Peaceful Goodbyes: Providing End‐of‐Life Care to Patients with COVID‐19

To the Editor: At the start of the coronavirus disease 2019 (COVID‐19) pandemic, I had the privilege of providing care to many patients as a resident physician who triaged and admitted patients to the wards based on their care need, and later as a part of the critical care team.

When I reflect on my clinical experiences, I still feel pain over my patients' unique hardship during coronavirus restrictions. For example, I would tell my patients, “I will check on you later,” after an initial evaluation and triage, only to shut the door and likely never return to their rooms the rest of the shift. Our hospital was flooded with COVID‐19 patients, and I had to rush to see them. There was barely enough time to review charts and answer pages, let alone go back into the rooms to provide supportive care to the patients who were already admitted. I would feel guilty and uneasy because they would spend most of their time alone, with minimal staff interaction and no visitors. With these unique restrictions, I witnessed challenges in arranging appropriate end‐of‐life conversations and preparing the patients and their beloved families for a dignified death. We faced challenges, such as communicating with family members over telephone or video instead of in person and helping family come to terms with dying patients who deteriorated rapidly and unexpectedly. Here, I hope to share two different farewells that I arranged between the patients and their beloved families, with the insight I gained in the process.

Mr J was admitted for acute hypoxic respiratory failure due to COVID‐19 and was intubated for weeks. He developed multiorgan failure, requiring dialysis and pressor support. I started building a relationship with his family early in his hospitalization, to lay the foundation for an end‐of‐life care discussion by keeping them updated over the telephone. There were some challenges in communicating with his family. They spoke limited English, and when I called via an interpreter, I sensed that subtle nuances in my message were sometimes lost. Furthermore, Mr J's family was unable to visit him and could not witness his clinical deterioration with their own eyes, which meant they struggled to understand the gravity of his illness. Despite these barriers, I tried to update his family frequently in a compassionate but honest way, and I gave them adequate time to discuss among themselves and ask questions. Our palliative care team provided invaluable support for Mr J's family as they came to terms with the fact that he was dying. When they were ready to withdraw care, the other hospital staff and I were prepared for the farewell. I arranged a final video call between them, a call that expressed both the family's bitterness at losing Mr J but also relief at seeing him in tranquility and peace in his final hours. His family shared their appreciation for arranging the farewell, which made me feel honored to have helped bring comfort and closure to them.

My second experience with preparing and arranging a farewell was with Ms B, a woman in her 40s who had also developed multiorgan failure on the ventilator. As her condition deteriorated, I kept in touch with her mother, who understood that Ms B likely would not survive and that heroic measures were futile. Unfortunately, Ms B's situation had another tragic complication: her husband was sick with COVID‐19 at the same time, and only after he adequately recovered did he join our conversation and learn of her dire prognosis. He struggled to cope with the news, and on his last video call with his wife before we withdrew care, he appeared frustrated. After I had connected their call, he sat and gazed on her in prolonged silence. “I love you,” he finally said. I asked if he needed more time, as I wanted to make sure he left nothing unsaid. “We're OK now,” he replied. Although Ms B died comfortably, I could sense the incompleteness, the lack of closure from her husband.

Thinking back, I observed that Mr J's and Ms B's deaths were marked by how different their families' expectations and preparedness were. It was important to have effective, continuous communication with their families and give them time to process and accept reality. For Ms B, it was especially difficult as she was younger, and her husband was initially excluded from the conversation due to his own illness. Witnessing many patients pass away during the pandemic has led me to reflect on the meaning of a good death. Everyone defines a good death differently; for me, it is when both the patient (if lucid) and family are prepared for the death and conclude the last chapter of life peacefully. It can be achieved through a process of working together to understand the severity of the patient's condition. Thanks to collaboration and communication with families, we overcame limitations and restrictions so that families could say goodbye to their loved ones. I will remember this pandemic for many reasons: the long, tireless working hours; the passion and dedication of hospital staff and physicians; and the opportunities to arrange and witness a good death.