I work as a physician in two small nursing homes in the Galilee. The first is on Kibbutz Yas‘ur, while the other, Beit Eliezer, which is reserved exclusively for Holocaust survivors, is in the city of Maalot-Tarshiha. Our provision of safety for residents has come at some cost to their quality of life. Allow me to share the turbulent odyssey our teams have experienced and coped with during the pandemic.
Rachel was a lucid, strong-willed centenarian resident of the kibbutz nursing home. Her children were no longer alive, but she had two doting twin granddaughters whom she herself had raised. I witnessed an example of her determination a few years ago, after she fell and sprained her wrist. Rather than rest as recommended, she turned up for occupational therapy the next day, deliberately using her wrist to weave a basket. Unfortunately, in early March she fell ill from a cause unrelated to COVID-19.
This was at the time when people in Israel began getting ill with the virus. Initially, I presumed that the coronavirus was simply a flu variant. However, disturbing reports within Israel and detailed first person accounts out of Italy and New York convinced me that this was a new and dangerous disease. More concerning was that data from Western countries began to show that, as compared to the regular population, nursing home residents were at increased risk of both catching and dying from the virus. The experience of Kirkland LifeCare in Seattle in March exemplified the danger: 80 out of 120 residents contracted the virus, and 35 of them died. Forty-seven of the 180 workers were likewise infected. I quickly came to appreciate the virus’s potential ferocity within a nursing home.
This rampant internal disease spread should not come as a surprise. While it was more likely to occur in institutions that did not implement adequate infection control policies, it was not confined to them. COVID-19 can be mercurial. Furthermore, for work-routine reasons, a nursing home is typically ill-equipped to prevent a highly contagious disease from spreading within its walls. Draconian policies, such as forbidding family visits, were a consequence of recognizing this.
Fortunately, the kibbutz nursing home administrator caught on early to the disease’s potential severity. She immediately obtained gowns and masks, mandated their use, and implemented social distancing and hygiene protocols. This contrasts with early examples of virus infiltration and its associated high mortality in nursing homes in America and elsewhere, where, for one reason or another, social distancing was not implemented, adequate protective gear was unavailable, or use of it was not enforced. Our head nurse addressed the issues of both care-worker safety and adaptation to the new protocols, including social distancing while at home. Consequently, we had none of the COVID-19-related absenteeism, illness, or viral infiltration that has been an exacerbating problem elsewhere.
The changes nursing homes have had to undergo to contain the virus interfere with applying basic principles of compassionate and competent healthcare. For example, wearing masks while talking with confused residents, or those with dementia, especially those with visual or hearing problems, impedes the effective communication essential for provision of optimal care.
Keeping absent families appraised of their loved ones’ situation was another challenge. After reading reports out of Italy and the US that some institutions did not update family members even about viral infestation, we were determined to handle the issue differently. In the kibbutz nursing home, where I am the only physician, I began initiating calls to the main family caregivers and providing them with regular updates, such as reporting some routine lab results rather than just abnormal ones. Other staff have augmented this family-oriented approach by facilitating family video chats with the residents. A group WhatsApp family forum allows notifications to be sent to all relevant family members simultaneously, including video clips of activities and more frequent updates than in pre-pandemic times. Tablets and cellphones have become a substitute for direct contact, with staff members inadvertently becoming technophiles. As families reconciled themselves to this new reality, they expressed gratitude both for the safety we provided and for the digital communication alternative.
The Beit Eliezer nursing home was established years ago by a German family committed to helping Holocaust victims, and with time it evolved into a full-fledged non-profit organization. Though the remaining Holocaust survivors are all physiologically and emotionally frail, they cling to life with the same dogged determination that helped them contend with Nazi oppression in their youth. It is, however, unlikely that any of them would survive exposure to the coronavirus.
Beit Eliezer’s care workers are compassionate German volunteers, who live in a dormitory adjacent to the residence. To decrease the risk of viral infiltration, the administration sealed off the nursing home at the start of the pandemic. Only one physician could come and go, and all care workers were required to stay onsite,
A case in point is Aharon, who, at 90, is intermittently confused and suffers from numerous medical problems. He still experiences vivid nightmares from his youth that do not respond to sleep medication. He eats best when his children visit and feed him. Under COVID-19, however, that option is forbidden for now, and he has lost some weight and vitality as a result. In fact, he can be quite aggressive, which is not in keeping with his pre-pandemic behavior. To an outsiderת the mild deterioration in behavior might not be perceived as important, but, for his family, the change is significant, especially because of Holocaust sensitivity to food and eating. Nonetheless, his family, like the others, has accepted the isolation policy because they would be devastated if, after all their parents have been through, they were to end up dying of the coronavirus, rather than old age.
To return to the case of Rachel: by mid-March, just after COVID-19 struck, she was dying (not from the coronavirus). Her time had finally come. Family visits were forbidden at the time, but it seemed cruel to let her die without a family presence. We bent the rules. As a former children’s house, our nursing home has a rarely used side entrance adjacent to her room through which a visitor could enter without encountering anyone. When it became clear that death was imminent, we allowed the family to visit, though we did insist on mask-wearing and social distancing to prevent potential internal spread. With the family present until the end, we felt that they could properly part from her and she from them. Furthermore, in the absence of a traditional burial or mourning ritual, due to COVID-19, this was the right place for a little latitude.
The descriptions above depict a paradoxical situation in which the isolating measures essential to keep residents alive also inflict suffering on them and their families, even in a COVID-free nursing home. COVID-19 adaptations have qualitatively changed how day-to-day care is provided and how families interact with their loved ones. Until a better solution is found, health providers, families and residents will need to adjust to this new era. Our team challenge is to provide compassionate and professional care while adhering to infection-control measures. Such successful adaptation and the attainment of a reasonable modus vivendi when dealing with vulnerable nursing home residents suggests that flexibility and proper planning in other areas of society should similarly contain the virus sufficiently to allow the public to continue their routine.