Covid-19 has represented a mere drop in the ocean, setting off a rippling effect touching nearly every aspect of human existence. Tenets of our society have been radically altered, leaving many questioning where we go from here. The Covid-19 pandemic has magnified the glaring faults within our healthcare system. In my nearly 10 years as a registered nurse, I have grown accustomed to the culture of the United States healthcare system. We thrive in a system based on excess, better equipment and medications, technological advancements, stronger innovations. We do this all for one thing, longevity of life. A system based on urgent excess breeds an environment where great age equates with success. In this system, however, quality of life suffers to the point of nonexistence.

 

Emergency medicine serves a distinct purpose in our healthcare system, saving patients from the brink of death. Covid-19 has ransacked and brutalized the respiratory status of many, yet emergency and critical care medicine offered them a chance at life. However, a chance at living does not equate to a life fulfilled. While many beat the virus utilizing our advanced medical treatments, they are left weaker than before they entered the hospital.

Our medical culture’s failure to discuss end of life and goals of care leads to futile and morally distressing situations. The pandemic has exacerbated our inability to hold important, potentially life-altering conversations with patients and families. At the beginning of the outbreak, Italy struggled ethically in choosing who to place on ventilators, and who would be given a chance to live. America feared the same would occur here while many hospitals braced for impact and prepared for mass casualty protocols.

 

In cases of patients with multiple comorbidities, great age, or immunocompromising conditions, contracting the virus puts them at a great disadvantage. Nonetheless, our healthcare system pushes medicine to the brink and patients with it. Covid-19 has required prolonged ventilator use, causing patients to become gravely deconditioned and weak. Many require the placement of tracheostomies and feeding tubes, to help them survive. Some face even greater complications from the virus: strokes, heart attacks, and amputations. Those that beat the virus face a long and arduous path of rehabilitation, some may never fully recover, requiring skilled nursing facilities and long-term care.

 

During my nursing career, I have had periodic experience in taking care of patients with tracheostomies. However, as a result of the Covid-19 pandemic, my colleagues and I have seen a noticeable increase of these specialized patients. Tracheostomy patients are often confused and agitated from being on ventilator support and sedation for countless days. As their mental status clears, they may grow increasingly frustrated with the inability to communicate. Most have had the intrusive placement of a feeding tube that bypasses the swallowing mechanism. In many cases, patients must be restrained in order to protect them from accidentally removing their fragile airway. Without the support of family members at the bedside, patients grow more exasperated with their situation. While patients may improve, they live days and weeks confined to their bed, unable to speak or eat. Cases like this are growing progressively more common.

 

Our duty as nurses is to provide exceptional care to these patients, yet our minds and hearts grow weary as time passes.

 

The advancement of medicine in the United States has allowed patients opportunities at life that otherwise would have led to their demise. A decade of healthcare experience has permitted me to observe many positive benefits of our advanced system. However, I have also watched our offered medical treatments prolong the inevitable. My 10 years of nursing experience have taught me that our healthcare system strives to prevent the inevitability of death at every cost. The prevalent use of tracheostomy placement during the Covid-19 pandemic has reiterated our aversion to the dying process. Instead of admitting that our efforts have been exhausted, we choose to push the boundaries of medicine further. We offer invasive treatments that at times yield minimal benefits. We strip our patients of their autonomy because of our system’s inability to admit defeat. Healthcare fails to offer the most beneficial treatment of all, comfort and relief.

 

Initiating end of life conversations and discussing ramifications of prolonged ventilator use with patients and families may prevent difficult situations. Healthcare should never be done in vain, yet this is the experience of many. I implore healthcare providers of every caliber to educate patients and family members before it is too late. Our healthcare system is doing a grave disservice by not having transparent and honest conversations regarding prognosis and quality of life.

 

The state of Massachusetts did a commendable job attempting to flatten the curve and spread the transmission of the virus. In doing so, our hospitals were not overwhelmed like many of our counterparts. While this should be treated as a substantial, well-coordinated effort, our post- hospital facilities may now be overburdened. Due to the rising costs of healthcare, many nursing homes and skilled nursing facilities had to shutter their doors leaving limited availability for patients with special long-term needs. In 2019 alone, 20 nursing facilities closed, causing a nearly 1,900 long term bed loss. The state’s healthcare system having saved lives in the name of Covid-19 is seeing an abundance of tracheostomy patients. Such patients require long-term care facilities and intense rehabilitation, some will progress enough to eventually return home, while others live out their days in skilled nursing facilities.

 

With a massive loss of long-term care options, where will recovered Covid-19 patients requiring specialized care go? While our healthcare system prepared for a massive influx of critically ill inpatients, we did not prepare for the surge of recovered patients requiring post-hospital care. The surge may not be what we expected at all. We are ill prepared to absorb patients requiring long-term care and skilled nursing needs. Our convoluted healthcare system has forced key facilities into closure; we must now examine how to shoulder the burden of complex patients, otherwise we may experience what we sought to prevent at the beginning of this pandemic.

 

The importance of emergency medicine as well as critical care should not be dismissed. Triaging and treating urgent and critical situations are hallmarks of medicine in our country. Stabilizing patients in danger of dying from their illnesses and injuries is a necessity. However, after the initial crisis passes, patients often face an uphill battle. It is here that we must take pause but so often do not. The divergence of medicine lives in this opaque place. One path forges on with aggressive treatment and management, distancing patients from their true self. The other path halts, considers individualized goals of care and comfort. Unfortunately, in our healthcare climate the two do not often co-exist. The duality of emergency critical care medicine and palliative care fail to subsist. The consistent placement of tracheostomies appears to reiterate that trend. Creating a symbiotic relationship between emergency medicine and palliative care is paramount for the sustainability of our healthcare system.

 

I thought the Covid-19 pandemic would give palliative care the chance it so deserves. Unfortunately, most still associate palliative care with hospice and it carries a stigmatization of the dead and dying. The two are not synonymous and each deserve their own place in healthcare. Palliative care helps to clarify and support goals of care and patient wishes. In our system of great excess and medical uncertainty, palliative care helps steer the ship towards calmer waters.

 

Our healthcare’s inability to have frank dialogue with patients and family members may have set them up for more failure than Covid-19. As a nurse, I am concerned we will be unable to support these patients in our current healthcare climate. Would having more transparent conversations with patients and families have changed the course of treatment? As healthcare providers we do not need to do better, we have to do better. Our fragile healthcare system and the patients it cares for cannot sustain the current path.

 

Covid-19 may be the catalyst of the collapse of our healthcare system as we know it. Our flaws have been exposed; I fear those most vulnerable are the patients we care for — the very reason we entered this profession in the first place.