Death and Covid-19
I began my career in psychiatry with the desire to work with dying patients. This is of course an odd way to begin, but I had begun my career with an interest in Oncology, and eventually discovered the field of Psycho-oncology. The first population I worked with after graduating were HIV infected individuals at the time when an HIV diagnosis was a certain death sentence. The work centered at helping the individual accept their impending death and work with them at creating a “good death”, one which there was family and loved ones involved.
The central theme was the use of time, which although shortened by the diagnosis, did allow for some of this work. At times individuals were helped, but there were other times that they were not. The issue was that acceptance and the calmness that seems to come with it was not always accessible. Kubler Ross had created a very neat package, but not everyone fit into this model. With time however we would be able to lower the amount of psychic distress despite the horror of watching young men and women die too soon.
Covid-19 changed our approach to the dying. To begin with the time from diagnosis to death was days, rather than weeks or months. But a part of the dying process that did not exist was the presence of those that they loved. There are no visitors, the only communication is using screens. The health care provides are covered from head to toe. We cannot see the smiles or frowns on anyone’s face. The lack of visitors has a chilling effect. Visitors connote the innate humanness of the individual. The visitors show us a person who prior to this episode had a life and people. The visitors open up a part of the individuals life that we are not often privy to. I recall early in my career being struck by the visitors in the Oncology Service. The individual being visited stopped being a “patient” but instead became a mother, father, brother, sister, child, parent, spouse or partner. Their existence came to full view by watching these interaction. The lack of visitors also opened up discussion especially around the loneliness and fear that comes with the process of dying.
The mental health provider early on decided that screens were useful, but they did not take into account the value of one’s presence, especially to someone so close to death. We avoided the patient due to fear. Fear of course is warranted in the case of a respiratory virus, that is quite efficiently transmitted, but the cost to the therapeutic relationship is high. People speak of the difficulties in doing an adequate evaluations using an Ipad or Android Tablet, but what about being able to help a person deal with their fear of death, especially when we show that we are so fearful we will not even go into their room.
Alone and frightened is the way COVID patients die. The only touch is that of a clinician checking an IV line or moving a limb. There are no faces, just eyes staring at you.
I am not even sure we can do better given our knowledge. I hope that we learn that we can protect ourselves from the infection thereby allowing us to at least go to the bedside more often and at least try to touch our patients with our words.
