All of our patients who die, do so alone. There is nobody to hold their hand. Nobody to comfort them
I begin my shift at 8am. Before I can even head to my allocated bay, a
nurse is already asking for a doctor to help her. One of the patients won’t put
on his mask and his oxygen levels are dropping. It takes me a few moments to
get on my PPE before I can get to him. I try to talk to the man, but it’s
difficult for him to hear me through my mask and the noise of all of the CPAP
oxygen machines. He tells me that he’s tired of fighting, and that he wants to
be left alone.
Through my mask I try to explain that he has been getting better, and
that we wouldn’t have a place for him on the high dependency unit (HDU) unless
we thought he had a good chance of survival. He tells me that I don’t understand
what it’s like, desperately struggling to breathe, which is true. This goes on
for around 10 minutes. Eventually, I have to take his request seriously.
Perhaps it isn’t illogical for him to want to die peacefully.
In order for me to allow him to make this decision, I have to be sure
that he understands the risks, so I ask him to explain to me what he expects
will happen if he takes off his mask and doesn’t put it back on. He says he
doesn’t know. I tell him that he has to understand that he will die and that he
needs to say those words to me if that is what he really wants. Eventually we
compromise; he will put his mask on for another hour, then phone his wife and
tell me his decision. This man is 61.
I am allocated B Bay, in which there are five patients. My patients are
mostly men, ranging from their early 30s to their 60s. This is younger than
normal on HDU because — as I explained to the man — we only have beds for
people with a fighting chance. I read their charts to update myself on what
happened overnight.
Who dropped their oxygen saturations? Who needed their CPAP (Continuous
Positive Airway Pressure) settings increasing? This comes via a tight mask that
goes over your face to help you breathe by forcing air into the lungs at high
pressures, keeping the airways open. I am told that it feels like you are
suffocating.
Who crashed overnight and is now on the ICU (intensive care unit)? Who
has died?
I then put on my PPE (FFP3 mask, hairnet, long-sleeved gown, gloves,
visor) and enter the bay to examine the patients. I feel lucky to have this
level of protection — my colleagues outside of the HDU only have surgical
masks, which offer little protection against an airborne virus.
The patients don’t ask many questions, mostly because they need to spend
all of their energy breathing. I try to work out if one of my patients isn’t
answering my questions because she is delirious, because she doesn’t speak
English, or because she is depressed. I work out that it is probably the
latter; her notes say that her husband died just before New Year, from Covid. I
try to remember every patient as an individual, since I can’t bring the notes
into the bay to write as I go, but each crackly chest I listen to blurs into
one. I summarise what I have found, for the consultant’s round later in the
morning.
By this point, the blood test results should be back. I had been
wondering why one of my patients was deteriorating — requiring more oxygen and
at higher pressure — and his blood results provide me with a likely answer: a
blood clot on the lungs. He is too unwell to enter a CT scanner, which would
confirm this theory, so I treat him as if he has one, with higher doses of
blood thinners. I corner the ICU doctor, who happens to be reviewing another
patient on the ward at the same time, asking him to have a glance at my
patient. He agrees that he will likely need an intensive care bed at some
stage, but at the moment they simply don’t have one. I worry that my patient is
going to end up with an emergency intubation, much more dangerous than a
controlled one in ICU.
I now have to update relatives over the phone, since they are unable to
visit. I always put this part off; I almost never have good news to deliver.
Hearing people cry on the other end of the phone, knowing that I am them
bringing news of the worst day of their lives, is heartbreaking. There is
nothing positive that can be made from the words “your father is currently on
the maximum support we can offer, and we are not sure if he is going to survive
today”. I feel like a bad doctor because — to put it bluntly — I’m causing
suffering rather than alleviating it. Why can’t I make them feel better?
We try to have our patients prone (lying on their fronts) since this
opens up their lungs at the back and improves their oxygen levels. The patients
hate proning, since the masks dig into their faces, their backs hurt and their
arms go numb, and we do not have massage table-style beds with holes for their
faces.
One of my patients has not managed to be prone at all. I speak to his
wife, who tells me that he is very claustrophobic, and that might be why he has
been resistant. She tells me that she has been pleading with him on the phone
to try it, but hasn’t been able to persuade him. I ask her if there’s anything
that has helped him in the past with his claustrophobia and she says sometimes
watching a film on the iPad. But I don’t have the courage to tell her that he
is nowhere near well enough to watch a film. She suggests a fan, so I arrange
for a fan to be set up for the patient, and he manages to prone all day. I feel
like a good doctor.
We have several patients who are not “fit” for ICU in the current
climate. Before Covid, they most likely would have been given a chance, but not
now. When we think that these patients have suffered enough, and are unlikely
to ever recover, we start talking about making them comfortable. It’s partly
that we need the beds for patients with a better chance, and partly that we
feel it is cruel to keep these people suffering when their chances of survival
are slim. It’s difficult to work out which of those is your true motivation.
The most distressing part of their struggle is the air hunger. You can
spot these patients easily, as they grasp the masks to their faces with both
hands and gasp visibly for air.
Once we decide to palliate someone, we give them morphine to reduce
their respiratory drive, and ease this feeling. We give them benzodiazepines to
lower their anxiety, antiemetics to stop them from feeling nauseous, and other
medications to prevent them from needing to cough. We then take off their
masks.
It is important that these medications are given before their masks are
removed, otherwise they will die terrified and gasping. This decision is made
for about two or three patients each day on my ward, out of 20 or so. However,
this process does not always run smoothly. Sometimes these medications are
prescribed but not given in a timely fashion, or at insufficient doses. With so
many patients, we cannot keep an eye on them all; to watch whether what we are
doing is working.
Once a patient is deemed to be dying, they are allowed one family member
to see them for 15 minutes. The patient won’t be able to see their loved one’s
face, since they will be wearing full PPE. Because the family member only has
one shot at visiting, we need to accurately guess the patient’s time of death
so that we can call them to come in. Sometimes we get this wrong, and the
family never gets to see them. But all of the patients who die do so alone.
There is nobody to hold their hand. Nobody to comfort them. Nobody to tell them
they love them.
Towards the end of the day, two of my patients are deteriorating and
destined for the ICU. Another doctor had an ICU candidate in her bay. They are
all between 60 and 64 years old, none of them with significant comorbidities;
all were working full time until coronavirus struck. They all now require 80%
oxygen at high pressures, breathing at around 50 breaths per minute and tiring.
There is only one ICU bed. I leave before the decision is made as to which of
them will get the bed. I am sure that whoever doesn’t get it is likely to
deteriorate overnight.
I pay for an Uber home, because at 9.30pm I can’t face walking in the
January dark to the train station and spending over an hour getting back. I
arrive home at around 10.15. In less than 10 hours, I will repeat the same day
again.
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