Monday May 04, 2020
Holding People Sacred in Time of Loss
Massachusetts has reached what may be its peak, or a high plateau, in this pandemic. We have had more than 100 deaths a day from COVID-19 since April 9, with a peak of 221 deaths in one day. Our death toll is more than 2,300.(www.mass.gov) Eight percent of those who tested positive with COVID-19 have required hospitalizations, our skilled nursing and long-term care facilities are filling, and our ICUs continue to be at maximum capacity -- which in actuality is higher than their pre-pandemic maximums because all hospitals have increased ICU capacity dramatically.
We have reached the grim reality of temporarily using freezer trucks to store the bodies that cannot fit in our morgues.(www.wbur.org)
Having sent my family away for their own protection, I have come to use the act of writing as a way to reflect on my observations.
After working on COVID-19 teams for two weeks on days, I switched to two weeks of COVID-19 nights. The first week of days was full of COVID-19 rule-outs and slow test results. The second was loud with rapid responses, telemetry and pulse oximeter alarms, code blues, and rapid intubations.
That was when I started hearing machine alarms in my sleep, waking up to ventilator sounds and alarming machines that weren't actually there. By the third week, things had become calmer. Not because the large repertoire of medications we have been using was overwhelmingly (or even moderately) effective, but because we had become better at managing patient care and acute patient events. We had what we called "pseudo codes" and "pseudo rapid responses." Nurses page the primary attending (me), I alert the COVID airway team and/or the COVID ICU evaluation team, we discuss the patient, and the patient either goes to the ICU -- some intubated -- or remains on the floor.
In my fourth week, my patient list has now grown to include an increasing number of patients with do-not-resuscitate, do-not-intubate, comfort-measures-only or similar orders. I've been declaring more deaths on the floor, talking to more families. I've been trying my best to give some space and sacredness to every passing. Usually, deaths in a hospital take up a lot of space -- lots of alarms and lots of responders, including respiratory therapists, and nursing, laboratory, ICU, anesthesia and primary teams. The whole hospital hears the alarms. The emergencies and deaths used to take up space both physically and emotionally. Now, they take up much less space. They make less sound. And they come in such quick succession that sometimes they blur together.
I have a new system for patient deaths. I go into the room. I do my exam. I meditate and pray. I don't pray often, in general, and I'm not sure why I started doing it; it was almost an automatic way to make myself pause. What it has become is acknowledgement of the sacredness that this patient was here, is loved, will be loved and has touched the earth in his or her own unique way.
I then call families. Sometimes I call more than one family member. Sometimes I call a few times if they ask for it. Sometimes, rarely, there are no family members to call.
I spend some time talking to the nurses who took care of these patients. If I am around when porters come, I talk to them, too. I try to hold sacred and special everyone who is involved in taking care of the patient, especially the person who has died. We are all devastated that during this pandemic, patients usually die alone. And when I call family members, they are devastated that they will largely mourn alone.
We do allow one family member at a time to come in when we know a patient is dying. I have worked in the last few weeks to improve these end-of-life discussions with families. I can never guarantee when someone will die, or if they will, but I hold heavy in my heart the people who have died without their family knowing it was impending. So I try to have those conversations as soon as I think someone may be unstable.
Sometimes I am the last person a patient talks to. I keep note of them, and there is a growing number. I have held the hands of patients while they get intubated. I have talked to them until they are sleeping. I treat them as I would want a loved one of mine treated.
The staff has come together. I have cried with nurses. We take time to acknowledge the weight we are all carrying. This isn't ending anytime soon. We hope there will be better treatments, better testing, better safety measures for our communities.
I don't have time to read the news. I hear from friends what the news is spinning -- whether it be a new medication some think will save the world, conspiracy theories about the causes or treatment, or the push to reopen the country. I don't have time to get frustrated, and I honestly don't have the energy. I understand that fear drives a lot of this oscillating anger and hope. People are afraid of losing -- or have already lost -- their jobs, their pay, their health insurance. People want to keep their families and loved ones safe. We all have similar fears, and I understand that energy. My energy is going into my work, into understanding and providing what limited treatment options we have, into understanding the evidence, into providing compassion and care in these lonely spaces of illness and dying. My energy is going into providing compassion and care for my teammates.
We continue to send home the majority of our patients who have battled and won against COVID-19, and I am so grateful for that. I am grateful to all my outpatient clinician friends who tell me about how many patients are fine and at home with mild cases; I am grateful because I don't see those patients. I am grateful for the patients and their families. Every time I speak to families, they are so deeply grateful to the health care teams that are taking care of their loved ones. For those who are still within these hospital walls, I will continue providing the most compassionate care for them and their families that I can.
MaryAnn Dakkak, M.D., M.S.P.H., practices full-scope family medicine and is an assistant professor in an academic hospital center in Boston. She is also women's health director at Manet Community Health Centers. Her views do not represent those of the organizations with which she is affiliated.
Posted at 12:40PM May 04, 2020 by MaryAnn Dakkak, M.D., M.S.P.H.