Melanie

Brief Outline:

Rhod was admitted to hospital in April 2020, and later transferred to the ICU unit where Melanie works. Rhod deteriorated on respiratory support (CPAP) such that he needed mechanical ventilation. Melanie was with him when he died. Melanie was interviewed for the study in December 2021.

Background:

Melanie and Rhod were members of the same church and longstanding friends. Rhod worked in the charity sector and was passionate about composing music for his church. Melanie works as a consultant nurse in the ICU ward that Rhod was admitted to.

More about me...

First symptoms/seeking help
Melanie’s long-time friend Rhod fell ill with Covid19 in April 2020. Little was known about the condition at the time. He worked in the charity sector and was a member of Melanie’s church, for which he composed and wrote music. Rhod lived alone and had many friends.

The first thing Melanie heard about Rhod being ill was in a virtual church meeting where they were asked to pray for Rhod. He had initially not believed that Covid was as serious a condition as it turned out to be, so it seemed to Melanie that when he developed symptoms he initially kept this to himself.

Next thing Melanie knew was that Rhod had been admitted to hospital and was discharged 48 hours later with oral antibiotics. Three days later, after another prayer meeting, a friend of Rhod asked to speak to Melanie. She told Melanie she had seen Rhod virtually and felt that he had deteriorated. Now about five or six days since the onset of his symptoms, he had called an ambulance. The paramedics had come, but gone again because he was on antibiotics, which they deemed sufficient. Melanie advised calling the ambulance again. That second ambulance took Rhod to hospital.

Admission to hospital

Rhod was re-admitted to the respiratory ward of the large (district general) hospital where Melanie works as a nurse consultant in the intensive care unit (ICU). At this time, Melanie remembers that she and her colleagues were just “facing each day as it came”, there was so much uncertainty that surrounded Covid and the rapidly changing situation. Melanie emphasises that nobody understood what was happening within ICUs, only those who were there. Colleagues would support each other not so much by talking, but rather by silently acknowledging the joint feelings of trauma. The only way to cope, she says, was not to talk about it. Melanie had kept a personal journal to contextualise what was going on, and what decisions she and her colleagues were making. From the day Rhod was admitted to hospital onwards, she was no longer able to write.

Communication on the ward

Rhod was struggling with his breathing, and was placed on CPAP (Continuous Positive Airway Pressure). He was in touch with Melanie and others through his phone and WhatsApp, which were crucial at this time. Many friends prayed for him. Although he mentioned that there was a sort of camaraderie between patients, all suffering from the same condition, Rhod was most in need of some social connection. All nurses on the ward were wearing PPE, which made this need all the more acute.

PPE shortages and visits to the ward

At the time, PPE supply was uncertain, which meant that it had to be rationed, and so it was not straightforward for Melanie to visit Rhod on the ward. Melanie was therefore aware that she could not go to the ward to see Rhod frequently, so made sure to be able to spend time with him when she did.

She described the visit: communication was difficult due to the loud noise of the various CPAP machines on the ward and due to PPE she was at the time was still learning to adapt to. Rhod’s bed was surrounded by various food gifts that friends had sent in. He did not like any of them particularly, but they at least countered some of the dryness in his mouth caused by the CPAP mask. Melanie brought Rhod a newspaper. Rhod tried to keep his mind active by doing the crosswords. Melanie found he was not quite the same as she had known him, possibly as he found it hard to sleep on the ward.

Admission to Intensive Care

During her day off, Melanie received a call from one of her colleagues who told her that Rhod had unfortunately deteriorated, and that he was to be admitted to ICU – the unit where Melanie also worked. Having seen several patients with Covid die on her ward, it was at this point that she realised that he may not survive.

In ICU, Rhod continued to be on the CPAP mask. Here he was given a light sedative to help him tolerate the machine, which helped his sleeping. He told Melanie he felt safe on the intensive care unit. He engaged in conversations with his clinical team.

Visiting Rhod on ICU

His admission to ICU made it easier for Melanie to see Rhod. She could now see him on all the days she was at work. Melanie sees this as a privilege, considering that many family members were unable to see their loved ones in ICU due to visitor restrictions. But she also found it difficult being both a friend and a nurse: Melanie was careful not to become the person who would comment on all things medical in the WhatsApp group with Rhod’s family and friends, not least because she felt that her realisation that Rhod may not survive was perhaps ahead of where others had got to at that point.

When Rhod deteriorated

Sadly, Rhod’s oxygen requirement continued to go up. He found it more and more difficult to see patients around him be intubated and proned, struggle and die. Rhod increasingly felt that he could not escape from this trauma. Although staff was aware of this, they could do little to shield patients from seeing this. Rhod asked to be placed in a side-room, but at this point side rooms were scarce, and his oxygen levels had dropped to a level at which it would have been unsafe to move him.

Melanie is grateful for having been able to care for Rhod. For instance, she helped arrange that the pressure ulcer that was forming on the bridge of his nose due to the pressure of the CPAP mask would be dressed. When he wrote down his last wishes, she received this note from him. She felt grateful that he trusted her with this. She emphasises that nothing was ideal, but it was as good as possible. Melanie is grateful to her colleagues for the professional way in which they cared for Rhod and how they got to know him as a person.

Despite all the efforts, Rhod continued to deteriorate and his doctors decided to intubate him. Rhod asked for Melanie to be present. She told her colleagues that she would be there not in a professional capacity but as his friend. Because this was the only space to be whilst the clinical staff was around Rhod’s bed, Melanie stood at the bottom of the bed and held his feet. The nurse in charge allowed everybody to get ready, and then asked them to step aside for five minutes, for Melanie and Rhod to have this time together. It was such “moments of insight and bravery” that mean a lot to Melanie, and that gave Melanie even more respect for her colleagues.

End-of-life visit

Days later, Melanie was at work when a consultant colleague asked her whether they could talk. Initially she thought it was about work, but soon realised that it was about how Rhod was doing, and that he was not doing well. Her colleague said, “Rhod is in trouble”. Melanie finished some urgent tasks and asked to spend time with him. As Rhod’s sister and his close friend were both shielding, neither of them were able to come in to see him. Melanie offered to hold the phone to his ear so that they could speak to him.

The nurse in charge initially said Melanie would not be allowed to be with Rhod if he did not invite her. Melanie thought she may be excluded from being with Rhod and found this difficult to hear. Reflecting on this moment, Melanie thinks this nurse possibly misunderstood how close she was to him, and that they had been friends over 30 years. It was the consultant who later invited Melanie to be part of the handover in which the clinical decisions about Rhod would be made, which she appreciated. She was able to hear with a professional hat on that they had done everything. She found this reassuring.

Melanie was then given some time with him. She sang a song to him. Only months later did she learn that all her colleagues stopped doing what they were doing and were silent whilst Melanie was with Rhod. Rhod died on full life-support. In some way, this was comforting, as this meant he could not have survived.

Looking back

At the time of the interview, there had not yet been a service for Rhod’s life. To Melanie, it still felt like ‘unfinished business’. Melanie had not talked about her experience of Rhod’s last days and death, as the ongoing work pressure had simply not allowed her time to do so without coming undone. Looking back, Melanie reflected that the bonds she had with colleagues became stronger through the experience of Rhod’s dying. She was aware of that it will have been hard for her colleagues to see her so broken over it. She felt supported by her family – her husband, daughter and granddaughter – who knew how to care for her throughout this difficult period.

A friend of Rhod’s was not happy that he was deteriorating and called the ambulance that admitted him to hospital.

And I guess the first I heard about Rhod was we had a, so we belonged to the same church, and we were at a meeting, a virtual meeting and they were asking for prayers for Rhod because he had Covid and was at home. And then the next thing I knew is that he’d got admitted to hospital but had again been discharged two days later just with oral antibiotics.

So, three days after that we had a prayer meeting at church and one of my friends texted and said, can I kind of talk to you straight after the meeting. And I said yes of course. And she phoned and she said that, thought that she’d seen Rhod that day virtually through the window, and she thought he’d really deteriorated. And he’d called the ambulance and the ambulance had come and they’d gone away again because he’d been admitted, was on antibiotics – and again we were all learning, we didn’t know the trajectory of this illness and how it would display going forward. So, I guess this was probably day five or six into his illness. And then, you know, she, she just said, I’m not happy that he’s not been admitted. So, I said, call the ambulance again and get them to go back again. Which they did that evening, and then he got admitted to hospital.

In her role as an intensive care nurse, Melanie advocated for more family visits wherever possible within the circumstances.

Can I ask one more professional question? So how did you see that patients were more delirious when family is absent? Does that make a difference to the degree to which patients are delirious?

I think the length of delirium and, for sure, and was more intense. And lasted longer. It's hard because it Covid is so complex and. Put that and also covered patients were with us for so much longer. I'm in trajectory was four to six weeks, whereas in an average length of stay is less than you know four to 10 days you know and so clearly they were going to get delirious just by default. But the severity and the duration. There's much, much more intense. So, when families could come in, you could see a change in the patient.

I was very much a champion of enabling families to visit because, they in themselves are therapy for patients. And when you're intubated, ventilated, sedated your, your mind is trying to make sense of what is going on and you don't know who you are, where you are. Even if your existing, and you know hearing people, familiar voices of those that you love kind of bring you back to reality and you know many times people have said as part of my role as following patients up after intensive care, many will say that they were drawn to a bright light. But a family member's voice drew them back and it made me think how many patients didn't ever hear a voice to draw them back. How many and so I was very. Wherever possible, we would try to get visitors to come before intubation and obviously end of life. But when patients were delirious like we needed families there to kind of bring them back to some degree of you know connection and but that that was a challenge throughout Covid.

Like how his lifelong friend and his sister were just relying on, not just, but were relying on phone calls. And we did do virtual visiting and…but it wasn’t the same as that human contact. For Rhod that physical contact was really important. And you didn’t even need to say anything; just your presence being next to someone that you love is enough. So, yeah that, that, that weighs heavy on my heart that so many families were not allowed to come in to see their loved ones.

Melanie sang to her friend Rhod when he was dying. Only later did she realise her colleagues in ICU had been listening and the impact of her grief on them.

I spoke to the consultant because they’d changed shifts, and I said, call, call me; don’t let him die on his own, call me and I’ll come back in. But I was still doing all my shifts as well, so it was like I don’t know how this is going to work but I’ll just manage it somehow. And I can remember going home and waiting for the call. And then I did get a call and the consultant said, there’s one more thing I think we can try. There was a new drug, tocil that had come out and he said, I think we can try this one more thing. Which they did do. But when I came in in the morning, I saw that his oxygen levels were still at 100 per cent and he was not making any improvements with the saturation, and actually visibly I could see that he was dying in front of us.

So, we had, like we had a morning handover where we would allocate where patients were going to be admitted to and where they were being discharged and where there were gaps. And we had that morning meeting and one of the nurses in charge of the pod, you know, I said that’s my friend and I want to be there and, you know, I’ve got consent to be there, she was quite like, well not if I don’t think so, not if I don’t think you should be there you won’t be there. I was like, sorry, like what, what, what, why do you think that you could possibly stop me. That really affected me, and I thought like I might be denied to see him. And I, I’ve never really been able to revisit that because it’s been a little bit too painful. But the same consultant that was on the Friday that spoke to me said, you know, we’re going to have handover medically, come and join us, come and listen to what our decisions are, be, be involved in that. I really valued that. I really valued sitting in the room. Again, it was a bit of a funny context, but, but to be able to hear it with a professional head and then know that they had done absolutely everything possible it was just so reassuring. And actually, you know, it, it was like an hour or so later that I was by his side.

And they didn’t need to withdraw treatment at all. He died on full life support. And I was there beforehand, and I was able to go in. And an agency nurse was looking after him, which again I think I was a little bit disappointed to begin with because I wanted it to be one of our own. But, you know, he was a lovely, lovely agency nurse and I said, I just need some time with him before. So, I went and again, you know, had full PPE on and everything, and I sang this song. And I hadn’t realised, because like the curtains were around and everyone was doing their busyness with their other patients, and I hadn’t realised till later, but they all stopped what they were doing and just listened. I probably wouldn’t have sung if I’d had known that. But like they just stopped, and they were all just silent, and I thought that was such a respectful thing to do. For them seeing me, I guess, because I was one of the leaders here, and you always put on a brave face and say, you know, we’ve got this, we can manage this, we’re in this together. But for them to witness me being so broken I think that, on top of everything else they were seeing, that was another layer of like trauma. And I hadn’t really appreciated that. I just did the thing I thought was right. [Crying] But to know that these people that you were trying to protect and trying to help, that you kind of I guess gave them more to deal with. And that was really tough.

Melanie was at work in the hospital when a consultant colleague asked to speak to her about her friend Rhod’s deterioration.

After he’d, he’d kind of given me his wishes so to speak, the very next day I was in. And it was, it was a Friday, and it was lunchtime, and I was in one of the offices just coordinating all the staff for that day, and it got to about lunchtime the consultant who was on for the unit came in and just said, oh can I talk. And I was like, yeah, yeah of course, because we have a very kind of close relationship. And he said, no I need to talk. So, I kind of knew by that look in this eyes that he was thinking that things were not really progressing in the right way. And he just said, you know, Rhod’s in trouble, I don’t know, I don’t think he’s going to survive. And I was thinking about this, thinking he’s my work colleague, he’s my friend, and how difficult that must have been for him to come in and, and say that, because he wanted to prepare me, but also, he knew I was in contact with everyone else. So, so like looking back that must have been really tough for him. But I’m so glad he did.

I then I can remember going home that night and just phoning the pastor from church saying, I don’t think Rhod’s going to make it. And that was a hard conversation because all of a sudden my worlds kind of mixed really: my professional world was going into my personal world, and, and like I was being professional but like I was still feeling it personally. So, it was a really kind of odd dynamic. But that was the right thing to do and that was what Rhod wanted.

And I spoke to his best friend, his lifelong friend, and I spoke to his sister. And she said, I want to talk to him, I want to, I want to come in. And of course, they were offered to come and visit, but his lifelong friend was shielding, as was his sister, so neither of them could come to see him, come to visit. And there was, you know, we were having some visiting. But I said, what I could do is I could take my phone to his ear, and she could talk to him through my phone. So, so that’s what we did on the Friday night. I took her, you know, virtually in with my phone and laid it by his side and she spoke to him and said what she wanted to say. And I, and I think that was really important; I think for her it was really important.

There was one particular song that he loved, and I’d go in every day and sing it. And now I, after she’d finished her call, I sang that song to him and then I went home.

Melanie was made aware of the PPE shortage, which meant she needed to restrict the amount of visits to her friend Rhod on the respiratory ward.

He was on a respiratory ward. He’d very quickly escalated to CPAP and was managing actually reasonably well with CPAP. He found it quite hard to manage to eat and drink without CPAP. He didn’t…wasn’t able to manage to have too many breaks, but he was okay. I guess one of the hard things for him was that he could see…he couldn’t see anyone. There were no visitors, there were no…he didn’t have any human contact, and the contact he did have was behind masks and shields and, you know, visors and PPE. And he really struggled with that kind of lack of social connection.

And I’d, my friend had texted me to say that he was on the respiratory ward so I asked if I could pop down to see him. And it was interesting because again at that time our PPE supply was quite variable, and so because we didn’t know the length of Covid, what, what was expected we were having to be really cautious about the use of PPE. And I was mindful of that going down to visit him, but equally I was equally, I was trying to balance the fact that he needed to see people.

Because he was texting; he would take pictures of himself and send it to our WhatsApp group and so we could see, but he just needed human connection. So, I went in, you know, I’m a senior nurse in the trust and I went in…

So, I kind of made negotiations with the ward if I could go down. And being a senior nurse in the trust I kind of thought I wouldn’t get too much opposition, but I did get quite a bit of opposition because they saw that it was not a good use of PPE for me to visit him. So, I recognised that I wouldn’t be able to visit him much. So, I kind of went to see him and he just spoke about the experience of CPAP mask and being in a bay with others and knowing that everyone had the same condition and feeling like there was a little bit of like camaraderie about that, like they were all in it together type of thing. He was managing and he was very aware of how much oxygen he was on and how much nutrition he was having, and so we just had some really nice sorts of conversations. And then I’d say, what do you want me to do. And he’d always say, can you bring the Times in. He was a big crossword fan. And he had a few deliveries from people to the hospital, so he knew that people were in contact.

And actually, the phone, you know, and WhatsApp was really crucial in keeping that contact in terms of his community, which was vast actually; he knew a lot of people, and that made a real difference.

So, I guess it challenged my thinking really in terms of rationing and about we were in this world where we really had to think very carefully obviously about exposure, but also about usage of PPE and balancing up the fact of social contact towards, you know, depletion of stock and stores for other patients. So, that was quite a challenge really.

Melanie was present when Rhod was intubated. She is grateful to her colleagues in ICU for the way they handled the situation.

When he became sick that day, when he’d given his, his like his wishes to me and my colleague was in charge of the pod, and they’d come to say they were going to intubate Rhod and he wanted me to be there. And so, I said, of course I will be there. And, and they were really senior anaesthetists like that had been moved from theatres to come and help us with intubation and proning. And our team became massive very short, in a very short space of time. And one of the senior anaesthetists said, I’m going to help with intubation, is that okay. And I’m like, yes of course it’s okay. And the team were around preparing for intubation and, and I just said, you know, Rhod wants me to be there, but I’m not here in a professional capacity, I’m here to be his friend. And so, the best place that I could be, because everything happens at the top end of the bed with intubation, the best place I could be was at the bottom end. And all I did was held his feet, and like he, he knew that I was holding his feet. And like he, so he only ever looked at me; he didn’t look either side, he was just about to look at me holding his feet. Which is like a really bizarre thing to do, you don’t normally hold your friend’s feet, but it was just the right, the only way I could have physical contact with him.

And so, and the team were just magnificent. Like, I know they are because I work with them, but when they’ve got your friend’s life in their hands like I, I totally trusted them, totally knew that they would do their absolute best, even though it’s in difficult circumstances. And we were seeing such horrors and traumas every day, and this was just yet another one. But they…and I shall always remember the nurse in charge of that pod; she was just magnificent. She allowed everyone to get themselves ready, and then she asked them to step aside and let me have just five minutes with him before he was intubated, and that again was so, so special. It’s just those moments of insight really and bravery, because, you know, there was bedlam everywhere. But just to have, to be able to stop the world just for five minutes was amazing. So, I shall always hold that memory.

Rhod saw patients around him suffer and deteriorate, but there was no way to escape it.

So, we were several days into, into ICU, and each day his oxygen requirements went up and his oxygen saturations became progressively lower. And I think he was seeing people in the bay around him deteriorating faster than he was and he was seeing patients intubated and seeing patients proned. And at one point, he had a bed by the window but at one point he just felt like he just couldn’t bear seeing the trauma anymore. And he couldn’t…even if he closed his eyes, he could still see it in his mind’s eye, and he felt there was no escape. He couldn’t…to begin with he was able to get out of bed, but then as the days progressed, he became weaker and weaker and wasn’t able to. And he felt like though it was a trauma that he was in and could do nothing about.

So, he spoke to one of the medical consultants and just said is there any way that he could be moved out of that room into a side room. But our, our need for side rooms is really great and we don’t have that many side rooms, and at that point his oxygen requirement was so high that it would have been unsafe to move him anyway.