Not even having the time to apologize to the patient I was in front of, I bounded to where I heard the groaning coming from. I found a small, round woman hunched over the side railing of her hospital bed, reaching for her bag on the floor.
The monitor above showed an O2 sat of 74% and a respiratory rate of 48. I straightened her out, raised the head of her bed, and placed a non-rebreather mask on her, watching her saturation climb to 88%. She was still in marked respiratory distress.
I instructed the woman to stay still, but she kept trying to reach for something. I asked her what she was reaching for and she only gestured to her bag. I studied her briefly, noticing her traditional shalwar kameez. I asked her if she spoke Hindi.
Mrs. G nodded between gasps. Most brown people speak English, too, so it didn’t occur immediately that there could have been a language barrier. I reintroduced myself again in Hindi, and Mrs. G grabbed my hand, grinning even as she panted.
I instructed her in the language we shared, “Stay still—your breathing is stressed.” I asked her what she wanted. She said “pankha”, and I retrieved a handheld fan from her bag. Then she said “pani” (water). I said she had to wait because her oxygen levels were very low.
I asked her to lie down on her belly, and she declined, so I suggested she lay on her side. I explained my concerns, what we could do to help, e.g. high-flow nasal cannula. I found that I didn’t have the sophisticated vocabulary to discuss her wishes re: mechanical ventilation…
… but I stumbled through it as best as I could, using words like “halaq” (throat) and “saas lene ka machine” (machine takes breaths for you). I asked Mrs. G if she had family I could speak to, and she told me her daughter’s name. I asked if she wanted to talk to her.
Mrs. G shook her head, asking again for “pani”. By this time, the nurse walked in. “Whoa, we’ve been looking for someone who speaks ERDDOO!” I chuckled and asked him if a phone translator wasn’t available.
The nurse replied that the phone translators they used couldn’t understand the patient because of how she was breathing. The nurse told me that the patient was already admitted and waiting in the ER for her bed upstairs, which explained why she wasn’t hovered over at this time.
I asked if the primary overnight team could come, since I knew nothing about this patient and we didn’t have a computer in the room. I fetched the patient some water and smoothed her hair out like I would my grandmother’s, as she lay on her side, her eyes closed.
O2 sat was now 94%, but respiratory rate still oscillated ~40. Something in me hesitated with Facetiming the patient’s daughter—in hindsight, I am grateful I didn’t rush to do that.
The overnight night float resident walked in, and I told her what I happened across.
The overnight night float resident walked in, and I told her what I happened across.
She informed me that the patient had a DNR order placed just today after extensive discussion over the phone with family. I learn that the patient has ILD and a cryptogenic organizing pneumonia—a terrible underbelly for #COVIDー19… most certainly a death sentence.
All there was left to do was to wait for her oxygen requirements to climb and for the non-rebreather to become insufficient, necessitating HFNC—but these were measures that only served to flatten the steepness of an inevitable drain being circled: namely, comfort-oriented care.
Additionally serving as the translator for the nurse, we both scooted the patient up. I had the patient lie on her other side, explaining she needed to be on each of her sides only, if not her belly. The patient’s breathing calmed somewhat, still effortful, but less rapid.
I departed her room, checking on her several more times that night from the outside, and going inside seven times as well. Each time, she asked for water. She was fanning herself with paper, and I took some cardboard and fanned her to give her respite. I dimmed her lights.
At one point, I asked her if she wanted to recite “duas” (prayers), aware that she was Muslim by the demographics section of the EMR. I had gone through her chart by this time. I saw documentation that the family had called in twice already in the past evening—
—to ask if the DNR order would be reversed in their hope that she may turn around. The patient was full code before she arrived to the hospital the afternoon before. I shriveled, thinking about the weight of making such a decision over the phone.
As a provider, I knew it was essential to have a DNR order in place here. CPR would be futile and only inflict more suffering. But for family to not be able to see their loved one worsen and realize why such a decision was necessary was nothing short of tragic.
The last time I walked into the patient’s room, I straightened out her socks, fanned her some more, and gave her more water. Her hair was in a plait that was coming undone from tossing and turning, and I put some behind her ear.
I offered her some of the comfort her family could not provide due to the visitor policy, and wondered darkly if the patient even knew she was dying. I realized with a frog in my throat that I didn’t have the words in my conversational range of Urdu to ask her this.
“You are expiring”—that is the literal translation of what I would have said. It was clunky, and embarrassing.
Like most clinicians in this era, where the extent of our therapy relies on oxygen and FaceTime, my dominant feeling was “helpless”.
Like most clinicians in this era, where the extent of our therapy relies on oxygen and FaceTime, my dominant feeling was “helpless”.
I chose ultimately to tell the patient I was very worried about her health. I figured discussing death would only add to her anxiety and worsen respiratory distress. Ignorance is bliss… or is it?
I wondered, if I impressed on her the short time she had left, maybe Mrs. G wouldn’t refuse my offer of dua (prayers). Maybe she would recognize the worry I harbored of her time coming to an end very soon and act on it with final affairs she needed to fulfill.
Maybe she would be less concerned about waking her children up at this twilight hour. I put myself in her daughter’s shoes, imagining this was my vulnerable mother. My eyes prickled.
To have to send your mother to the hospital alone—
To have to send your mother to the hospital alone—
—without the faculties to be independent and without a full voice, I found it crushing.
As an ER resident re: already admitted patient, I didn’t feel like I had the authority or space to answer the patient’s daughter’s questions should they have talked in front of me.
As an ER resident re: already admitted patient, I didn’t feel like I had the authority or space to answer the patient’s daughter’s questions should they have talked in front of me.
Perhaps it was cowardly—or perhaps motivated by knowing that continuity was important in delicate end-of-life situations—but I knew I wouldn’t be able to comfortably talk to Mrs. G’s daughter about her situation without the risk of disrupting the primary team’s careful work.
I left the ER at 7:30 AM, returning to the COVID bay that evening at 7:30 PM. No sooner than I had sanitized my desk, I checked up on Mrs. G on the EMR. I saw that the family and primary team spoke on the phone several times today. Mrs. G was now getting comfort care.
My throat felt tight, but I was otherwise prepared for this. I was relieved to see that her family was allowed to visit her that evening. I stopped short of imagining what a meeting like that would consist of—there were patients waiting to be seen in the ER.
I visited the patient upstairs after my shift the next morning. She was asleep, still with an elevated respiratory rate, but appeared more comfortable.
I returned again that evening at 7:30 PM to the ER for my next shift. I went to Mrs. G’s chart—wilting as I saw the death note.
I returned again that evening at 7:30 PM to the ER for my next shift. I went to Mrs. G’s chart—wilting as I saw the death note.
The time of death was forty minutes prior. I saw a note from the palliative care doctor dated thirty minutes ago—the doctor called the patient’s daughter after the patient’s passing. In their conversation, the patient’s daughter expressed that her mother was her “life”.
She said God didn’t give her children so that she could care for her parents. Mrs. G and daughter were very close and never took each other for granted. I sent a silent prayer for peace to both Mrs. G and her family. A part of me wished I could reach out to Mrs. G’s daughter—
—but I knew this would disrupt her peace. It would mostly serve me and my wish for closure, even if it was to tell her that her mother was attended to by someone who could speak to her without barriers. Still, Mrs. G and her family would be in my heart forever.
It’s felt like a month since I met Mrs. G.
I imagine it’s felt like an eternity for her family.
Ultimately, I’m grateful my parents emphasized the importance of speaking the language of their home country, something they actively worked on via formal lessons as a kid.
I imagine it’s felt like an eternity for her family.
Ultimately, I’m grateful my parents emphasized the importance of speaking the language of their home country, something they actively worked on via formal lessons as a kid.
I never knew that it would take me here. It’s terrible that people are deprived of loved ones in their twilight hours. What a time in medicine.
