Facing COVID in long-term care
Posted on Thursday, June 25, 2020
Dr. Alan Chaput was one of several health professionals deployed by The Ottawa Hospital to assist long term care facilities coping with COVID-19 outbreaks. We spoke with Dr. Chaput, Assistant Dean of Postgraduate Medical Education and an anaesthesiologist at TOH, about his experiences in an Ottawa long-term care facility where he was deployed in May and June.
You saw several long-term care residents who had COVID-19. What was their condition like?
There are many residents who were younger than I was expecting, but are living in a long-term care facility because they have chronic conditions that require a high level of care. I was pleasantly surprised to see that many of the residents that were infected with COVID were doing well and this included residents who had risk factors such as immunosuppression. That was reassuring. It should be noted, however, that at the time I arrived to work at this facility, a great many residents had already died of COVID infection, so my experience came after the worst of the outbreak.
The other thing that struck me was that I didn't see residents with active infection coughing and sneezing. Rather, infected residents were more likely to report loss of appetite, feeling unwell, a general sense of malaise and lack of energy. While these residents didn’t complain of feeling short of breath, and they don’t appear to have any difficulty breathing, they often have low blood oxygen levels, which in most cases responded well to low levels of supplemental oxygen. Residents requiring supplemental oxygen needed to be watched closely, however, because in some, there was a rapid deterioration in their status.
Do you speak with the residents about what would happen if they became severely ill with COVID-19?
Most definitely. If they were cognitively competent, we had a good discussion about what they wanted to have happen if things got worse. Did they want to be sent to hospital? If they were offered a breathing tube, would they want this? We had a realistic discussion about alternatives and possible outcomes related to different treatment decisions that they may face. For example, we know that the likelihood of full recovery after intubation/ventilation in COVID patients is quite low and outcomes are worse if you have certain other medical conditions or are elderly. So you can put this information into context for individual residents. If residents cannot make their own treatment decisions, we have that discussion with family.
How did the long-term care home deal with the fact that some of their residents were infected with COVID-19, while others were not?
In the long-term care facility where I worked, they tried to segregate residents as much as possible: a specific ward was for COVID-positive residents, and a separate ward on the same floor was a ‘spillover’ ward with a COVID-positive section and a COVID-negative section. I’ve seen COVID-negative and COVID-positive residents sharing rooms and sharing bathrooms – fortunately, this was quickly rectified soon after I started to work in this facility. Overall, COVID-negative residents on this floor were much more likely to contract the infection, and if they contracted it, were much more likely to become very sick with it than the average person. The COVID negative patients who lived on the floor were quite concerned about getting infected – they were literally surrounded by COVID-positive residents. All residents were acutely aware that several residents, many of whom they knew personally, died of COVID. Many residents reported to me that all they could think about was when they would get infected and if infected, whether or not they would die from the infection.
What is the relationship, between the residents and the staff?
The staff is fantastic. When I go in to see these residents, who haven’t had a whole lot of social interaction beyond the people who are looking after them, and I ask them: “Is there anything I can do for you?”, the vast majority of residents say: “No, it's just good enough that you're here. We're so glad you're here. You and all the staff are here to help us.” The regular staff who usually work in the facility were very attentive to the residents. They were critical in helping us understand when there was a concern with any specific resident, since they knew them so well. This was important in helping us ensure rapid assessment and support.
How do the facilities in long-term care compare to the facilities in the hospital?
In general, we managed the residents on the COVID floor the same way we manage patients in a hospital ward. We rounded on everyone and whenever possible, we had the RN, RPN or one of the other regular staff round with us. In this way, we rapidly got to know each of the residents. What we quickly realized, however, was that we did not have access to the same level of medical support that we were used to having in the hospital. For example, vitals were often challenging to obtain because the machines were broken or unavailable. Additionally, information on a resident’s past medical history and medications was only available on the electronic record, which could only be accessed in a central nursing station (to get there, we had to remove all personal protective equipment and we tried to avoid doing this as much as possible to minimize our own risk of infection). Additionally, although blood tests and limited x-rays could be ordered, it took a long time to get results. When oxygen was required, it was not immediately available as it had to be ordered from an outside company by ordering an oxygen concentrator. So often, an oxygen concentrator would be borrowed from a resident who no longer needed it because residents could not tolerate any delays in starting oxygen therapy. If a new medication needed to be ordered, the order had to be sent to an outside pharmacy and could take 1-2 days before it was delivered and initiated. Early on, it was recognized that there was a need to have a palliative care drug box available because it was critical to start these medications as soon as possible when a resident was deemed to be end of life.
I wonder how you feel about the difficulty of people being isolated and potentially being very sick and dying without their loved ones, versus the harm that would come by having loved ones come and potentially spreading the disease?
That is a question without an easy answer. We need to balance the needs of a dying resident and those of their family against the need to protect society as a whole. I’ve seen how devastating this disease can be to many different individuals. There is no way to accurately predict who will get mild symptoms versus who will die. As such, we need to be hypervigilant to protect who we can from potential infection. In my opinion, exposing the family member of a resident to a ward full of COVID-positive residents does not justify the risks, even when that resident is in their final hours or days of their life. Part of my role in the long-term care facilities has been to ensure that patients in the end stages of life receive appropriate end of life care, including administration of medications that minimize suffering. I hope that family members take comfort in knowing this was being done for their loved ones.