Metro-area hospitals may be getting a little less crowded, but COVID-19 remains an overwhelming fact of life–and death.
Many patients, with the support of their loved ones and hospital staff, have been fighting to stay alive, and for some that has meant going into intensive care units to be put on ventilators. It is often a one-way trip. But others who are admitted to hospitals with advanced illness are having conversations with palliative care specialists about not fighting, if they have a relatively low chance of survival, and some are opting to go to hospice units.
Dr. Craig Blinderman is the director of Adult Palliative Care and the Palliative Care Unit at Columbia University Irving Medical Center, and over the course of several recent days, he recorded an audio diary for WNYC/Gothamist about what it’s like talking to patients and family members who are trying to decide how hard to fight COVID-19, when their health was already tenuous before the coronavirus struck. His reflections are lightly edited and condensed.
Starting the Day with Intention
Each morning when I get on the unit, I make sure everyone's done with whatever tasks they're dealing with, and we all sit together, and we try to let everyone have a moment to just be with their breath. We do a short guided meditation just to ground us for the day, to give us a sense of peace and a little respite from the chaos and the busy-ness and the day-to-day life in the hospital. Everyone seems to appreciate the moment to sit together and just collect ourselves. I often ask people to focus on an intention for the day, and maybe bring some element of their past desire to go into the health professions and what that means for them—and let that be a place of practice, so they can have an intention for the day.
I just finished rounding.There are about six patients. A few patients passed away, and we’re waiting for a couple more to come in. All of our patients are very near to the end, probably within hours, maybe days. Some are closer than others. All of them are getting comfort-directed therapy, getting medications like morphine, hydromorphone, and sedatives to keep them sedated, so they're not experiencing any shortness of breath or pain as they begin the dying process. It's hard seeing patients separated from everyone that they care about in their life, isolated, not aware of their surroundings. We're doing everything we can to bring them comfort so they're not suffering. We make every effort to bring families here if they can and if they’re willing to accept some risk in coming into the hospital. Or we’re using technology when necessary.
Listen to reporter Fred Mogul's radio story on WNYC:
Musical excerpt courtesy of The Knights and Christina Courtin, from their performance of Paul Simon's "American Tune".
A New Patient is Admitted
I just examined our newest admission. Unfortunately, the patient is not awake and, at this point, is fairly sedated. I also spoke with the patient’s family members and suggested they come in and see her sooner rather than later. I’m hoping they can visit today and just have an opportunity to say their goodbyes. This is a window of opportunity that not everybody has, and for some it closes sooner than others.
Instead of a Comma, a Period
I just finished up a meeting with some family members of patients that came onto the unit recently. It’s distressing to have to give them answers that really aren’t answers but are our best guess as to why this is happening. It's different than when you're dealing with cancer, and you're dealing with a patient who's struggling for many months or years. It’s very shocking for families, and it's hard to provide the kind of consoling that we normally do.
I was reading a wonderful novelist and poet, Ocean Vuong. He wrote a novel to his mother, and in one passage he says that the saddest thing is a “comma that's forced to be a period.” You can imagine a sentence or a life continuing on, but instead of continuing on, it's just stopped with a period.
Down in the Emergency Room
I was asked to see a patient in the emergency department who wasn't doing well and was on full oxygen support. And it was clear the family wasn't interested in the patient going to the ICU and didn't feel that was something the patient would want. Whether or not he would or she might pull through—it's hard to know. We have predictive factors, age, other criteria that suggest that someone might not do well. But there's still this uncertainty. Under normal circumstances, you'd explore that more and learn more about the tradeoffs. What would one be willing to go through for the possibility of gaining some more time? What would that ‘more time’ look like? What functional status would they have? Would they just survive on mechanical ventilation for weeks? Their quality of life would most certainly be diminished, maybe to a state that they would find unacceptable.
We’re trying to have these conversations under difficult circumstances, where patients can rapidly decompensate. Those pauses that you might have to think things through, and to reflect on what makes the most sense—we often don't have that time. Decisions that are difficult at best become even that much more imperfect and difficult. But we try to focus on the basics: what are someone's values about longevity versus quality? It's very challenging.
One of the gifts we're able to give families in this nightmare is some peace at the end [by allowing them to] visit, say their goodbyes, be in contact with each other for some moments. And we can offer that in our palliative care unit and not in other parts of the hospital, where visitors are just not able to get in. It's just too, too chaotic. It's not safe. And we've created a little space where that is possible, so that even though you're suffering through a nightmare, at the end of that nightmare, there's a little bit of peace that they might otherwise not have.
And I wonder how this is going to affect everyone's collective grief, particularly in communities of color and with families who've lost loved ones in a very rapid way without necessarily having opportunities to say the things that they need to say to each other. There's going to be a lot of need for healing for sure.
At Twilight, Shouting Brings Peace
I just finished listening to the 7 p.m. appreciation for frontline workers. Over the past week and a half, someone on my block has taken to playing Frank Sinatra's “New York, New York.” It brings everyone's spirits up. It’s such an important part of my day. I try to get home or at least try to get outside at 7 o’clock every day, just to take it all in.
It's one of the beautiful things about the city, and the people in the city, and how we just come together and support each other. It's such a beautiful testament to the spirit of the city and what everyone's doing. I guess people are also trying to find their own catharsis in this moment, too, and letting it fill the air. It’s so sweet.