It was my first day back in the hospital since the COVID-19 pandemic began. Because of the long hiatus, I felt like a brand new third year, lost and struggling to get a handle on the medicine service. During rounds, I was scrambling just to write notes and learn all the patients, but I paused when I saw Mr. K. He was in his 30s, not much older than I, but his skin clung to his bones, and his pallid face seemed hollow. The darkness under his eyes gave the impression of a fatigue that belied his years.
Mr. K had been admitted with dehydration and malnutrition secondary to diarrhea in the setting of HIV. During his stay, he developed refeeding syndrome. When the resulting electrolyte imbalances paved the way for cardiac arrhythmias, he coded twice in the ICU. The care team managed to bring him back each time, but not without consequence; the brutality of numerous cycles of CPR left him with multiple rib fractures, inflicting him with sharp pain every breath.
Two days after his last code, I tapped on the glass door of his ICU room during pre-rounds. He was watching the sun start to come up over the mountains into what was still a dark blue sky. He looked so small in that vast ICU room, taking up less space than all the equipment he was attached to.
I approached the edge of his bed and told him that his electrolyte levels were still too low for us to move him out of the ICU. Tears quickly filled his sunken eyes. He buried his face in his hands.
“I can’t be here anymore. I need to leave. I will leave.”
Over the next few days, our care team spent more time by Mr. K’s bedside than with any other patient, exploring his desire to leave against medical advice (AMA). His discomfort and determination to leave only grew though. Each time I saw him, the weight of his anxiety was more and more apparent in the dark circles under his eyes, in the way he stared into the void of his empty room.
As his anxiety was intensifying, my team’s patience was waning. The residents, already worn ragged by the toll of COVID, were tired of pleading with Mr. K to stay at least another 24 hours under our care, tired of explaining the severity of his illness, tired of reiterating why it was so dangerous for him to leave the safety of the ICU.
As clinicians, we become frustrated when our patients want to leave AMA. We cannot fathom why a patient would not want to take care of themselves or at least allow us to take care of them. Our tendency is to focus on educating the patient of the severity of their illness and the necessity of treatment.
As with Mr. K, though, many of these patients fully understand their illness process and the need for hospitalization. We are sometimes unable to step back from the intricacies of adjusting electrolyte disturbances or after the stress of running a code to recognize that a patient is suffering from something we are not addressing.
When I think of Mr. K and of many of the other patients I’ve seen leave AMA, I can recognize the fear. I can recognize the dire loneliness that only comes from severe illness. It is the unique anxiety that comes from being sick and isolated in the hospital, away from both the comforts and constants of life outside of the hospital.
This anxiety is highly visible in COVID-19 patients. In fact, it has become recognized as part of COVID-19 care recommendations that this anxiety must be addressed to support the patient and improve their care. However, despite multiple studies showing the value in addressing the psychological needs of patients with other conditions, we do not regularly extend this support to our general hospitalized population. The consequences of not doing so can include increased risk of mortality, physical disability, post-traumatic stress disorder, or the decision to leave AMA and not continue with any treatment.
Late that week, I headed to Mr. K’s room to attend a meeting regarding his treatment plan. When I walked in the door, I was taken aback by a transformation. His parents sat in chairs next to his bedside, and, with their arrival, the whole atmosphere had changed.
The cold cell of an ICU room now radiated the warmth and comfort of a room pictured in Southern Living magazine. Mr. K lounged against pillows from home on a bed covered with patchwork quilts. He still looked exhausted, but there was a light in his eyes now as the attending began the discussion.
“Your electrolyte levels continue to dip despite our efforts to replace them and give you appropriate nutrition. You’re still not ready to leave the ICU.”
Mr. K looked at his mother and simply shook his head with grief, his eyes too tired to fill with tears. Our team expected him to demand to leave again, perhaps with the support of his parents. At this point, Mr. K could easily articulate how his deficits in magnesium, potassium and phosphate could cause another electrical abnormality in his heart and lead to death, but this knowledge didn’t seem enough to overcome the anxiety he experienced stuck in the ICU. Our team watched in silence, waiting for Mr. K’s refusal, but instead we heard something else.
“Son, I know it is hard being here. I hate that we can’t be here with you all the time. But please don’t leave. I watched them beat on your chest to keep you alive, and I can’t bear for you to go through that again.”
Mr. K’s father had always been a quiet figure in the room each time he visited. His emotional plea was raw and heavy, but it came from a place of boundless love for his son. With it came Mr. K’s willingness to stay in the ICU. Each day after that he appeared stronger, more resilient, bolstered by the support of his parents and the therapeutic alliance with his care team.
Though Mr. K did not have COVID-19, the emotional distress of his severe illness and the isolation were similar. As a medical student learning during this pandemic, I’m continually asking myself what I will take away from this strange and haunting period. With the backdrop of the global isolation we have all felt to an extent during this year, the ups and downs of Mr. K’s journey highlight the need to be more intentional about assessing the psychosocial needs of any hospitalized patient, COVID-19 or not, especially in light of the new restrictions on family visiting. Though we must provide diagnostic and therapeutic care, we must also be vigilant about recognizing emotional distress in our patients and thinking creatively about addressing it.
Image credit: ICU lobby (CC BY-NC-ND 2.0) by TheVeganPsychonaut