HONORING DEATH: Clinician, Meinhard Kritzinger

Meinhard Kritzinger, MD ICU-Anesthesia (ITALY)  is a specialist in anesthesia and intensive care with diploma in tropical medicine and public health. He has trained in Austria, South Africa, Italy, America, and in several war zones working for MSF-Italy.
I am a consultant in Intensive Care Medicine and Anaesthesia working and living in South Tyrol, the northern most Italian province bordering Austria. We serve a population of 500.000 people with one large and four smaller hospitals, all with Intensive Care Unit (ICU) facilities. The experiences I will recount are based partly on my own experiences and experiences of fellow doctors working in the wards.
The 1990s was the last time that a special Italian law for infectious diseases was applied for the then new “AIDS epidemic. When HIV patients were admitted to hospital, they had to stay in a newly constructed unit which had negative pressure isolation rooms and closed doors. The rooms had glass panels facing balconies and the visitors could see their relatives through the glass window (55).
Since there were no real therapeutic options at this time, those patients did not have any contact with relatives or the outside world. Their families could only see them from the balconies through a closed and locked glass window. As knowledge about this disease improved, this inhumane practice was abandoned. Little did we know that 30 years later, this practice was to be reintroduced.
On the 31st of January 2020, a state of emergency was declared and a COVID task force, introduced by the Italian Ministry of Health, was created to handle the health emergency crisis and to govern all clinical decisions (56). End of February 2020 saw the beginning of a widespread lock-down following the disastrous spreading of the disease in the Province of Bergamo, situated 2 hours south of our hospital. There were dramatic pictures from the overflowing emergency departments and ICUs. The first cases in South Tyrol were diagnosed at the beginning of March with the peak around middle of April (57).
In the subsequent weeks the number of ICU beds was increased from 25 to 60. This was achieved by converting operation theatres to ICUs, and normal wards were converted to COVID only wards. Triage units were created and doctors from other departments such as dermatology, urology or ophthalmology found themselves in charge of newly admitted patients with almost daily differing case definitions and treatment protocols. Diagnostic pathways and responsibilities changed throughout the emergency, and doctors who never had seen a patient die under their care, had to face dying patients every day.
By the beginning of April, at the peak of the epidemic, sick patients were flown out to Germany and Austria. The daily death count reached 10 patients a day with 234 patients admitted to different hospitals in the region (58).
When caring for terminal patients in ICU we would normally invite family members to spend the last hours with their loved ones. Despite strict visitor regulations of only one close family member per patient and only close family, in such situations, makeshift rooms were creatied with privacy screens, so that family could accompany their loved one.
In the normal wards, family would be given ample space and possibility to talk to nurses and doctors while staying with the dying patient. Once the death had occurred, the corpse would be brought to the hospital chapel, where the deceased would be dressed and rested for 24 hours. This allows friends and family spend some time in prayer with the deceasedsince it is not customary to display the deceased in an open cask at the funeral in our region. The next day, the mortician would remove the body for the funeral, which takes place after a couple of days. Cremation is the exception since people like to see a coffin at the funeral and not an urn.
During the COVID epidemic ,a “no visitor” policy was strictly enforced by the task force for COVID but also non COVID patients. Doctors shifts were adjusted on daily basis as the workload dramatically increased. Changing diagnostic pathways and triage options left patients on the ward with a different doctor being responsible for them almost daily. Dermatologists and ophthalmologists, who had never cared for dying patients, let alone discuss terminal care faced difficult situations, as they were never trained in this area. Daily increasing patient numbers, uncertainty and fear to get infected decreased the time, that staff interacted with family and patients to the absolute minimum. Personal protection equipment with mask, gown and a triple layer of gloves did contribute to reduce any personal contact.
The majority of the COVID patients were elderly and they had to stay in an isolation room, deprived of human contact during their final hours. In contrast to people dying of other diseases, patients with COVID sometimes were lucid until the very end. They were well aware that they were suffering from a disease where no cure was known and they were about to die from it. Nursing staff even at the deathbed was reduced to a minimum for fear of contagion.
Not only did the patient have to die alone, sadly even family members were also left on their own. They could not leave their house as lock-down prohibited all movements so they could not even meet to mourn.
In addition, frequently an elderly spouse was left alone at home confused and startled by having to stay in quarantine, with their partner taken in an ambulance with people dressed in gowns and masks, only to have him or her back as ashes in an urn a week later.
Once the death had occurred, the corpses were undressed and soaked with disinfectant and zipped into a plastic body bag. There was no way any relative could see the deceased, nor was it possible to dress the body with clothing sent from the family.
Once the ashes were returned to the household, funerals were limited to 10 people attending and lasted for a couple of minutes only.
To alleviate their patients’ final hours, the nursing staff would sometimes stick printouts of photos of the family onto the surrounding walls, so that the patient could picture the presence of their loved ones in the room. In one case, a little dog was smuggled into the isolation unit for a quick farewell as this was the patients last wish. In other cases, the relatives could see their loved ones through a glass window standing on the balcony of the isolation unit. Even though the regulations were uniform in the whole province, they were only strictly adhered to in the main hospital. In the smaller hospitals, one family member with protective clothing could sit with their dying relative.
The provincial ethical committee was aware of this problem and on the 1st of April, they wrote an urgent letter to the task force regarding the increasing loneliness of the patients, the lack of patient’s involvement in therapeutic decisions and access to terminal care (Irmgard Spiess RN, Alessandro Felici MD, e-mail communication, April 2020). Unfortunately, this letter was never published nor did the task force respond to this letter.
It was as if regarding the dilemma of honouring death, the epidemic had abolished patient’s rights.