Nursing Home Care and COVID 19

“Our thinking and actions are being challenged in this new “COVID–WORLD”. Remember this is easy for no one.”

Nursing Home Care and COVID 19

Dr. Diarmuid O'Shea 

President of The Irish Gerontological Society

Over the past few months everyone has worked extremely hard to tackle the global pandemic that has arrived at our door.  There has been much talk of swabs, testing, illness, comorbidities, cocooning, ventilators, nursing homes, death and bereavement.  The constant change, the pace of change, and the uncertainty, has made work in the COVID 19 world challenging, exhausting and concerning for all.  Supports and treatment for COVID-19, and other forms of resource allocation associated with this crisis, must be based on need.  The need in the nursing home sector is great.    

With nearly 50% of the recorded deaths from COVID 19 to date occurring in nursing home residents, this brings an increasing focus on the investment, supports and services being made available to the staff and patients who live and work in nursing homes.  There is a range of residents in nursing homes, from those that are relatively independent to those that require full support and care with all activities of daily living.   Depending on their comorbidities, dependency levels, chronic illness, and for some dementia and frailty, these residents can be more vulnerable should they contract any viral or bacterial infection.   COVID 19 is a new virus that none of us is immune to.  Even with all the protective measures we are taking it is hard, at times, not to feel like a “sitting duck”.     

There is a variety of reasons that a person chooses to live in a nursing home.  Over time, connections and relationships evolve between the staff, the person themselves, and their families.  Near the onset of this pandemic nursing homes took decisive and early action to reduce or suspend visiting.  At unprecedented times like this, when visiting has been suspended, appropriately, for nearly six weeks, additional stresses and strains occur.   These are not easy times on the staff, the families of patients and the patients themselves, and naturally leaves people worried and concerned.

As has been said by many, trust in the professionals running the nursing homes and the people providing the care is important.  So too is access to the advice and services of the local crisis management teams, public heath, occupational health and infection control advisors.  For the health care workers themselves the access to prioritized testing and personal protective equipment is an “absolute priority”.   The challenges and needs of those working and living in the nursing home sector are now very much on the agenda of our National Public Health Emergency Team and Minister of Health, Simon Harris.   This central leadership and guidance can only work if local services implement and deliver the plans tailored to the needs of the local nursing homes in their communities.  The supports outlined above, now being put in place, in addition to the HSE COVID-19 Updates and the Clinical Programme for Older Persons, are vital. 

Wellbeing, life planning, illness and end of life care have and will always be part of residents’ individual care plans in a nursing home - and more challenging in unprecedented times like this.  On that background, we all appreciate the need for the volume and variety of supports that is required – from addressing staff shortages, access to testing, availability of personal protective equipment to the health and wellbeing of staff. 

Nursing Home Transfers to Acute Hospital

Any nursing home resident who requires hospital care is being referred to the acute hospital, after discussion with their GP and the staff who know them best, where this is appropriate and where there will be a clinical benefit.    In the context of many illnesses, including COVID 19, many residents are managed appropriately and well with expert and supportive care, including their end-of-life care in their place of residence and will not require transfer.  In certain circumstances it is appropriate to admit a person from a nursing home to an acute hospital.  It is important that the life plan and stated wishes of the person, in terms of their own advanced care and end of life care plans, are part of this decision making process. For many nursing home residents these discussions will have occurred and been documented long before the issue of COVID 19 arose.   However, a resident’s clinical context dictates such decisions.   Getting the balance right between doing everything that is technically feasible – but clinically and ethically appropriate to improve quality of care at end of life - is not always easy.  Subjecting a person to a non-beneficial treatment – one given with little or no hope of having any effect – is the opposite of compassionate end of life care.   The responses around the country with the development of innovative and new ways to support the Medical Officers, GPs and Directors of Nursing Homes by the Geriatricians, Advanced Nurse Practitioners, Emergency Care Physicians, Palliative Care, Pyschiatry of Old Age Services and Public Health among others is truly breathtaking and admirable, given everything else that is going on. 

At the Minister of Health’s request, The Health Information and Quality Assurance (HIQA) team is to look at nursing homes again.  I hope they outline and document the additional significant inputs being provided to the nursing home sector during this pandemic.  I hope they record the unmet needs identified for future reflection and direction, so that we can all learn together how to improve and develop the care and services required in the nursing home sector after this pandemic has passed.  They should then update the robust care standards in line with evolving national and international knowledge and developments in the care of older people in nursing homes.  We should ensure that the experience gained during this pandemic is used as a resource to further advocate for improved investment and services delivery for older people across the country.  Our soon to be appointed new government should start with a new dedicated Minister for Older People that has a cross departmental and societal reach.

Uphold dignity, respect and compassion 

Consideration, compassion and kindness are qualities that are always important, now more so than ever.  We should spare a thought for each other, the patients, and the families of patients, both in our communities and in our nursing homes.  Striving to uphold the dignity, respect and compassion that we all wish for each other over the course of our lives conflicts with some of the things we are seeing happening around the world now.  We need to continue to grow a culture in our country that upholds this dignity, respect and compassion for each other over the course of our lives.  Let Ireland lead by example, and be a beacon of hope for the post pandemic recovery ahead.

I would like to thank the many frontline workers sincerely, including heath care professionals, for their contribution, commitment and most of all for the compassion they are showing to those in their care, be it in our community or in our nursing homes.

There is no doubt that our thinking and actions are being challenged in this new “COVID–WORLD”. Remember this is easy for no one.