Challenges and Responsibilities in Caring for the Most Vulnerable During the COVID‐19 Pandemic

To the Editor:

COVID‐19 has upended our lives, our work, and our hospitals. Our colleagues have created intensive care units in post‐anesthesia care units, operating rooms, and regular floors; redeployed subspecialty and nonmedical staff must rapidly acquire new skills to care for inpatients; subspecialists have become hospitalists and hospitalists have become intensivists as we have tried desperately to care for so many people whose illness can be rapidly progressive and often fatal. People are alone, deprived of family who could help them heal or be present as they die.

I have just finished my first week attending on a Geri‐COVID service in a New York City hospital. Although all of us have geriatric outpatient and/or palliative care responsibilities, currently six from the geriatric/palliative care division are caring for inpatients at our hospital: two on Geri‐COVID, two on a hospitalist service, and two in the newly created COVID‐19 hospice unit. Our plan is to alternate weeks on service to give ourselves sufficient time to rest (physically and emotionally) and to catch up with other work. Ours is just one contribution to inpatient care; my colleagues in critical care, emergency medicine, nursing, and hospital medicine are my hospital heroes.

To cope with this pandemic, we have had to change the way we practice medicine. On the general medical floors, we decide daily which patients will be seen and by whom, usually only one house officer per patient, and sometimes no attending; exams are cursory, often visual; stethoscopes are rarely useful. We round by numbers, where the most important information about the patient is the amount of supplementary oxygen needed to maintain effective saturation. We have been encouraged to limit the time we spend with the patient, and when we are there, gowns and goggles and masks and gloves make us look alien and remind us to stay away. And staying away violates everything we have been taught as geriatricians. Once, after I had helped a nurse walk a patient to and from the bathroom, I had to slap away the thought I had spent more time than I should have in the patient’s room.

We no longer have an acute care of the elderly unit. Instead, we are the peripatetic Geri‐COVID team, and the median age of our patients is in the mid‐80s. Those who do not have COVID‐19 have also been desperately ill; too sick to be discharged or managed at home, they too have succumbed, alone. We have spoken to families daily and have tried to use tablets so they can see their loved ones, but these are no substitute for their presence.

I suspect that our service has seen so much death not just because our patients are in a high‐risk group, but also because families expect and understand the conversations about goals of care. Only a minority (three during the past week on my service) were intubated; many patients are frail and/or cognitively impaired, and most families want their loved ones spared the ventilator. Some recover, to our great joy; most we care for until they die.

I am old enough for a resident to have asked me which was harder, caring for people with acquired immunodeficiency syndrome (AIDS) (when I was a house office in the 1980s) or people with COVID‐19. It was tough question to answer, but I truly believe this is more difficult, with patients dying so quickly and so alone, in a numbing sameness. Like COVID‐19, AIDS was frightening, and up to one‐third of our patients had it. It was a killer of young people like us, a disease whose etiology was unknown and almost invariably lethal. But its longer time course led us to develop emotional ties to our patients. We savored small therapeutic victories, and we felt we could champion our patients when the rest of the world seemed indifferent. Of course, I will never speak for those with human immunodeficiency virus (HIV) about what they lived through then and are experiencing now; rather, I am also hoping to learn from and find new ways to support long‐term survivors of HIV as they cope with a new pandemic. But we are all thinking of those years.

I would like to believe that I have chosen academic geriatrics because I love proselytizing to house staff for what it offers: small victories, intellectual challenges, collaborative care, and meaningful opportunities to help patients and their families. We are deprived of all of this in the pandemic. As an educator, I am impressed by the rapidity with which our house officers have embraced caring for so many people with COVID‐19; they have understood and welcomed the new responsibilities asked of them. But I am also unnerved by how the practice of medicine has been altered by this disease, and I worry about permanent effects of this pandemic on doctoring in general and geriatrics in particular, both because our bedside care has changed and because we hear public pronouncements denigrating the value of the lives of older adults, asking the country to make the (false) choice between saving older people or the economy.

We faculty are trying to ensure that our patients receive the best care possible and our trainees learn the right lessons from this pandemic; at the same time, my patients are also reminding me of one of the core responsibilities of geriatricians: by our actions we must demonstrate the essential worth and dignity of even the most vulnerable.