a recent study. Over 3,000 were still hospitalized; 553 had died.
More than 800, like Ms. Toro, remained on ventilators. Many physicians in hard-hit hospitals have grown concerned that a substantial number of critically ill patients with Covid-19 seem to reach a “Twilight Zone” status — their lungs not improving.
“What are you going to do with these people? Where will they go? Will they get better?” asked Dr. Mangala Narasimhan, a regional director for intensive care at Northwell. Given the limited understanding of the new disease, doctors disagree about how to care for patients who might survive with prolonged treatment but could be chronically critically ill or have serious lasting medical issues.
Three days before Ms. Rendón came to the hospital, several relatives joined what one physician, Dr. Eric P. Gottesman, head of the intensive care unit, described as a “goals of care” call. Ms. Toro was sedated and not in pain, Dr. Gottesman told them. But after keeping her on a breathing machine for two weeks, he said, “we’re having a hard time ventilating her — getting the gases, kind of the exhaust of the body, out.”
The physician listed the efforts he and his colleagues had made: several medications, an experimental treatment and repositioning Ms. Toro to help improve her oxygen levels. “Still,” he said, “we haven’t been able to get her lungs any better.” They were very stiff, he continued, “like an old sponge that won’t work anymore.”
If Ms. Toro recovered, Dr. Gottesman cautioned, “she is going to need a lot of help and probably won’t be anywhere near to what she was before.” Then he added, “We need to discuss what we should do from here and what she would want.”
A Pillar of Her Family
On the trip back to Colombia in late February, Ms. Toro stayed in a rented house with about two dozen other family members who now live in the United States. They went on mountain hikes, attended a baby shower and visited the grave of Ms. Toro’s eldest son, who died two years ago, according to family members.
Ms. Toro, Ms. Rendón and her 18-month-old, Matias, returned to New York on March 8. Matias soon developed a runny nose and diarrhea. The next week, Ms. Toro was unwell, losing her appetite and feeling fatigued, with what she assumed was a nagging cold. Ms. Rendón, while cleaning the apartment with bleach, remarked that she could not smell it or taste the salmon she had cooked, common symptoms of the virus.
Being sick was unusual for Ms. Toro, who had seven children and more than a dozen grandchildren. She took medications for high blood pressure, a fast heartbeat and hypothyroidism but was robust.
She exercised with a set of weights, traveled to Colombia several times last year and went swimming in the Florida Keys. She had so much energy, flying up the steps to the third-story Queens apartment, and was so quick to turn out food from the kitchen that Ms. Rendón called her Abuela Cohete — Grandma Rocket.
She had grown up poor in Colombia, cleaning houses and doing laundry to help her widowed mother raise her 12 siblings. Her fortunes changed when she married a veterinarian, and the family had a large house with plenty of food. But her husband left, and Ms. Toro opened a small produce shop to support herself and their youngest children. Later, she helped raise most of her grandchildren, including Ms. Rendón, spoiling them with sweets from her store.
About a decade ago, Ms. Toro followed her eldest daughter, Martha Jaramillo, to Cape Coral, Fla. She helped care for Ms. Jaramillo’s mother-in-law, who has dementia, until she went to an assisted-living facility.
After that, Ms. Toro complained to Ms. Jaramillo, “I don’t have anyone who needs my help.” Then Ms. Rendón’s pregnancy presented the perfect opportunity. The grandmother headed north.
In Ms. Rendon’s small Queens apartment, Ms. Toro’s bed and belongings were tucked behind a living room curtain. She watched over Matias while Ms. Rendón worked inspecting accessories at an Oscar de la Renta warehouse and her husband stripped lead paint in the New York subways. Ms. Toro fed the little boy, crawled on the floor with him, took him to the park and lifted him up to the window over and over again to share his delight as the J train rumbled by.
Three times a week, she walked around the corner to pray at the Lluvias de Gracia church. She liked to say that everything she owned could fit in a suitcase, allowing her to move easily between family members, they recalled. Money mattered little to her. “Put God first and everything else will follow,” she told her relatives.
Within days of her first symptoms, Ms. Toro’s condition worsened. She did not want to go to a hospital because she feared catching the virus, family members said. But Ms. Rendón, 32, and her husband, 48, insisted she get attention, calling her doctor, whose office was closed, taking her to an urgent care center, which prescribed antibiotics, and bringing her to the Jamaica Hospital Medical Center. She was sent home because she had no fever.
On March 19, she developed one. “I feel very weak, dear,” she told her granddaughter.
The next evening, Ms. Rendón and her husband drove the older woman to North Shore hospital, just over the border from Queens. Mr. Valencia’s 16-year-old daughter tried to join Ms. Toro, who spoke only Spanish, to translate, but was not permitted in the emergency room. The three of them waited in the parking lot from 5 p.m. to almost 4 a.m., keeping in contact with Ms. Toro by phone.
She was admitted as an inpatient, and her family learned she tested positive for the coronavirus on March 22. During a call, though, she told her granddaughter that she did not believe she was infected. “God is not going to allow that virus to get to me,” she said, “but people come all covered up to see me.”
Beginning that week, North Shore was flooded with coronavirus patients. Across New York City, hospitals had a terrifying upswing in cases, and doctors were in distress as they tried to treat a disease with no cure that they did not understand.
Physicians ordered a CT scan of Ms. Toro’s chest, and the results were consistent with pneumonia caused by Covid-19, the report said, including scattered hazy patches that looked like ground glass.
Urgent Conversations
As far as her family knows or a review of her medical records by one of her doctors shows, Ms. Toro was not asked her wishes about what options to pursue — or avoid — if her condition deteriorated. The family had not discussed what decisions might lie ahead, several relatives said, because they initially believed she would recover.
In fact, Ms. Toro said she was feeling better at first. Soon, though, she sounded increasingly tired and short of breath on the phone. She told Ms. Jaramillo, the daughter in Florida, that she was hungry, but she could not communicate with staff members across the language barrier; they were bringing her food, but she was too weak to feed herself. Then she needed an oxygen mask, making it hard for her to speak by phone, and an X-ray indicated that the pneumonia was worsening.
At home, Matias peeked around the curtain in the living room, searching for his great-grandmother. “’Uuela, ’uela, ’uela,” he called, meaning “grandma” — the way he always greeted her.
On April 2, about two weeks after she had come to the hospital, Ms. Toro’s oxygen levels declined to 85 percent — normal is in the 90s — and she was working harder to breathe, according to medical records reviewed by Dr. Gottesman. The medical team placed her on her stomach, a technique known as proning that sometimes improves oxygen levels in people with Covid-19. But the levels in her blood dropped further, to 75 percent, and then into the 60s, so she was turned over on her back.
An anesthesiologist placed a breathing tube in her airway, and she was moved to the intensive care unit. Doctors believed that she’d developed acute respiratory distress syndrome, or ARDS, and that it had progressed to a severe stage, Dr. Gottesman said.
Relatives had noticed that Ms. Rendón, a Spanish speaker, was overwhelmed by calls from the doctors and upset that she could not visit. “We feel powerless, because we want to be with her at this time,” Ms. Rendón later said.
So her aunt, Ms. Jaramillo, had taken over the decision-making in consultation with her siblings. Her husband, Esteban, who speaks English, coordinated calls between her and the rotating medical team caring for Ms. Toro, often translating for the family.
Three days after she went to the I.C.U., a resident doctor told relatives about what he called her “poor course” and “worsening ventilation status.” The call resulted in a do-not-resuscitate order being placed in her record, meaning that if Ms. Toro’s heart stopped she should not be revived. But Ms. Jaramillo was not yet ready to shift to what the doctor referred to as comfort care.
Her husband, a Junior Reserve Officers’ Training Corps instructor, was frustrated by what seemed like a lack of clarity in calls with doctors. What was comfort care? Mr. Jaramillo learned that it meant removing the ventilator, and that a family member could visit Ms. Toro’s bedside to say farewell. How much time would someone usually be given on a ventilator to show improvement? About two weeks, he recalled being told.
Most important, what were his mother-in-law’s chances? A doctor said he was not even sure Ms. Toro would survive the night. Mr. Jaramillo quickly arranged a group video call with a pastor, the family and Ms. Toro for what he feared might be a goodbye.
Ms. Rendón sat with her grandmother’s well-worn Bible, peering at an image on her laptop of the older woman, medicated and asleep, breathing rhythmically with a tube in her mouth. Family members took turns praying and speaking to Ms. Toro, tearfully telling her how much they loved her.
At the end of the nearly hourlong call on April 6, the family thanked the social worker who had connected them, Elisa Vicari, who was wearing a double mask, face shield and goggles. Not every social worker was comfortable going into the rooms of coronavirus patients. But Ms. Vicari, 33, was coming in on her days off to facilitate video chats and join family members for goodbyes — then happening almost daily.
“It’s a drop in the bucket compared to what these families need,” Ms. Vicari later said. “You can hear the pain and sadness in their voices.”
Dr. Gottesman and his colleagues continued with treatments they thought might help Ms. Toro. They had tried the antimalarial drug chloroquine as well as anakinra, typically prescribed for rheumatoid arthritis. Doctors placed a scope down her airway twice, to no avail, to check for blockages that might explain why it was so hard to ventilate her.
They now enlisted the palliative care team, which focused on comfort and end-of-life issues. One of its doctors spoke with the family the day of the video call to “assist in complicated decision-making,” a note in her chart said.
Ms. Toro’s illness affected only her lungs — “every other part of her body was working,” Dr. Gottesman later said — but her lungs were not improving.
‘One Last Hope’
On April 16, 10 days later, he and Ms. Vicari met in an I.C.U. office for the “goals of care” conference call with Ms. Toro’s family.
Preparing for the call, Dr. Gottesman told a reporter, “I’m giving her one last hope.” He had put Ms. Toro on a three-day course of high-dose steroids to try to help her lungs. Failing that, he and colleagues agreed, she should be taken off the ventilator. “If she does well, that’s great. If she doesn’t, we’ll support her that way, too.”
He said he was not planning to propose an option that might continue Ms. Toro’s life support but not restore her health, he believed, because her lungs probably had significant scarring.“She was an active, lively woman before this,” Ms. Vicari said. “I don’t know how in line that would be with her values.”
The option he referred to was a tracheostomy. A surgical opening in the neck, it can be fitted with a ventilator for patients who need longer-term or indefinite use of it, allowing the uncomfortable breathing tube to be removed from a patient’s mouth and throat.
That makes it easier to decrease sedation and try to wake patients up, though that can be difficult in those with the type of lung damage Ms. Toro appeared to have, Dr. Gottesman said. He added that they did best when sedated and kept still to allow the ventilator to work for them. North Shore, he said, had done relatively few of the procedures on coronavirus patients.
Intensive care specialists differ in their approaches to Covid-19 patients on ventilators, and have been debating what is most effective. “All over the city, there are a lot of discrepancies about tracheostomies and what to do,” said Dr. Narahsimhan, of Northwell.
At some hospitals, doctors perform the procedures frequently, often less than two weeks after a patient is put on a ventilator, believing they may shorten I.C.U. stays and improve chances of recovery. “I think it’s better care,” said Dr. Roopa Kohli-Seth, director of the Institute for Critical Care Medicine at Mt. Sinai.
But others, including one national surgery organization and the team caring for Ms. Toro, favor waiting “to see which direction people are going,” Dr. Narasimhan said. That was in part because the procedure, and the continuing care the tracheostomy required, risked exposing staff members to the virus. It was also because a significant proportion of the patients would die no matter what course was taken, she said.
Dr. Narahsimhan pointed out that it was difficult to find long-term care placement for patients with severe lung damage at the best of times. Inside the Northwell system, she said, there were discussions about creating its own long-term care facility, much as areas of its hospitals have been converted into intensive care units in recent weeks.
The hospital did not consider Ms. Toro a candidate for another treatment, using a heart-lung machine that allows those organs to rest. The resource-intensive therapy — called ECMO, for extracorporeal membrane oxygenation — was in short supply and reserved for younger patients, the hospital had decided, Dr. Gottesman said later. It was unlikely to help her lungs heal, he added.
Finally, the call began, with Ms. Toro’s relatives in the United States and Colombia joining in. “We’re really kind of in a bind,” Dr. Gottesman told them. “No matter what happens, she is not going to be an independent woman anymore.”
Ms. Vicari asked whether Ms. Toro had made her wishes clear, and Ms. Toro’s youngest daughter answered, sounding tearful as she spoke through a translator.
“She once told me that she wanted to go to sleep and for her heart to just turn off,” Andrea Rendón said, adding that her mother had told her, “I want to die before I’m a burden to you and for you to see me ill in a bed.”
Her older sister, Ms. Jaramillo, said their mother had had a similar conversation with her, saying she had “asked the Lord not to see herself lying on a bed suffering for a long time.”
The doctor and social worker looked at each other and nodded. “It sounds like both Carmen and the rest of the family is very spiritual and have a lot of faith in God,” Dr. Gottesman said.
The doctor proposed finishing the three-day course of steroids. If they did not work, as he suspected, he said, “I think that we should do what I think is medically correct and also sounds like the wishes of what Carmen would want and the rest of her family is, is maybe take her off the respirator, but make sure that she is not in pain and that she is very comfortable and that she will most likely pass fairly quickly, but very calmly and quietly.”
Ms. Jaramillo’s voice broke as she responded, “There isn’t anything else they can do for her?” Dr. Gottesman said, “We’ve tried everything that we can.”
Another daughter asked how dependent her mother would be if she lived.
“If she were to survive, she’d probably need oxygen,” Dr. Gottesman said. “She wouldn’t be able to breathe very much on her own. If she could walk — which we have to see after all the, you know, staying in bed for a long time — she’d need a lot of rehabilitation. And if she could walk, her lungs wouldn’t let her walk very far at all because she’d be too short of breath and she’d be basically a pulmonary cripple.”
That evening at home, Dr. Gottesman kept thinking about his patient, he recalled later, wondering what else might be done. The physician, 56, had devoted his career to treating diseases of the lungs and providing critical care in part because his father, a doctor, had died young from a blood clot in the lungs after he survived being struck by a car.
Dr. Gottesman was aware of a new study testing whether the blood plasma of survivors, which contains virus-fighting antibodies, might help people battling the disease. The next day, he asked if the family would be interested in having Ms. Toro participate.
“We’ll do anything to try to save her life,” Mr. Jaramillo told the doctor, after consulting with his wife. “Anything.”
That night, the family gathered for the daily online prayer session, using the Zoom app. The theme was victory. Ms. Rendón joined from her kitchen table in New York, praying and singing quietly, wiping tears and occasionally laughing as relatives shared memories. Her husband sat beside her, his arm behind the back of her chair.
Family members read passages about David and Goliath and gave testimonies. One woman said she had seen a news story about an older man discharged from a hospital after his battle with the virus. “All the doctors and the nurses were applauding,” Luz Arce, a niece, said. “There was music, and everyone was happy.”
“Can you imagine us going to pick her up and bringing her with us?” Ms. Rendón whispered to her husband.
She read to her family in Spanish from the Epistle of James: “Blessed is the man who remains steadfast under trial, for when he has stood the test he will receive the crown of life, which God has promised to those who love him.”
The next afternoon, a Saturday, Dr. Gottesman reported to the Jaramillos that the steroids had not worked. After discussions, he and colleagues had decided against the blood serum treatment, thinking it would not make a difference.
“Nothing’s working,” Dr. Gottesman later recalled telling them. “We should talk about when we want to take the tube out.” The family accepted what seemed inevitable, though there was no formal decision.
Finally, Ms. Rendón would be allowed to come to her grandmother’s bedside. “You were the soldier, strong for all of us,” one relative would say.
‘Open Your Eyes’
That Sunday, April 19, Dr. Gottesman took Ms. Rendón and her husband into the I.C.U. “It’s going to be a little scary,” he warned. “Everybody is on a respirator there.”
Ms. Rendón and her husband were brought to the hall window of her grandmother’s room. “You are the most noble and humble person I have ever met in my life,” Ms. Rendón said, speaking through the glass. “Open your eyes, my queen. Open your eyes.”
The medical team blocked the window and removed the ventilator while Ms. Rendón and her husband were helped into gowns. The Spanish praise music was readied on a computer tablet, to help Ms. Toro “have a smoother transition,” a staff member said.
The social worker, Ms. Vicari, made a Zoom call to Ms. Toro’s other family members, and went into the room with Ms. Rendón, her husband, Dr. Gottesman and a nurse.
Ms. Toro was breathing but unconscious, having received morphine, a sedative, and the anesthetic drug ketamine. He had not planned on giving her oxygen by mask or nasal tube, because she was sedated and he did not think she needed it for comfort. But the granddaughter requested it, thinking it might help keep her alive.
A chorus of voices rang out from the tablet greeting her, telling her how beautiful she was, thanking her, expressing love.
Ms. Rendón pleaded with God for her grandmother to live, even if it meant caring for her on a ventilator. In her mask, she leaned over and kissed Ms. Toro on the forehead. She stroked her face and arms and held her hands. She walked to the bottom of the bed, pulled back the covers and kissed her feet.
As voices rose in prayer, Carmen Evelia Toro’s breath slowed and, after about an hour, stopped.
Ms. Rendón stayed at her grandmother’s side, bent with grief, until the team gently said it was time to leave.
