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Closeness in a Time of Distancing: There is Always Something We Can Do

Intimacy in all its forms is fraught with danger. Love, particularly the kind you fall into, features an element of terror, and physical closeness has always run the risk of disease. To be intimate, we have to let our guard down, but what we gamble – heartbreak, loss, vulnerability – is for many of us worth the prize: an abiding, almost neonatal sense of protection, trust, and support.


In non-pandemic times – which is to say, normally – intimacy is all bound up with closeness, literally and metaphorically. (When we report the death of someone we knew, we’re often asked, “Were you close?”) But COVID-19 has amplified the perils of proximity, altered the risk-reward, and challenged us to find intimacy beyond arm’s length. Dating, at least the in-person kind, is on hold. Hugging among friends is off-limits. And families of infected patients are struggling with restrictive visitation policies at times of hospitalization and death. Even after death, social responsibility is depriving us of familiar funeral rites, as Ebola did (and still does) in West Africa. Writing recently in The Washington Post, Michele Norris commented, “COVID-19 is indeed a cruel illness that snatches away lives and robs families of the things that help provide closure and comfort.” In light of all this, what alternatives have we found so far?


In late March, at the outset of my last medical school rotation, I was given the option of joining a team in the ICU or completing online modules for school credit. I decided to try the hospital, thinking they could use an extra hand. On any given day, the lobby would have been crowded with visitors, arms full of gifts, trying to navigate the elevators or find the restrooms, but on my first day back, the hallways were eerily empty. In the ICU, nearly every patient was sedated and intubated. The glass doors to their rooms were closed, and IV poles, normally beside the bed, had been posted outside the rooms, extended via connectors over a dozen feet. Their plastic tubing curved through the air like telephone wires on utility poles so that nurses could manage their settings without needing to don PPE. I had never seen anything like it before. More than anything else, it gave me a sense of the seriousness of this disease. For many reasons, including resource and risk management, I was discouraged from entering patient rooms, and I didn’t need much convincing.


At some point that afternoon, a patient’s heart began failing, and there was a small flurry of activity. Even at that point in the pandemic, before academic papers about COVID cardiomyopathy had been published in medical journals, and before major newspapers carried headlines of the virus’s mysterious cardiac reach, the ICU team had seen enough patients with the novel coronavirus to notice an ominous and unexpected pattern of heart failure that signaled a likely irreversible decline. The ICU fellow told a resident physician on my team to prepare the patient’s adult children for an imminent death, and the resident picked up the phone. She introduced herself to the family, apologized for the circumstances, and said she would have preferred to deliver the news to the family in person. Then she told them that their father was likely to die, if not that afternoon, then very possibly the next day. From where I stood, a few feet away, I could hear the family wailing over the phone. The resident and the family cried together.


After that day, with the team’s blessing, I decided that for me at that time the benefits of joining them at the hospital did not warrant the risks of exposure, my use of PPE, and the concern of my seniors, who would have felt guilty if I, as a medical student, had contracted the virus on their watch. Like most of my classmates, I switched to completing educational modules online, but I knew that once I became a full-fledged doctor, I would have to do what the resident on my team had done. Now, back at the hospital as an MD, in the past week I’ve had to tell a patient’s husband that no, he is not allowed to visit his wife, even for five minutes, despite the fact that she has been hospitalized for a month, despite the fact that her cell phone has been disconnected, and despite the fact that she feels completely abandoned by her family and by the hospital staff, who are trying to limit the number of times we enter her room.


A few days ago, one of my patients, a woman in her nineties, began gasping for breath. Though she wore an oxygen mask, she was effectively drowning in mid-air. She spent two of her most valuable breaths to tell me, “Let. Me go.” Meaning no CPR, no tube down her throat. As far as I knew, intubation was the only thing that could save her life, but her wishes had been clear to us as soon as she had been admitted – Do Not Resuscitate (DNR), Do Not Intubate (DNI). As the Rapid Response team arrived and took control, I picked up the phone to call her son.


These kinds of COVID-19 end-of-life stories are being told so often in the medical community nowadays that they are becoming a genre, and they’re proving over and over again that the doctor phrase from TV, “There’s nothing more we can do,” is factually untrue, is a cop-out, is a failure of imagination. As my professors drilled into my head throughout medical school, there is always something you can do, even if what you do is not strictly medical. While researchers are frenetically searching for vaccines, pharmaceutical therapies, prophylactic measures, and optimized ventilator settings, others on social media are promoting ways to preserve a measure of intimacy and humanity during a patient’s hospital course, even in their last moments.


I’m starting a little collection of them, like old Star Wars figurines, and trying to keep them from collecting dust. These days, because everyone is masked, when patients enter the hospital, they may never again see another human face. Is there nothing more we can do about this depersonalization? The Gold Humanism Society has suggested wearing pictures of us on our gowns so that patients can see who is caring for them. What about the masks on our patients? Danielle Ofri has suggested displaying photos of the patients themselves. A recent New York Times piece explored how COVID-19 has deprived Hasidic Jews of the last rite of a bedside prayer. An organization has created a hotline to deliver the prayer by phone in multiple languages. In my unit at the hospital, patients have been provided an Amazon Echo Show to enable virtual face-to-face check-ins. I’ve used them myself to save time, preserve PPE, and ameliorate the isolation that many patients are experiencing behind closed doors. For one of my patients who developed disorientation and delirium after weeks of sedation on a ventilator, we were able to connect her to her family through a tablet. Is there anything more we can do? At the very least, we can say, as Dr. Elizabeth Fontana said recently, “Your loved ones did not die with you there, but they did not die alone. I was there. My team was there. And we are grieving with you. You are not alone.”


None of these are medical interventions, but they can mitigate the psychological and spiritual suffering that surrounds death and dying, which, after all, is part of care. Not long after my first day on the ICU, my “family group” of classmates met up via Zoom to discuss ways to penetrate the new barriers between families and facilitate connection. Our preceptor introduced us to the work of Ira Byock, a palliative care physician, and offered advice for us to pass on to family members searching for final words. His suggestions might seem obvious, and the phrases may have been uttered many times before, but they convey messages that always bear repeating, especially at the end of life: “I love you.” “I’m sorry. Please forgive me.” “I forgive you.” “Thank you.” “Goodbye.” If we cannot be physically present for those we love, perhaps we can create some semblance of closure through what we say and how we say it.


As ants touch antennae, we humans must have some biological imperative for physical proximity, some cellular requirement for contact with others, because we seem to crave closeness with a kind of hunger, the way infants yearn to place objects in their mouths. As I hung up the phone with the son of the patient in her nineties, I learned that the Rapid Response team had accomplished one of the simplest possible things: just as I thought there was nothing more we could have done, they had turned her onto her stomach (known as “pronating”), and the redistribution of blood flow within her lungs was enough to save her life. For how long, I have no idea. But they gave her and her son the opportunity of a few more moments together – to reconcile, to reiterate their love for each other, to say whatever they needed to say. We need to keep thinking of ways to help our patients connect, to not abandon them. In the end, we will not always succeed in saving their lives, but we can help to preserve what it means to live.

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