Dr. Amber Barnato is the Distinguished Professor of Health Care Delivery at The Dartmouth Institute at the Geisel School of Medicine at Dartmouth, a preventive medicine and palliative care doctor at Dartmouth-Hitchcock Medical Center (DHMC), and a Fellow of the American College of Preventive Medicine.
It has been three weeks since I was last on rotation at the small rural New Hampshire academic medical center where I work for the inpatient palliative care consult service covering the intensive care unit (ICU) as well as managing inpatient palliative care. Fortunately, we have not experienced the overwhelming COVID-19 caseloads and chaos that our neighboring state of New York has seen, although the spillover effects of policies designed to protect patients, staff, and the community have nevertheless taken their toll.
To date, we’ve had a little more than a dozen cases of COVID-19 and, mercifully, only one death. However, we are intensely prepared. But in the process of preparing – developing policies, procedures, and practices – we have heightened our many anxieties: the possibility of having to ration ventilators, of practicing outside of our expertise, of running out of personal protective equipment, of patients dying alone.
And one simple policy has had an oversize impact on us: visitation restrictions. We, like most hospitals in the U.S., have implemented strict visitor policies to support social distancing. Sick children and laboring mothers can be accompanied by one adult. Patients who are near death may receive a single visitor in the main hospital; two if they are in our inpatient palliative care unit. But, sadly, zero if the patient is dying due to COVID-19.
As palliative care providers, we are professionals whose resilience in the face of death and dying depends on the meaning-making that comes from deep human connection, particularly with patients’ family members. During my last week of service, I cared for 15 patients. Only one had COVID-19, but all were affected by the pandemic.
Each of the family meetings we held with the loved ones and medical decision-makers of our ICU patients was by telephone. We strained to listen for the signs of emotional distress we’ve been formally trained to spot using non-verbals that make up more than 85% of human communication. We used silence to hold space for grief, but without making the eye contact that usually signals our care and companionship. We struggled to manage our own moral distress at not allowing patients to be surrounded by their loved ones as they died, while simultaneously trying to support the distress of grieving family members.
Families made excruciating decisions about which of them would say goodbye in person. I stood six feet away from these sobbing envoys as their father, wife, grandmother died. Without touch, I could only express my condolence by kneeling, as if asking for their forgiveness.
I cannot even begin to imagine the scope and scale of the grief that my colleagues across the world are facing as the waves of this pandemic breach seawalls, when the gulf I feel between what I have been trained to do and what I can actually do in this time is so very deep. My training in palliative care and preventive medicine tells me that the suffering we are witnessing first-hand is magnitudes smaller than the unseen suffering caused by an unmanaged pandemic. I know that what we are doing is right. But that doesn’t make it feel any better.