and, therefore, have to find another hospital in town that might have room.
I called the next day.
Now the Transfer Center told me that the hospital was no longer on divert but was only accepting patients who were having a stroke, heart attack, or were involved in a trauma, like a car or ski accident. My patient didn’t fall into any of those categories.
I called the next day.
This time I was elated to discover there were now open general hospital beds. I could finally get my patient the care he needed. As I explained the condition of my patient and what type of medical floor and monitoring he would need, I was again told that there wasn’t a bed available for him on a general medicine floor or on a surgical floor.
I was back to square one.
When was this going to change? When could I get him the medical care he needed? He was definitely too ill to discharge home, so I just kept taking care of him the best I could at the rehab hospital. I mentioned to my medical director that I kept trying to transfer this patient and told him there weren’t any available beds. He gave me the direct number of the head of the medicine service over at the main hospital; finally, at 10 pm, I was able to get him in the back door.
Since that time, I have continued to keep tabs on him. Every day I look at his chart to see how his workup and treatment are going. I wasn’t surprised, but definitely saddened, to discover that he had cancer at an advanced stage. But he was getting the only treatment available to him, and the palliative care service was managing his pain and nausea much better than I was able to. I was relieved he was finally in the right place.
Yesterday I went to electronically check on him again, and I got the pop-up box that is most dreaded in medicine: “You are entering the record of a deceased patient. Are you sure you want to continue?” WHAT?!! Yes! I want to continue! Yes! I want to know what happened! How could this happen? He was getting the right care! Tears welled up in my eyes as I felt the loss. To his family, his friends, his community, to the world.
His cause of death was thankfully not due to the delayed transfer to the hospital, nor was it directly from his cancer or the treatment either, but more from an indirect combination of factors: his underlying health issues, the newly diagnosed cancer, his debility and lack of reserve to fight. I know that death is a part of life, a part of medicine, a part of illness and disease. I just don’t want it to happen to my patients. I remember holding his hand as he suffered his symptoms. How I promised him I would continue to try to get him into the main hospital. I know that he was grateful for my effort. I know that I did my best. I know that it is not my fault that he died. But it still hurts.
I can’t begin to imagine what it’s like in the COVID ICUs where early on in the pandemic only 58% of patients that were intubated survived.(1) I remember how difficult my ICU rotation as a medical student was, how devastating it was during one particularly dreadful week when we had a very high death rate of our patients. It wasn’t due to a lack of appropriate care, and we all put so much energy into trying to save all of their lives. All the residents, attendings, and students like me were so despondent that social workers were brought in to give us all emotional support. Yes, in the ICU death is a part of the daily routine, yet not in such high numbers, and not every day, every week, for months on end. The medical community has not yet had to deal with the high amount of trauma and PTSD healthcare workers are going to experience due to this pandemic.
I am fortunate that I get to take care of patients who, for the most part, are recovering from their strokes or brain injuries. And yet, there is still so much sadness and trauma. Some of my patients have died from COVID, some have severe long-term effects from the disease that will not allow them to return to their previous lives and level of function. Many of my patients know someone who has had COVID-19 or someone who has died from the disease.
I struggle with having continued compassion and the stamina to do my job. I often wake up and my first thought is “I don’t want to go to work today.” I want to sleep more, both to restore my often-empty gas tank, but also to escape the reality of daily loss. I get pissed off when I hear the stories about people not wearing masks. I want to drag them into the hospital and show them up-close a patient devastated by this disease. See? See? See? THIS is why you wear a mask. THIS is why you get the vaccine.
And yes, I struggle with compassion fatigue, as many in healthcare do, even when it’s not a global pandemic. I often think I don’t have a right to complain, that this is just all part of the job. I chose this career. I chose to be a physician. Yet I had no idea that I would someday be practicing medicine while a highly infectious virus was sweeping the globe, killing so many, disabling many others, and isolating us all.
1. Improving survival of critical care patients with coronavirus disease 2019 in England: A national cohort study, March to June 2020.external icon Dennis et al. Critical Care Medicine (October 26, 2020)