Facing Death in a Pandemic
Authors: Sophia R. Yapalater
Journal: Annals of Internal Medicine (2020)

On Being a Doctor1 September 2020Facing Death in a PandemicFREESophia R. Yapalater, BASophia R. Yapalater, BAPerelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (S.R.Y.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-2538 Audio Reading - “Facing Death in a Pandemic” Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads “Facing Death in a Pandemic” by Sophia R. Yapalater, BA Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail My personal death anxiety began at age five when I learned that the sun would burn out in 5 billion years. I developed elaborate plans to discover another solar system. As I matured, so did my anxiety: My parents would die. Everyone on the subway would die. Later, I lost friends to suicide and my grandfather to cancer. I had to contend with a brain mass, which thankfully proved to be benign.The first patient death I witnessed was in the trauma bay on a cold night in 2019. I entered for an overnight shift just as a man arrived who had been shot in the chest. Before I could even get a mask on, a resident was massaging his heart. After 40 minutes, the attending called time of death and handed me a needle driver, gesturing for me to close the man's splayed-open rib cage. With the team focused on central line placement in the next bay, I approximated his chest, willing every stitch to provide closure for not only the wound but also his family, to shield them from the gore of our attempts to save him.There were more deaths that year. A teenager dead on arrival whose mother sent a grinning photo for identification. A late-term, unexpected pregnancy loss. A patient with end-stage COPD who wanted to die at home but was too sick for transfer. Finally, an unidentified woman found in cardiac arrest whose return to spontaneous circulation came under the weight of my frantic, inexperienced chest compressions. Her condition deteriorated 30 minutes later. This time, despite repeated efforts, her pulse could not be maintained.“I would like everyone to take a moment of silence,” the attending said, “to respect and honor the life this woman has lived. We do not know who she is or who her loved ones are. We are her family right now.”Later, I thanked the attending. She knitted her brow, looking slightly perplexed. I explained that it was my first code and that it had been meaningful to see compassion in the face of such stress. “Ah, well, that's just how I do things,” she said, her expression softening, “So often in the ED our patients are alone in their deaths, and we're all that they have.”I pursued a career in medicine knowing I would have to face my longtime adversary and somehow broker peace between us. Throughout my training, I have perseverated over what it means to have a “good death.” Every day since early March, I have stumbled over the paradox of whether one can die a good death in a pandemic. When my medical school sent out a list of volunteer opportunities for students to assist with COVID-19 efforts, one in particular stood out to me. Critical care physicians, with the assistance of two medical students, had put together a virtual visitation effort for hospitalized patients and their families. Given the limitations on hospital visitation, the program's stated aim was to enhance connection among the family, care team, and patient by providing remote emotional and communications support. I grabbed at the chance.To date, I have spoken with more than a dozen families. I have cried with a woman whose brother was intubated in the ICU with COVID-19, afraid she would have to comfort him over the telephone. The patient's nurse brought a telephone to his room and conferenced the family in. His niece sang him a get-well song.“Your team has been so communicative,” the husband of another patient said to me on our third call. In a different time, his wife would have had multiple visitors a day. He continued, “It's been hard not to be able to visit her. I feel like I know you all, though. The care has felt so personal.” The sentiment of each family has been the same: Despite the distance, they have been made to feel as if they are present.Each afternoon, scanning my patients' charts for updates, I see new advanced care planning notes, pastoral care interventions, and social work outreach. Earlier this week, there was a long note from a resident detailing an early-morning comfort care conversation she had with a patient's daughter. They spoke about the family's faith and how it informed the guiding principles of the patient's life, as well as how to best make a decision consistent with the patient's values. The team FaceTimed the patient's daughter on one of their personal devices. She spoke to her mother and said goodbye. Her pastor was conferenced in to administer last rites. The patient quietly passed shortly after.To ask what it means to die—and what it means to die well—is fundamentally a human question.As a child, I thought that I was alone in this thinking. So many years ago, I was unable to apprehend these ever-present thoughts of mortality. It has been my medical education that has brought clarity to my own enduring anxiety. The role of the physician has always been one of guidance. Death, much like birth, requires careful shepherding. Our bodies have intrinsic ability for both but benefit from gentle facilitation. In this new era of distancing, medicine has been faced with the challenge of how to provide the solace, grace, and dignity that our patients both need and deserve. To be sure, this is a challenge that will continue as we move forward into an uncertain future. With this awareness has come a surprising peace: I will not avoid death, but neither will I be its passive bystander. Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania (S.R.Y.)Corresponding Author: Sophia R. Yapalater, BA, 3400 Civic Center Boulevard, Philadelphia, PA 19104; e-mail, sophia.[email protected]upenn.edu.This article was published at Annals.org on 16 June 2020. PreviousarticleNextarticle Advertisement Audio Reading - “Facing Death in a Pandemic” Audio. Michael A. Lacombe, MD, Annals Associate Editor, reads “Facing Death in a Pandemic” by Sophia R. Yapalater, BA Your browser does not support the audio element. Audio player progress bar Step backward in current audio track Play current audio trackPause current audio track Step forward in current audio track Mute current audio trackUnmute current audio track 00:00/ FiguresReferencesRelatedDetails Metrics 1 September 2020Volume 173, Issue 5Page: 401KeywordsAnxietyCOVID-19HeartMortalityNursesPatientsPregnancyRibsSuicideThorax ePublished: 16 June 2020 Issue Published: 1 September 2020 Copyright & PermissionsCopyright © 2020 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...