COMMENTARY: COVID-19 Diary Day 3: Facing the Prospect of Dying Alone

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APRIL 07, 2020 -- This is the week. As of yesterday, Monday, April 6, Rhode Island has 1082 cases; 109 people are in the hospital, with 37 in intensive care units and 26 intubated. Twenty-seven people have died. For weeks, Governor Gina Raimondo has told us that the numbers will continue to go up: more infections, more hospitalizations, and more deaths. We're now beginning to experience this.

What that means for my institution, Lifespan Cancer Institute, and the faculty, fellows, staff, and patients greatly worries me. I've been telling my own patients that we intend to continue operating as normally as we can. This means treatments as scheduled, visits as necessary (with most moved to the virtual space), and normal operating hours, including on Saturday. COVID-19 may be in Providence, but it's not like cancer will take a holiday. To that point, my clinic remains busy. This week, for example, I saw eight people dealing with a new cancer diagnosis; most of them I saw alone because of visitor restrictions. For the first time, I wasn't sure if the sadness staring back at me was due to cancer or the fact that the patient had to face it alone.

Late last week our leadership met to create Plan B: How would we manage our patients and practices if the surge occurred? The house staff would be deployed to the medical and surgical floors to care for the very sick. We would be expected to staff the inpatient services ourselves.

Yet it raised more questions than it answered:

  • Could we ensure that the oncology floor would be kept COVID-19 free?

  • Would everyone be expected to do inpatient services?

  • Who would assume the care of patients with cancer who were also COVID-19 exposed?

  • What happens if we get sick, and would those of us with young families be given a place to live so as not to expose them?

We were dealing with staffing of four infusion sites and two hospital inpatient services. We decided that our fellows would help staff the inpatient wards, working with our hospitalist oncologist. The outpatient attendings would staff all consults, doing 1 week at a time. But given that some have greater risks for severe infection, we would not have physicians over 60 or those with severe comorbidities in the rotation; instead, they would form the backbone of our clinics.

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This schedule was thrown together in a matter of days. It was not lost on any of us that it rested upon one very shaky assumption: that everyone would remain healthy and able to work. If more than one of us got sick, the schedule would need to be redone, with fewer people able to cover. As for our inpatient service, our institution recognized the need to have a COVID-19-free service. Still, given the high numbers expected on the general medicine wards, we would admit those with cancer and COVID-19; they just won't be allowed on the floor. Instead, they will be admitted to those floors designated as "COVID-19" under oncology.

This means that there is no way that I can prevent possible exposures for my friends and colleagues. We will simply have to do our best. Still, as the surge starts, I feel like we're in a good position to make sure our patients are cared for. My team is on board, and the camaraderie among us has never been greater.

With staffing and logistics planned, I take a minute to think about my personal situation. If—or perhaps I should say when—this starts and I am pulled into service, caring for patients on our COVID-19-positve floors or the field hospitals being set up around the state, where should I stay? Do I come home and run the risk that COVID-19 comes home with me, or do I take a more cautious approach and move to Providence until the situation improves?

My head tells me to move out. There really isn't an option to quarantine myself at home, and it would be far easier on everyone if I dealt with this in Providence. But what stops me is the darkest possible outcome: What if I get really sick? COVID-19 seems to be worse in men compared with women, and preexisting conditions—I have asthma—can mean a rougher time as well. What if I get so sick that I need to be hospitalized, moved to an intensive care unit, and wind up intubated? I would have lost any chance of saying goodbye to my family. There is a chance I'd never see them again. There is a chance I would die alone, like so many others already have.

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I try to convince myself that it's not likely to happen. I know that the vast majority of those infected have mild symptoms. I also know that of those who are hospitalized, only the minority require life support. But if a life spent treating cancer has taught me anything, it's that nothing is guaranteed.

Still, I made an oath when I became a doctor. I'm determined to keep it.

Don S. Dizon, MD, is an oncologist who specializes in women's cancers. He is the director of women's cancers at Lifespan Cancer Institute and director of medical oncology at Rhode Island Hospital.

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