My friend Jim called me with urgency in his voice; his elderly father, living alone in New York City during the peak of the pandemic, had a multiday fever and was losing weight. He wanted to know, should he take him to the hospital?
My typical response in this case — sudden illness in an otherwise healthy person — would have been yes. As an ICU doctor, I have sometimes been able to save elderly patients with serious urinary tract infections or pneumonia. If Jim’s father had one of those infections, the hospital might save his life, or at least buy him some time to figure out next steps. But after three weeks of doctoring in a pandemic, I realized that my answer had changed.
Jim’s father lived on the Upper West Side of Manhattan. While many other elders chose to stay inside, he had continued to take frequent walks and shop at the neighborhood bodega. I realized that there was a distinct possibility that COVID-19 was responsible for his symptoms. This virus was different from the more common bacterial infections I was used to. Coronavirus wreaked havoc on older bodies and had no proven cure. By that point I’d cared for several very sick elderly patients with COVID-19, all of whom were in the process of dying, with no family or friends allowed to visit. I’d watched too many families sob their goodbyes to intubated loved ones on Zoom, the phone held next to the patient’s ear by PPE-wearing nurses. This was not the death that I imagined Jim’s father — or for that matter, anyone — would want.
Jim was still on the line, “What do you think I should do with my dad?” It suddenly felt as if there wasn’t a moment to spare. “Listen,” I told him, “You really need to plan quickly because you might not have a lot of time. Your father might deteriorate fast and I’m not sure that the hospital is the best place for him to go. The truth is that if he goes in he may never come out. You may never see him alive again.” I was surprised at the words coming out of my mouth. As a palliative care doctor, I’ve learned how important it is to take time to discuss end-of-life medical decisions with patients, friends and family. It is hard for people to confront their mortality in a rush. We learn to create a space where it feels safe to explore one’s values and preferences before making serious, even irreversible decisions. But the shocking pace of this pandemic spurred me on.
Jim was silent for a beat. Then his voice caught as he realized that he was in a situation that few Americans have previously had to imagine. He needed to talk with his father about something that few of us ever summon the courage to do, even when there isn’t a pandemic breathing down our necks.
“Dad wouldn’t want to go into the hospital if he has coronavirus,” he finally said with resolve. “I need to go and get him.” But there was more difficult information to process. If his father went home sick with COVID-19, he would need medical support for any symptoms he might have; whether shortness of breath, anxiety, pain. And so I forwarded Jim the numbers of several hospice agencies in the event that they would need quick access to one.
The hospital has always been thought of as the best place to go if you’re really sick. Studies show that while approximately 80% of Americans prefer to die at home, only half that number actually do, the other half tempted by the false promise that the hospital will surely save them. The fantasy of perpetual life is an ingrained part of the American psyche, and we’ve all, patient and doctor alike, cast the hospital in the starring role. People with advanced age or serious illness come expecting help, but too often get treatments that make things worse.
They are placed on what I call the end-of-life conveyor belt, their bodies treated like objects, the focus being on their organ dysfunction and diseases instead of on them. Their preferences are ignored or never even elicited in the first place. This has resulted over the past many decades in a public health crisis of non-beneficial, high-technology deaths. The palliative care movement rose up in protest against it, but our culture is slow to change. People keep coming to the hospital as a mecca of hope, with its ICUs and machines.
But now, COVID-19 has made it impossible to pretend. The data are clear: Elderly or chronically ill people who become sick enough from COVID-19 to need a ventilator will not likely benefit from one. Many will die on those machines, or quickly after being liberated from one. With visitation from friends and family essentially prohibited, they will go through this alone, likely to suffer agonizing and lonely deaths at the end of machines. It’s truly dystopian, and it’s happening now.
This feels so dramatic, yet it’s simply highlighting the fact that hospitals and ICUs were never the best solution for people with serious illness, frailty or end-stage illness. Even without the visitation restrictions of the COVID-19 pandemic, few family members can maintain a bedside vigil for their loved one in a hospital or long-term care facility. And even without the extra ravages of COVID-19 upon the elderly and chronically ill, end-stage illness doesn’t usually respond to heroic ICU maneuvers. Long before COVID, and I suspect long after it, too many patients with advanced age and life-limiting illness will be harmed by their choice to come to the hospital for support and respite.
Maybe it’s time to reconsider our view of the hospital as the solution. We have learned a harsh lesson about its limitations these past months, especially for those who are at high risk of dying if infected by the coronavirus. For them, the possibility of dying alone on machines that are not helping, surrounded by harried, gowned and gloved health care providers, might be a risk they are unwilling to take. It’s not to say that one shouldn’t go — hospitals still can be a solution for certain conditions even among this population —but the full set of outcomes must be weighed, and the choice not motivated by desperation or fantasy.
And so COVID-19 has a lesson to teach us all — even when this virus is long gone: the hospital is rarely a good place to die. If you are in a group that will be less likely to benefit, do you really want to go? And if you don’t, what are your plans?