Covid-19 Series, Entry #3

Okay, I was going to try to lighten the mood and talk about all of the shenanigans happening in my house right now, but there are some serious things I need to tell you.  I promise I’ll post something lighter soon-ish.

A quick update on my job.  I am a Palliative Care physician in a big hospital.  My team sees patients all over the hospital. People with cancer, heart failure, traumatic injuries, lung disease, burn injuries, renal failure, dementia…the list goes on.  We focus primarily on symptom management, quality of life and making sure patients and their families understand what is going on medically to make sure they are equipped to make the best choices for how to manage their care going forward. Some people decide that they want aggressive care in terms of life support, dialysis, feeding tubes, etc.  Other people decide they want their care to focus on comfort, allowing their bodies to shut down naturally and peacefully.  Obviously these conversations are best had at the bedside, with the patient, family and specialist physicians present to address questions and concerns. Just last week we held a family meeting with a patient, three family members, the primary hospitalist, the hepatologist, the hepatology nurse practitioner, the hepatology social worker, the palliative care social worker and myself.  The patient and family were able to get a lot of information from a lot of people, in person.

That was last week.

This week, everything has changed.  In an effort to conserve personal protective equipment and slow the spread of Covid-19, our team is working on ways to interface virtually with patients and families.  While I will still be spending some time in the hospital, it is very likely that the majority of my work will be done remotely.  It is entirely possible that I won’t have to actually gown up and walk into a room with a known Covid-19 patient, but will rather help address goals of care and symptom management using technology and collaborating with the primary physician.  I’m envisioning this role as being similar to an offensive coordinator, sitting in a booth watching the game from a distance, but helping to call plays and still actively involved in the game.  (Full disclosure, I had to run this metaphor by Danny to make sure this was an accurate scenario.)

I very much appreciate all of the well wishes and gratitude, but honestly, it is the ER docs, the hospitalists, the intensivists, the anesthesiologists, the bedside nurses and the respiratory therapists (I know I’m missing some peeps) who are literally face to face with this monster.  Please concentrate your thoughts, prayers and well wishes on these people.

So what can you do to help/prepare for when things get really crazy?

Stay the F home. Seriously.  You can go get groceries because you need to eat, but don’t make a Target run every other day because you’re bored.  Try to limit your shopping trips to once/week at the most.  The fewer times you’re out in the community, the lower your chance of contracting and/or spreading Covid-19 to others.  Be aware that you can be completely asymptomatic and still carrying/spreading the virus. You can go outside in your yard, but don’t go to public playgrounds. Coronavirus can live on surfaces for 72 hours.  That means if a kid was playing on the monkey bars on Friday, their sneaky little corona germs may still be lurking on Monday, waiting for your kid to snatch them up and bring them home.

Consider buying a pulse-oximeter.  This is a little clip that you can put on your finger to test your oxygen saturation.  There is no formal recommendation to do this, but I’m hearing from other docs that they are using O2 sats as a measure to help determine if someone needs to come to the hospital or if they are safe to stay home.  These can be ordered on Amazon.

Talk to your loved ones about their wishes in terms of medical interventions.  This is a really hard thing to talk about even under “normal” circumstances, but it is critically important right now.  In the event that we see an explosion of critically ill patients in our community (which seems very likely), we will have to start rationing life support.  Under usual circumstances, if someone is really sick and needs life support, they have the option to use pretty much whatever they need (ventilator, non-invasive ventilation, vasopressors, cardioversion, ECMO, dialysis, etc).  Unfortunately we are now bracing to run out of ventilators (already happening in NYC) and we need to decide how best to allocate this precious commodity.  If we have one ventilator left and two patients who need it, who gets it?  The 80 year old with cancer, early dementia and renal dysfunction or the 30 year old mother of three?  Let me be very clear, WE HATE THIS!  During residency we were all taught to “SAVE THE PATIENT!” We advocate for autonomy and want more than anything to allow patients to make their own medical decisions that are in line with their values and beliefs.  But this luxury may soon be taken away.  And again, WE HATE THIS!  The thought of telling a family that their loved one is going to die and doesn’t even have the option of going to the ICU for more aggressive care absolutely guts me.  So this is why having conversations about medical preferences is so important.  Knowing the wishes of your loved ones ensures that we understand the interventions they would and wouldn’t want.  I have had many conversations with my grandma and understand very clearly that she would never want to be on a ventilator and would want to be allowed to die naturally and peacefully were she to become very ill.  Giving your loved ones the opportunity to express these wishes could potentially save resources, limit the spread of Covid-19 (think high risk procedures on positive patients) and, most importantly, ensure that their wishes are respected should they become gravely ill.  The situation that we need to try to avoid is this: A person who has very strong feelings about forgoing life support interventions (breathing machines, CPR) comes into the hospital and ends up on a ventilator or getting CPR because their family didn’t know their wishes.  Now we have inflicted aggressive and uncomfortable interventions on someone who didn’t want them in the first place, put the healthcare team at greater risk for contracting Covid-19, and utilized resources that could have been diverted to someone else.

Please know that it hurts my soul to talk about conserving resources and end of life care in the same sentence.  This is absolutely unprecedented.  However, we need to be prepared for this horrific scenario.  And for the sake of conversation, for those who are dying and choose to forgo aggressive measures (or who are not eligible for it), we will do all that we can to ensure that they are as comfortable as possible during the dying process.  They will not be abandoned by their doctors or nurses.

I hope that these conversations turn out to be for not.  The absolute best case scenario would be that you and yours remain healthy, but with newfound insight into how you all feel about medical interventions and end of life care.  This would also be an opportune time to tell the people you love how much they mean to you and perhaps, mend fences that need some attention.

The other thing you need to understand right now is that hospitals are not allowing visitors.  My hospital is only allowing visitors for patients who are actively dying, but these policies are changing daily.  Please know that we will do the best we can to connect our patients to their families using technology, but you just won’t be able to come to the hospital to support your loved one.  We understand how badly this sucks.  I can’t imagine someone I love being stuck in a lonely hospital room and being told that I can’t come to visit.  We hate this too.  So please, if you are in the unfortunate position of not being able to come and visit a loved one, try not to yell at the doctors and nurses.  We are doing our best.  We can’t make exceptions.  Everyone is deserving of an exception, but we just can’t.

Sending love to my family, friends and community.  Please feel free to reach out with questions or comments. Just realize that policies are changing rapidly and I may not have all of the answers (or any for that matter).