A Covid death
Dealing with grieving families takes a toll on physicians, but watching patients die alone is worse. Until Covid it was also rare.
The other night at work, I pronounced a patient dead from Covid. He was a man in his sixties who was being treated for the disease on the medical floor. He had been getting steroids and oxygen, remdesivir and IV fluid, when his lungs stopped working. He had signed a “do not resuscitate” order when he entered the hospital and so we did not intubate him. When his body could no longer outrun the virus, the nurses did everything they could to make him comfortable and then we let him go.
I was seeing patients in the ER when one of those nurses called to ask if I could come “pronounce” the patient. Anyone can observe that a patient is dying, but pronouncing a patient dead, and naming the time of death, is something—in many states—only a doctor can do. And in the middle of the night in small hospitals, like the ones where I work, pronouncing a patient often falls to the only doctor in house—the one staffing the Emergency Room.
So I finished seeing another Covid patient in the ER and walked to the medical ward wearing a PAPR. The nurses were sitting at their station and pointed in the direction of the patient’s room. “Is any family with him?” I asked, not sure if our current visitation policy allowed visitors.
“No. It’s just been his daughter, but she had to leave hours ago,” the nurse responded.
The room was dark and I entered alone. The patient was lying face up on the bed with both arms under the covers. His head was turned to the left with his mouth partially open. It looked like he had died in the middle of a yawn—or that the work of keeping his mouth closed had finally required too much effort. I pulled back the blanket, reached for the patient’s hand and checked for a pulse. There was nothing there. I watched his chest for the rhythmic rise and fall that had been with him his whole life. It was gone, too. I looked at the clock. “Time of death, 1:17 a.m.,” said out of habit, although there was no one else in the room to hear.
It was in my fourth year of medical school that a senior resident first taught me the process of pronouncing someone’s death. “Be unintrusive but kind to the patient’s family,” he said as we were on our way to the patient’s room. “If you do your job right,” he explained, “they won’t remember you. But if you screw up, you’ll be the only thing they remember about their loved one’s death.”
“OK,” I responded.
“And you have to touch the patient,” he continued. “This not something you can read from an ECG or monitor,” he said. “It may surprise you not to hear heart or breath sounds when you listen with your stethoscope. But you need to know what that silence sounds like, too.”
“OK,” I said again, and swallowed hard as we entered the patient’s room. Then I watched as the senior resident slipped sideways through family members that were gathered around the patient’s bedside, motioning me to follow. He introduced himself, expressed sympathy for their loss, then told them what we were there to do. He placed his fingers on the woman’s wrist and carotid artery to check for a pulse. Then he put his stethoscope on the patient’s chest and had me do the same.
He was right. After listening to thousands of hearts, it is a very unusual sensation to lay your stethoscope on someone’s chest and not hear anything at all. Death, it turns out, is defined not so much by signs that are present, but by the absence of others.
Since that initial experience in medical school, I have pronounced many people dead. In fact, it happens often enough that I have developed a pattern, or my own way of doing things. I have certain sympathetic phrases I find myself repeating to families and a way of interacting with the dead body that I hope shows respect.
And perhaps because I taught English before going to medical school, I always try to personalize the death note—the official account of the patient’s death that is left in the patient’s medical record—just a little bit. In addition to the physical exam details required for the note—“heart sounds were absent at five points of auscultation across the precordium”—I try to include a human touch: “family was present at the bedside,” I will note, or “the patient died with her husband of many years by her side.” But it is a humbling thing to witness another human being’s death and then try to summarize it in a sentence or two.
And before I leave the room, I always stand at the bedside for just a minute, trying to imagine the cause of death and the life that preceded it. Sometimes, in the ER, this is easy: I can visualize the motor vehicle accident that led to a patient’s death by examining the injuries it caused—or I can watch the patient’s heart on a cardiac monitor and see the irregular rhythm that precedes its final beat.
But alone with my Covid patient that night, I could only wonder who he was—what his job had been, who his children and grandchildren were. And almost in spite of myself, I saw coronavirus everywhere, filling up his heart and lungs, shutting down his kidneys, causing tiny blood clots in tinier blood vessels, and triggering the giant immune system storm that culminated in his death.
And in the same way that a tiny piece of debris on a freeway can set in motion a series of events that leads to a pileup of cars, multiple injuries, and one person’s death, I wondered who gave this man the virus. Had one of his grandkids brought it home from school? Or had he been getting groceries when a mask-less stranger coughed in his direction? Or had a neighbor complained over the back fence about the hassle of social distancing and covering their face?
Back at the nurses' station I inquired about writing the death note. But instead of of having me log onto the electronic medical record or handing me some “progress note” paper, a nurse pushed a form across the counter towards me. “This is what we are using now,” she said. “You just have to check a box.”
I looked down at the paper. There was a sticker at the top of the form with the patient’s name and medical record number on it. Next to this, there was a box for me to check and the phrase “I witnessed this patient’s death.” There was another box for me to enter the time of death, and then two lines under it for me to write and sign my name.
I sighed. “He will be one of the statistics reported by the state in their Covid death-count tomorrow,” I said as I took the paper and then thought about how the end of his life would be summarized: “Man between ages 65 and 84 who was hospitalized when he died.”
Staring at the death form, breathing filtered air through my PAPR, I thought that everything about this situation felt wrong, from the spacesuit-like gear I was wearing, to the absence of the patient’s family, and the end of his life being reduced to a box I would check on a form. And even if his family wrote a proper obituary to serve as a record of his life, it would be just one of many that filled newspapers and online mortuary listings where people all died of the same thing.
In the early years of my practice, I had once taken care of an over-the-road truck driver who collapsed in our small town while pumping fuel. Despite our best efforts in the ER, we had not been able to resuscitate him. For much of my career, waking this man’s wife in the middle of the night to tell her her husband had just died alone—in a state far away—was a benchmark for my most painful death notification.
Dealing with grieving families takes a toll on physicians, but watching patients die alone is worse. Until Covid it was also rare. So perhaps that is why, while I was pronouncing the Covid patient, memories of that long ago night—watching the truck driver die and then listening to his wife and children cry on the other end of the phone—came flooding back.
When did we get used to this? I wondered, as I signed the paper the nurse handed me. When did it become OK for so many people to die of a disease that simple measures could prevent? And when did it become acceptable to overrun hospitals and leave people to die alone—with only overworked ER doctors and nurses to witness their death? I puzzled over how pandemic fatigue and political expedience had somehow come to outweigh our obligation to loved ones and neighbors—and to other people’s loved ones and neighbors, as well.
Walking back to the Emergency Room in my PAPR, I realized that the simple pronouncement of death I had just made on the medical floor far surpassed the sorrow I had felt for the truck driver years before. His death had been so painful because the details of it—dying alone, in a roadside hospital in a far-off state—were so outside the norm. But by checking a box and filling in the time of his death, the man I had just pronounced joined legions of other people for whom this kind of lonely, solitary end of life had become the norm. The specificity of my first patient’s death had broken my heart; the anonymity of my second patient’s death crushed me.
I pondered this for a few minutes and wondered if I would be able to recognize this man by his demographic information on the state health department website the next day. Then I took off my rubber gloves, put on a fresh pair, and walked back into the Emergency Room to see my next patient.
Details about individual patients have been changed to protect their identities. Descriptions of Covid are exactly as I experienced them.