While much of the world is waiting on tenterhooks for the Pfizer and Moderna vaccines to be administered en masse and hopefully work their magic, we are still reeling from the many dangers and harmful effects of COVID-19.
Among the consequences of the COVID-19 pandemic is the havoc it causes to nursing home staffing. Boring though this issue may sound, it nonetheless interferes with the smooth behind-the-scenes running of nursing homes. As the rate of infection in the community rises, more and more people who have contracted COVID-19 or have been exposed to positive contacts are obliged to go into isolation and not report for work. Fewer people are now willing to seek employment as health aides, as nursing homes are deemed perilous. Nursing homes are likewise reluctant to hire new and inexperienced people during this particularly demanding and dangerous period. Finally, as governments have tended to provide generous compensation for those laid off because of the pandemic, potential aides are less eager to seek out work. The resulting shortage of aides can lead to the inexorable dilemma of either being short staffed or allowing staff members to return to work before they have completed their official isolation period.
A short time ago we faced this dilemma in our nursing home. A worker who had been hospitalized for reasons unrelated to COVID-19 and was recuperating in voluntary isolation at home, asked to return to work. Policy dictated that we allow her to return only after a negative COVID-19 test result, but, as she was asymptomatic and staffing problems were pressing, she was allowed to come back to work after doing the test, but before receiving the results.
This turned out to be a mistake, as the test revealed her to be positive for COVID-19; she was sent home and the nursing home went into lock-down.
At this time, coincidentally, two residents, Amos and Carlos, happened to be running fevers. Neither case suggested COVID-19 or hospital referral, but because of possible contact with the infected health aide we had to assume the worst, and, in accordance with Ministry of Health policy, refer both of them to hospital for urgent COVID-19 assessment. Amos’s three children opposed their father’s hospital referral. When he had arrived at the nursing home three and a half years before, at the age of 91, he was in poor shape. Both his cognitive and medical situation had gradually improved and then stabilized in our institution, and his children were now loath to risk undermining his condition. However, as nursing home physician and medical director, I had to take into account not just Amos’s wellbeing but also the welfare of the entire institution. This exemplifies another COVID-related nursing home quandary: what may be best for the institution is not necessarily best for a particular resident.
By the middle of the night we had learned, to our relief, that both men were COVID negative.
Nonetheless, both were hospitalized. In Carlos’s case, the cause of the fever was never found, and it went away on its own. While in hospital, however, he developed an unrelated medical problem that required investigation, and he remained hospitalized both because of COVID precautions and for further investigation.
In Amos’s case, after a CT, a definitive diagnosis for his fever was found, which incongruously did not in any way correlate with his presenting symptoms. It was treated effectively by doctors on the ward. Once the medical problem had been addressed and his isolation period was over, he returned to the nursing home in relatively good health, apart from an unaddressed breathing problem.
To me it was no surprise that his medical condition (i.e., his breathing) had destabilized while in hospital. After working in nursing homes for many years I have come to a conclusion which, although not research based, I believe to be true: On the one hand, hospitals’ diagnostic and treatment options are superior to those of a nursing home, as physicians are specifically trained to deal with the diseases they treat in their department, and Amos, for example, received excellent appropriate care for the medical condition with which he had been diagnosed. On the other hand, it may well be that having their medical problems actively investigated and treated in an unfamiliar hospital milieu is not the best solution for vulnerable nursing home residents.
The problem in my view is not which is better – treatment at the nursing home or hospital referral – but rather a matter of individualization.
My question would be: “In a given situation with a specific resident, which approach is more likely to lead to a favorable outcome?” The hospital approach is to pursue medical problems actively and treat them exigently: even a low threshold abnormality can initiate an investigation. However, while sophisticated hospital-based investigations and treatment offer more options for improvement, hospital interventions are also associated with a higher rate of complications.
In contrast – or perhaps in complement – the nursing home approach is often to ride out a storm rather than meet it head on. After all, in many instances, if there are new-onset medical problems, or even deterioration, given the state of many institutionalized geriatric patients, no cure-oriented intervention may be available, or the residents may not be able to tolerate the surgical or medical treatment necessary to “improve” their lot. The nursing home threshold for medical investigation and treatment is therefore higher than that of the hospital and is often based on different parameters, such as a decreased level of alertness or even diminished appetite. While it is true that some problems will escalate if unidentified and untreated, others appear to go away, or at least not destabilize the patient. As it is, many nursing home residents have long-standing abnormal laboratory results that are “normal” for them and which may fluctuate periodically without any deterioration in their overall condition.
Furthermore, especially when dealing with debilitated and frail patients, who, even on their better days, are not doing that well, I have come to believe that attentive and individualized basic nursing-aide-type care often counts for more than sophisticated medical treatment in hospital. Nursing home staff know their patients well. When assisting with eating, showering or other basic functions, the aides are trained to treat the residents individually and encourage them to do what they can on their own, helping them only when needed and accommodating their preferences. When performed caringly and professionally, these actions can in themselves become as therapeutic as an effective medication, and residents, even confused ones, feel cared for. This level of care cannot normally be provided in a hospital, where the nursing staff does not know the patients well enough. Also, in a hospital, precedence is generally given to traditional nursing procedures such as measuring blood pressure, carrying out tests and administering medication, with high-level provision of the basics given lower priority. Another important nursing home factor is one of long-term trust: If, after numerous earlier positive interactions and storms weathered successfully together, the resident and his / her family consider the overall nursing home care level to be reliable and reputable, the resulting ambience of trust can also have a powerful therapeutic effect. It is true that the reputation of the hospital may also inspire trust in the residents and their families. However, this “medical” reputation, in the case of a debilitated elderly patient, may well be less relevant than the department’s standard of basic nursing care.
Returning to Amos, his breathing problem was severe enough to warrant our notifying his children. As this problem had occurred while he was in hospital, I concluded that we should not send him back there. Instead, we would provide him with supplemental oxygen – though initially this was only partially effective – and a high dose of TLC – tender loving care and see what happened. To our relief, his condition gradually improved: within two days his oxygen levels became acceptable, and they later improved to the point where he needed no more supplemental O2.
Then there was the problem of visitation. As we were in lock-down, we were not allowing family visits. However, it seemed unreasonable and untenable that on the one hand I was warning the family that their father’s condition was unstable, with no reassuring solution to offer, while on the other forbidding a family visit. Moreover, Amos’s daughter had been permitted to visit him regularly while he was hospitalized. Consequently, we made an exception, as we do periodically; the daughter could visit provided she was masked, gowned and kept her distance.
The corollary would be misconstrued if the reader were to conclude that medical interventions and referral to hospital are unnecessary. However, I do believe that, while a standardized interventionist approach will typically work best when dealing with a relatively young and healthy person suffering from a precisely defined problem, things are not so clear cut where elderly and debilitated nursing home residents with an unclear diagnosis are concerned. The nursing home physician must seek out the most appropriate trade-off between superior state-of-the-art medical intervention and treatment, which can be somewhat risky for a nursing home resident, versus the limited but individualized use of medical resources augmented by optimal personalized nursing and supportive care in a safe and familiar milieu. This decision is further complicated by the fact that families, and often the patients themselves, generally have their own preferences, which do not always agree with those of the physician.
In Amos’s case there was no choice but to refer him to hospital. However, in general, given the complexity and ramifications of making a less favorable choice, the decision to refer or not to refer a nursing home resident to hospital should not be made automatically, but, rather, with deliberation. In addition, even though the final decision is ultimately the physician’s, when possible, the family’s and / or patient’s preference should be elicited before that final decision is reached.
One other health worker, who had driven to work with the first positive contact, went on to contract the virus. Given that no residents came down with the disease, our assumption is that, while both staff members had been meticulously careful at work, they were perhaps less so on their way there. Though COVID behavior can be capricious, and while luck may play a role, I still surmise that the spread of the virus to the nursing home residents was prevented thanks to the now routine strict adherence to the draconian protective measures we had implemented.
It is these well-nigh impossible recurring predicaments that have led me to support the present mass vaccination policy. The vaccine’s development has been rushed, it uses a new technique, its long-term effects are still unclear and there are many other unanswered questions – but we have seen the terrible damage the pandemic is inflicting on our society and on its most vulnerable members in particular. This, in my view, justifies accepting the vaccine, even within a context of some uncertainty.