I was examining an 85-year-old patient with moderate dementia who lives in a nursing home because she is no longer able to take care of herself independently. She is a loving mother and grandmother with three children who used to visit her regularly.
After the examination, I said what I often say: “You sound good.” That day she replied: “But what good is it?” Then she shook her head and started crying: “This is not how it is supposed to be.” She had not seen her family in two months.
The Centers for Medicare & Medicaid Services issued a rule in mid-March barring nursing homes from allowing families to visit residents, except in end-of-life situations. This rule made sense at the time and was started with the intention of stopping COVID-19 from entering into the nursing home and infecting the vulnerable patients who live there. The plan did not work, so why are we still holding onto it?
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Almost 70% of deaths from COVID-19 in the state where I live, Pennsylvania, have occurred in patients who live or work in nursing homes. Nationwide, this number is closer to 30%, though in 14 states more than half of all deaths from COVID-19 have occurred in persons living or working in nursing homes.
The plan to lock down nursing homes to eliminate any contact between those in live-in nursing homes and anyone from outside was formulated when COVID-19 was rare in the community. The idea that we might be able to keep it out of our facilities seemed plausible. As time passes though, the emotional pain experienced by residents and families who are unable to see each other steadily increases as the benefit from continuing such a policy diminishes.
Now that COVID-19 is common in the community, we know that it may enter the nursing home in many ways, only one of which is by families visiting.
Something that I have always been acutely aware of as a family doctor and geriatrician is that relationships are precious, and the time for those relationships is fleeting. A 90-year-old woman I took care of once told me: “Remember to tell those you love that you love them.”
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Long before COVID emerged, I tended to the death of many patients and advised many families. Under the best of circumstances, many of the patients whom I take care of in nursing homes might not be with us in six to 12 months. For many of my patients, family is what gives their life meaning. The pandemic policy, which does not accomplish its goal of keeping COVID-19 out of the nursing home, has no clear end in sight.
If this were the only way to keep our nursing homes safe, then we might have to weigh the difficult decision of how much it means for families to see one another against the need to protect them from infection. It is not the only way to keep our loved ones safe, though. We know better now. We have learned a lot about COVID-19 over the past two months. We need to move ahead so that our actions, informed by new knowledge, match our values.
Masks are effective at decreasing transmission rates. The recent Infectious Diseases Society of America's guidelines on protecting health care workers from COVID-19 clarified the enormous benefits of simple surgical face masks in protecting against infection. When both a patient and a clinician wear a mask (based on findings during the H1N1 influenza outbreak), even if one is infected, the transmission rate may be less than 0.5%.
We need to think about a sustainable protocol for family visitation in nursing homes. It won’t be what it used to be, but then again nothing is since COVID-19 started.
Instead of families visiting whenever they want — which could lead to many families crowding the building on Sunday afternoons — there could be assigned times for visitation with limits on the number of visitors at any one time. Visitors would be screened for signs and symptoms of illness. Visits could occur in a designated visitation room separate from where the residents live, and the room could be disinfected between each visit. The patient and family members would maintain social distancing, and everyone in the room would be required to wear a mask.
Using the most current understanding of how COVID-19 is transmitted, we have not just an opportunity but an obligation to restore a compassionate approach to protecting our older adults from COVID-19.
The next time I examine a patient and tell her “you sound good,” I'd like for her to be able to reply: “I’m happy to hear that.”
Neil Skolnik is associate director of the family medicine residency program at Abington Jefferson Health.