Medical professionals at Steere House in Providence talk about the physical and emotional toll of caring for the population hit hardest by the coronavirus: residents of nursing homes.
In her decades working in nursing homes, this was Donna Rondeau-Marzullo’s most difficult moment. On a recent Monday, she arrived at work knowing they had lost four souls to COVID-19 over the weekend. As the home’s nurse practitioner, Donna would have to fill out the death certificates.
Even in a world that deals with end of life, she had never experienced so much tragedy in a few short days.
This happened not long ago at Steere House, a gracious brick compound that serves 120 elderly not far from Rhode Island Hospital.
But the toll of the virus has been similar at dozens of the state’s 60 or so nursing homes. Around 75% of Rhode Island’s 800-plus virus deaths have been at long-term-care facilities, which house our most vulnerable.
Being both nonprofit and inner city, Steere House serves a mix of backgrounds. Most folks there have frailties requiring skilled care, with one ward catering to those with dementia.
It is challenging work, but Donna and her colleagues see it as a calling.
With most outside visits barred, the staffers have become the residents’ most present family, and the deaths have left them heartbroken.
Donna, 60, grew up in Pawtucket as one of nine children of a pipefitter dad and homemaker mom. Nursing homes have been her career.
As she walked this recent Monday toward the elevator, a fellow nurse approached her, mentioning one of the ladies who’d just passed away — an almost 10-year resident in her late 90s.
The woman had become a Steere House mainstay, and now, suddenly, because of COVID, she was gone.
Donna asked her colleague, “How are you holding up?”
The nurse said not well — she’d bought a plant for her backyard that she would call by the woman’s name to remember her by.
Then the colleague broke down. The deaths, she said, were almost too much to bear.
Donna wanted to console her, but both were in protective gear, and even a supportive embrace would be risky.
Besides, with some employees out on quarantine, both had a lot of work to cover.
Soon, the two parted, Donna heading to her office to fill out the four certificates.
Dr. Nadia Mujahid, in her late 30s, is one of the two main physicians now working at Steere House.
She was at her Pawtucket home on a recent Saturday with her physician husband and their two young children when a message told her one of the residents had developed a cough and needed oxygen.
Nadia knew the man’s advanced Parkinson’s and mild dementia put him at worrisome risk.
Immediately, she called an on-duty nurse via FaceTime so she could assess through a virtual visit.
Nadia’s years as a geriatrician have given her an instinct for the appearance of an elderly soul at end of life.
The gentleman, whom she knew well, was unconscious and breathing heavily — the virus had hit his lungs. His face had a telltale ashen look that alarmed her.
Things were grave.
Nadia felt she needed to call his family.
She reached his son, saying she was sorry, but his father likely had COVID and was nearing the need for end-of-life comfort.
The son was upset, asking how this could have happened.
Nadia understood. Families were already bereft at not seeing their loved one for months, then, suddenly, they’re hit with terrible news.
Nadia feels that her job, at times, is to absorb a family’s pain. She stayed on the phone, mostly listening.
Finally, she told the son that although regular visits were banned, Steere House had decided final goodbyes were important, and a family member would be allowed to do so in protective gear.
But in another twist of the choices loved ones face with COVID, the son had other health issues and worried he would be vulnerable.
“The public,” Nadia would later say, “has no idea what these families go through.”
Soon after, Nadia arranged a goodbye visit with the gentleman’s daughter, telling her it should happen soon, because with COVID, one never knows.
Donna Rondeau-Marzullo sat at her Steere House desk and took one of the single-page death certificate forms from a drawer.
She looked up the first woman’s final details on her computer chart and with a pen entered time of death, and then diagnosis.
The immediate cause was acute respiratory illness, but on the line below, she added COVID-19.
It only took five minutes to fill out.
As she finished, Donna thought: “There’s so much more to a person than that.”
This particular woman, in her late 90s, had still had a lot of life in her, and an edgy sense of humor. When Donna would ask how she was doing, she’d joke, “How the hell do you think? — I’m in here.”
The woman added a lot of personality to Steere House, and now, because of COVID, she was suddenly gone.
Briefly, Donna paused to collect herself, then moved on to the next death certificate.
Until recently, Dr. Nadia Mujahid had split her time as a gerontologist between Rhode Island Hospital and Steere House, but once COVID hit, she felt it best to focus just on the nursing home to avoid bringing in exposure from elsewhere.
So Steere House was now her world. It was a good fit. Nadia felt she was meant to be there at this time.
She was born in Pakistan to a family with a U.S. focus — her dad got a master’s degree at Stanford and her sister is a doctor in California.
After medical school in Pakistan, Nadia did a residency at Brown, then a geriatric fellowship here, coming to embrace Rhode Island as home.
In 2011, she began at Steere House, where she has lately been one of the two main physicians, along with Dr. Lynn McNicoll.
For two months after the virus surfaced, Steere House managed to stay free of it, a testament to stringent measures. Outsiders were barred, and each time staffers entered, they were asked about travel or exposure, and had their temperature checked.
But at a point before widespread testing, a staffer with no symptoms likely brought it in.
It turns out that even vulnerable elderly can be asymptomatic carriers — no temperature or cough. One or more picked it up. Nadia explains that those with dementia tend to wander, touching many surfaces. That’s likely how it suddenly spread.
To contain it, Steere stopped taking new residents and closed their 18-bed rehab center for short-termers being treated for things like falls and surgery.
The home is now down from its 120-person capacity to about 75 residents, with 30 or so isolated on a COVID-positive floor.
Ask Nadia the number they’ve lost, and she’ll simply say, “Too many.”
The state’s Department of Health says 20 to 25 Steere House residents have died of COVID — inexact because other conditions can make cause of death unclear.
Of the state’s 60 or so nursing homes, some have had only five or even zero COVID deaths. At the high end, a few have had more than 40.
But the majority, like Steere House, have had around 20, give or take.
Death rates are lower in the state’s dozen assisted-living facilities, where fewer residents have dementia or need constant care.
Nadia now does rounds at Steere House in full protective gear, including two masks that make her breathing labored.
But she will tell you the real heroes there are the CNAs who spend long hours in the hot zone feeding and cleaning residents suffering from the virus.
Because of dementia, says Nadia, some resist help, even aggressively at times. When you add that to the exhaustion of wearing protective gear all day, Nadia is in awe of how the CNAs maintain their loving attention.
It’s why Nadia embraces working at Steere House — she’s honored to be part of a team fighting for the residents despite risk and heartbreak.
Donna Rondeau-Marzullo moved on to the next death certificate, this one for a younger resident, a woman long debilitated by MS who had now succumbed to COVID.
Donna would miss her. The woman used to love the Steere House Wednesday bingo games and never complained about the hand that life had dealt her.
Donna wrote down the same cause of death — acute respiratory illness, triggered by COVID.
It got her thinking of another gentleman lost to the virus the week before. The two had a joking routine when they ran into each other. Donna would sing, “You Are My Sunshine” at fast tempo, and he’d dance with his walker.
Such small moments are why she chooses the work she does. The simple act of giving a smile to those in their final years, or weeks, gives the feeling of making a difference.
Although used to seeing folks pass on, Donna has found COVID particularly distressing, in the way it sucks the life out of older folks. They stop eating and drinking, and it gets to a point where even coughing is too much work.
That’s when the staff’s final role is simply to keep them comfortable.
Many families have orders to neither resuscitate nor hospitalize, since hopes are low and staying in Steere House gives the dignity of a familiar place with caregivers who are like family.
Often, knowing the time is near, a CNA there will sit for a long time holding a resident’s hand until the end.
On a recent typical day, Dr. Nadia Mujahid walked inside Steere House with her N95 mask and went through the ritual of having her temperature taken.
Then, preparing for the COVID floor, she put on another mask, face shield, surgical bonnet, glasses, two sets of gloves and a gown.
She wore no jewelry — one less set of items to wash after work to protect her family.
Nadia, a petite woman, had to talk loudly to be heard by the nurses through the masks and shield. Despite air-conditioning, she was soon perspiring. Her mask this day felt too tight, but she didn’t dare adjust it since touching the face area is risky.
She began rounds, never sitting. She feels that avoids picking up the virus on her gown.
As she went from room to room, Nadia spoke, even to the residents who were unconscious.
“How are you today?” she would say, adding the patients’ names. “I’m your doctor and I’m here to take care of you.”
She often touched their hands as she assessed them. Despite their dementia and even unconsciousness, Nadia felt that on some level, it conveyed a human presence.
Soon, she reached the room of the gentleman with Parkinson’s she had treated only days before by FaceTime.
She was gratified to know the man’s daughter had already visited. She’d heard it had been a lovely goodbye.
Nadia could see the gentleman’s time was now close. Despite the COVID, he was peaceful. Nadia was relieved that the medications she’d prescribed had left him comfortable instead of struggling.
In her line of work, that is at times her mission — helping patients pass away with dignity.
Nadia is a spiritual person, and before she left the room, in her heart, she offered a prayer, hoping he would move on without suffering.
Not long after, he did.
Donna Rondeau-Marzullo finished the four death certificates and brought them to the front desk to be given to funeral homes.
Then she began her long day of caring for patients while wearing full protection. As she worked, it struck her how many were sick with the virus — one after another.
But not all were grave. A few had voiced a half-joking nursing home complaint in this time of COVID: When could they stop being prisoners in their rooms and walk the facility again?
Donna took such frustrations as a good sign — perhaps they would survive COVID, as others here had.
Indeed, in the last few weeks, she has been filing out fewer certificates; a sign things might be improving.
But she knew this was far from over. Many of those here with the illness would be lost to it.
As nurse practitioner, Donna made a point of keeping her own emotions in check, even as she consoled colleagues.
Finally, at day’s end, she finished her shift and headed outside to her car.
She opened the hatch, took off her masks, changed her shoes and sanitized her hands.
As she got behind the wheel, she took a moment to lean back against the headrest.
She began to go over the day in her mind.
The sadness of filling out all those certificates sank in.
For long minutes, Donna sat there and wept.
Then she collected herself, pulled out of the lot and drove home.