Doctors find themselves in the wrenching position of arranging conversations between critically ill coronavirus patients and family members.
The elderly coronavirus patient arrived at the Manhattan hospital extremely sick and rapidly deteriorating. Dr. Marissa Nadeau, an emergency medicine physician on the night shift, had little time to ascertain his wishes.
The patient, gasping for breath but alert, made it clear he did not want to be intubated and put on a ventilator, which might have been his only hope for survival.
Nadeau placed her hand on his shoulder, then used her phone to FaceTime with his family, telling them of his choice and holding up her phone so they could say what might be a final goodbye.
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It was the third time that night at Columbia University Irving Medical Center that Nadeau had helped critically ill patients communicate with their families over FaceTime; the two other patients had also rejected intubation — a decision with potentially life-ending ramifications.
One of the cruelties of Covid-19, the illness caused by the coronavirus, is that many patients may have just minutes to settle their affairs. With family members for the most part barred from visiting their loved ones, doctors often are left to facilitate such moments, full of emotion and tears. They are wrenching for physicians, too.
"I cried multiple times on my shift last night," Nadeau later texted in a WhatsApp group chat where her colleagues trade advice and experiences and try to comfort each other.
"You guys are going to see me with red puffy eyes for the next few weeks," she wrote. "I just feel like I went into this specialty to save lives, and it kills me that we can't save everybody."
In a pandemic, the normal rituals around death are suspended. In New York City, where on some days the illness has been killing someone every four minutes, some funeral homes have stopped holding wakes, cemeteries are limiting graveside gatherings and authorities have warned people not to gather for religious services.
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The actions are meant to keep the living from congregating around the dead and dying. And nowhere is that principle more strictly enforced than in hospitals.
Intensive care units in the city once saw a steady stream of visitors. Nurses and doctors learned about their patients through them: which patient had the spouse who spent every waking hour at the bedside, which patient had the large family.
Now bedside vigils, and visitors generally, are a thing of the past.
In recent weeks, an exception has sometimes been made when a patient is on the verge of death. But even then, the visitor is usually not allowed in the actual room.
In one Manhattan emergency room, a woman recently stood by the secretary's desk. A doctor handed her a phone. "I love you," she said. "Things will be OK."
The words were played through the call bell in her husband's isolation room, 20 feet away. He was in a medically induced coma, dying. They had been married 40 years, according to a hospital employee who described the scene.
Dr. Dylan Wyatt, a resident physician at NewYork-Presbyterian Brooklyn Methodist Hospital, said one recent image is seared into his memory: A woman who had been summoned to the hospital because her mother, in her 90s, seemed close to death.
"She wanted to go in to see her mother, but she couldn't, so she was standing there crying with her hand on the glass, looking in," Wyatt recalled. "What struck me most is just how lonely people are at the critical hour."
Even that sort of goodbye is growing rare, as some hospitals strain under the number of critically ill patients. Some patients are dying unnoticed, doctors said in interviews.
Other times, doctors have no time to summon relatives, or the relatives are unreachable.
When a 38-year-old man was dying of Covid-19 at Elmhurst Hospital in Queens last month, doctors searched for a relative to call. But the patient's mother was in another hospital, sick with the same disease.
Patients who are going to be intubated and connected to a ventilator are generally first placed in an induced coma.
When told what awaits them, some respond with disbelief and denial. Most patients, though, are just afraid.
"I try to explain that his breathing is getting worse and he's getting tired because of it," said Dr. Meredith Jones, an emergency room physician at Brookdale Hospital Medical Center in Brooklyn. "That puts a strain on the body, and sometimes it's best to take that strain off and let the ventilator do the breathing for you."
They ask, "How long will this last?" Or, "Will I die?"
We hope you will wake up in a week or two, say the doctors who believe in giving hope. Others just say, "We don't know."
But the doctors generally offer the same advice before proceeding. "Now is the time to call your loved ones and tell them all the things you want to say," one doctor at NewYork-Presbyterian Hospital/Weill Cornell hospital said he tells his coronavirus patients before they are intubated. "I'll come back in 15 minutes."
It is difficult to overstate how isolated some of these patients are. Doctors and nurses try to avoid entering their rooms, for fear of infection. In one hospital, the IV pump lines are extended out of the room, so they can be managed at a distance.
In hospitals across the city, there are silent, lonely ranks of thousands of such patients. Some are face down. Others lie on their backs, eyes closed. Many have been temporarily paralysed so their bodies can't resist the ventilator that is breathing for them. "They appear very lifeless but for the work of the machine," Dr. Colleen Farrell, a resident at Bellevue hospital, said.
Doctors try to call their families daily with an update. With this illness, days can go by with little to report.
Farrell said she often tells families, "I hope his lungs recover, but I worry that they won't."
Not all critically ill patients opt for a ventilator. "I want to die comfortably," some patients explain, said Dr. Joseph Lowy, head of palliative care at NYU Langone Health. They are given a room and if appropriate, medication like morphine.
Columbia University Irving Medical Center is expanding its palliative care response by training and deploying other doctors, like psychiatrists, said Dr. Craig Blinderman, director of the service.
At another Manhattan hospital, doctors, in their final calls to next of kin, have taken to asking if there is a song they should play. Some requests have surprised the hospital staff, like Cyndi Lauper's Girls Just Want to Have Fun.
A physician assistant holds the patient's hand, while the doctor positions the phone so the dying patient can listen to a relative's voice. The music covers up some of the coughing.
Nadeau said she never thought that as an emergency physician she would have as many difficult conversations as she was having now. For reasons of privacy, she declined to provide more specifics on the three critically ill patients' cases.
She had taken it upon herself, she said, to learn the kinds of language and techniques that palliative-care doctors use so she can "have the right words to say with both patients and their families."
Dr. Barbara G. Lock, a veteran emergency physician at NewYork-Presbyterian Hospital, said she remembered receiving Nadeau's WhatsApp messages and had responded with support.
"We are being asked to do things that are tearing at our souls," Lock wrote. "We must not normalise this."
Lock said even doctors who had not yet confronted dying patients were feeling anxiety at the deluge.
"There is going to be no shortage of doctors who are crying at the end of their shifts," she said.
After the crisis ends, Lock said, some doctors might feel like Vietnam veterans returning home from war.
"It seemed like they can only relate to each other," she said, "because nobody else knew what they went through."
Written by: Joseph Goldstein and Benjamin Weiser
Photographs by: Gabriela Bhaskar, Kevin Hagen, Stephen Speranza and Gregg Vigliotti
© 2020 THE NEW YORK TIMES