The Parking Lot: End-of-Life Conversations in the Era of COVID-19

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“She was just up, walking, and jovial last week doctor,” Shauna told me less than an hour after I placed a central venous catheter into a large vein in her mother’s neck. Just shy of fifty years old, her mother, Jameela Carter, had discovered far too late that she had endometrial cancer.

By the time I met Jameela in the Emergency Department (ED), her cancer had made its home in every recess of her abdomen, traveling as far as her lungs, breasts, and possibly even her brain. A good majority of patients with her brand and degree of metastatic endometrial cancer had less than five years left to live. Having just discovered her cancer a month prior to meeting me, she was at a doctor’s appointment to follow up on her condition, when staff found her blood pressure to be low. Really low. Her systolic blood pressure (the top number) was in the 50s as opposed to 120, where it’s supposed to be. Worried that she wasn’t effectively getting blood to the rest of her body, her cancer clinic sent her to the ED.

Although her blood pressure stabilized in the ED, it was still far too low for comfort.

The possibility of her having an infection was at the forefront of our minds as we tried to figure out what was going on with her. Jameela underwent a CT scan with me and her nurses keeping a close eye on her blood pressure, ready to intervene if it dropped any further. Once we got her back to her room, she became increasingly tired and confused. We started giving her intravenous (IV) medication to keep her blood pressures up, but she needed a special kind of IV line to safely receive the high doses of medication she was requiring. That’s when one of the doctors on our team contacted Shauna to discuss the procedure Jameela would need to undergo to have the special IV line, called a central venous catheter (central line), inserted.

As I was getting ready to place the central line, a friend from the Surgery service found me: “She has a bowel perforation,” he said, “We’re talking about whether we can offer surgery given how high risk a patient she is and the prognosis of her cancer. It’s not looking like we’re going to go in though, just a heads up.” I nodded, scanning through her labs and noting to myself that she would be at a higher risk of bleeding during her central line placement.

“I’ll keep that in mind,” I said, “Any idea if her family is going to be able to come over to the ED?”

“Yeah, I’ll talk to them as well about our thoughts on the surgery and ask them to come in so you can speak with them in person.”

“Thanks!” I said. We readied ourselves to do the procedure, laid her back, monitored her breathing, and placed the line as quickly and precisely as possible. Seeing that she wasn’t breathing out carbon dioxide efficiently when we sat her back up afterwards, we placed her on a BiPAP machine. Every fifteen minutes, we checked her carbon dioxide levels, hoping she’d breathe better on her own with the least support possible. We knew that if she didn’t, she’d need a tube down her throat and a ventilator to help her breathe. For someone as sick as Jameela, we knew being on a ventilator may be permanent rather than temporary.

Placing a tube down her throat was a last resort: though it could help her breathe better, it could also mean she may never speak with her family again.

We were determined to avoid that eventuality for as long as we possibly could. With a hole in her bowel and a terrible infection, Jameela deserved a few moments with her family. I breathed a sigh of relief when her breathing improved on the BiPAP machine before my friend on the Surgery service stepped into the room to let me know that Shauna was on her way to the ED.

“I spoke with her daughter,” he said, “we’re not offering the surgery, but they still want us to do everything necessary to keep Ms. Carter alive.”

“Even if it means intubation?” I asked, fully aware than Jameela’s mild improvement in response to the BiPAP machine didn’t exclude her from requiring a tube down her throat in the near future.

“Yup, full code,” he said, referring to the fact that her family wanted Jameela to have chest compressions and ventilator-support if her heart or lungs stopped working appropriately.

“Okay,” I said, “Full code it is.”

Jameela’s blood pressure started dropping again. Her nurses came in, increasing her blood pressure medication as necessary to keep Jameela’s blood pressure high enough to get oxygen to the rest of her body. The speed at which we needed to increase her medication surprised us all. After an hour of monitoring, her blood pressure stabilized. And Shauna was waiting outside of the Emergency Department.

“Y’all got this?” I asked the nursing team in the room, since Jameela’s vital signs had been stabilized.

“Yeah, Pavitra, go ahead and update the family.”

“Thanks,” I stepped out of the room and walked through the waiting room, filled with sick patients: some were coughing, some were sleeping while they waited to be roomed in the medical core of the ED. I walked past our triage nurses working diligently to talk with every patient who had walked into the ED. I walked past security. And, finally, I walked right into the parking lot of the Emergency Department, where I first met Shauna.

It was dark outside, Shauna and her family pastor stood near a white car, Shauna stepped out of the driver’s seat when she saw me walk out of the ED, a worried expression on her face. I peeled the large industrial-grade respirator that protected me from COVID off of my face, smiling briefly in greeting before switching it out for a surgical mask instead. Shauna, I felt, deserved to catch a glimpse of the face that belonged to the doctor taking care of her sick mother.

“Hi, I’m Dr. Pavitra,” I introduced myself, my feet sore from spending the majority of my shift standing with Jameela while we examined, scanned, and stabilized her. I wished desperately we could sit down and have this conversation — this conversation about whether or not Jameela would make it through a hospital stay, what her cancer meant for her even if she did survive her current condition, and how Jameela would have wanted to spend the end of her life.

In the height of the COVID-19 pandemic, that was a luxury we did not have. Instead, we had a dark parking lot with puddles of water on the ground reflecting an ominous glow from the red sign reading “Emergency Department” that hung above me like a caption describing the last location in which Shauna’s mother would want to be.

“How’s my mother,” Shauna asked.

“Right now, she’s hanging in there — we’re working on supporting her blood pressure and breathing at this moment...and we’re trying to get her to an intensive care unit (ICU), where a team of critical care doctors can take care of her.”

“Thank god,” Shauna sighed in relief. My breath caught in my throat. Relaying bad news was never easy, but there was usually a quiet and calm room to sit in, sometimes a few bottles of water, always a box of tissues. Today, it was me, Shauna, her family’s pastor, and our masks.

“I wish we weren’t having this conversation out here in the parking lot,” I started hesitantly, looking around us before resigning myself to the fact that we didn’t have another space where we could have this discussion. “Can you tell me a little bit about what information you’ve heard about your mom’s condition?”

“Well, she has cancer in her uterus,” Shauna started, “we just found out 5 weeks ago, it was all very sudden. And, today, she just drastically got worse all of a sudden, I don’t even know how it happened. She was just up, walking, and jovial until last week doctor.”

I noticed a silver car pulling up in my periphery and instinctively shifted the three of us further away from the main doors to give us some privacy. “I understand,” I said, “Unfortunately, patients with the type of cancer your mom has can become very sick and it’s not always predictable how quickly that can happen.”

“The surgeon said it was real bad, like in her breast too,” Shauna relayed.

“Unfortunately, yes, it goes beyond her breast and is in her lungs and other parts of her body as well.”

“Her lungs?” Shauna asked. This was new information for her to grapple with.

A man opened the silver car’s door. “I got shot!,” he called out. I looked over at him. He was wildly waving his arms and his legs as he looked around, “Ma’am, I got shot!” I glanced back at Shauna before turning my attention to the man.

“Sir, we’ll get someone to help you immediately, just do me a favor and go inside — they can get you to a room,” I turned back to Shauna, but before I could continue our conversation, the man grew frustrated.

“Whatchu talkin’ ‘bout b****, I got f***ing shot in the leg and you’re tellin’ me to go inside, I got shot in the f***ing leg and she be like ‘GOOO inside,’” he yelled. I looked back over at him and noticed a slight darkening of his sweatpants over his right leg, though it was hard to make out whether it was blood under the dim lighting.

“There’s no need for language like that!” the pastor spoke up.

“It’s alright,” I said softly, positioning Shauna and the pastor further away from the car and placing myself between them and the man inside the vehicle, “Just give me one moment please.” Right as I was about to call for help, a security officer walked out.

“We’re going to get you a stretcher man and get you to the back alright?” he said.

“Geeeez, alright, I got shot,” the man in the car muttered. I thanked the security officer before turning back to Shauna.

“I’m sorry about that,” I apologized before resuming our conversation. “Yes, unfortunately your mother’s cancer is spread all over, including in her lungs.”

“I see,” Shauna said, tearing up. I held her hand, noting I had sanitized my own hands right before stepping out of the department.

“When my patients are this sick, I always encourage their loved ones to think about what they would have wanted for themselves, especially when it comes to how they would have wanted to live and how they would have wanted to go when it’s their time to go,” I started once Shauna had taken a moment to process the news about her mother’s cancer.

“Is it her time to go now? Does she look that bad?” Shauna tensed up.

“No, not right this moment, but she does look quite sick at this time. I want to make sure that during her hospitalization you’re not getting any calls at two o’clock in the morning asking you to make life and death decisions about Ms. Carter when you haven’t had a chance to think about what she may have wanted for herself. That’s why I bring this up now,” I said.

“Ah, I see,” Shauna said.

“And, even if she does make it through this hospitalization, it’s still important to consider what she would have wanted for herself because of how advanced her cancer is. Unless you or she tells us otherwise, we will do everything in our power to keep her alive — whether that means doing CPR if her heart stops or placing a tube down her throat to help her breathe even when she may never be able to have the tube taken out in the future.”

“Okay,” Shauna paused, “Do we need to do any of that now?”

“No, but earlier in the night your mom gave me a bit of a scare and we thought she may need a breathing tube placed for help. Luckily, she recovered without us having to do that, but a lot of my hesitancy came from whether or not she would have wanted that for herself. Of course, you all know her better, which is why I ask you to think about what she would have wanted.”

“Do you believe in miracles, doctor?” the family’s pastor asked.

“Absolutely,” I said, without missing a beat, “I’ve seen miracles and I do believe in them, but I’d be doing you all and Ms. Carter a disservice if I didn’t discuss the medical information I know with you today because the decisions you’re going to be asked to make are going to be medical decisions for Ms. Carter.”

Shauna paused for a moment in thought before speaking again. “Everything doctor,” she finally said softly, “Do everything.”

I nodded by head. “Okay, I said, I’ll pass that information along to the critical care doctors who will be taking care of her then,” I reassured her.

“You all do everything you can do and we’ll keep praying for a miracle and let the Lord do what he can do as well,” the pastor said as Shauna nodded, feeling the power in her pastor’s words.

“Yes, absolutely,” Shauna agreed, “Is there any way I can see her?”

I looked at Shauna, wishing I could unequivocally say ‘yes.’

I wanted so desperately to take her to her mother’s bedside, pull up some chairs and ask her and the pastor to sit by Jameela’s side and talk with her. I wanted to be able to tell them they could visit to their heart’s content and hold Jameela’s hands for as long as they wished to. Yet, in the height of a pandemic that remains unprecendented in many of our lifetimes, I was powerless to do so. Like most hospitals in this time, ours appropriately developed a strict no-visitor policy to keep our patients and the community safe. Sometimes, we made exceptions made for patients’ who were actively dying or who had died.

Jameela, I decided, fell into the former category: Bad infection, Worse cancer. Jameela, I knew, may never walk out of the hospital once she was moved to the ICU. Shauna may not have a day to sit by her side and hold her hand, but if she could have at least five minutes to see her mother again while she was alive and talking, I knew that I couldn’t be the person to deny her those precious moments.

“Okay,” I said. With a nurse’s help, we gave Shauna five minutes with her mother before walking her back outside and moving Jameela to the ICU, where she’d spend the rest of her hospital stay. Wheeling her into the elevator, I watched as the heavy chrome doors shut between her and our Emergency Department. I hoped that, against all odds, she’d be a miracle who makes it out of the hospital and has the chance to spend some more time up, walking, and jovial with her family before it would be her time to go.

Pavitra P. Krishnamani is an EM resident physician with a background in global health interested in innovating how we deliver healthcare to our patients at home and abroad. To learn more about her and her work, check out her website.

*Publish dates for articles discussing patient encounters are disparate from when the encounter actually occurred in order to protect patient privacy. Names, ages, and other encounter details are also modified to protect patient privacy.