Saturday, April 18, 2020

People in Nursing homes, COVID-19 and Access to Intensive Care

As a disability studies scholar I am trying to understand some of patterns of life and death that are emerging from the COVID-19 pandemic, especially in relation to the precarities of long term care facilities such as nursing homes. The vulnerability of nursing homes was revealed in New Orleans during Hurricane Katrina where 100 nursing home residents died after being trapped or abandoned. New policies were passed following Katrina regarding the procedures for evacuation in an attempt to prevent similar tragedies from occurring. Though the pandemic is a different kind of threat, it is just as real and deadly as rising waters, and as with Katrina, the precarity of nursing home residents is once again being revealed in a time of crisis.

In March to April 2020, Pinecrest, a full to bursting 65-bed nursing facility in Bobcaygeon Ontario had 29 resident deaths a 44.6% mortality rate to COVID-19. The Life Care Center in Kirkland Washington in the United States was a facility with an estimated120 residents and had 37 deaths, a 30% mortality rate. The Life Care Center has now been fined over $600,000 and in danger of losing its license due to health violations found at the facility. At Residence Herron in Quebec 31 out of 150 residents have died so far, more than 20% mortality rate. One researcher, Nora Loreto, has found that so far as of mid-April over half the COVID deaths in Canada were in long term care or other types of residential facilities. In New Jersey, one nursing home asked for body bags on April 13th and it was found that 17 bodies were stacked in a tiny morgue meant to hold no more than four people.

At Pinecrest in Bobcaygeon, visitation at the facility was restricted on March 14th. The outbreak was reported to public health officials on March 18th by the nursing home administration. According to news reports, sick and healthy were not separated until two weeks later after 16 people had already died. The reason given by a staff at the home is that the home was too crowded to allow social isolation, with up to 4 people per room separated only by curtains. It was only when people began to die that space opened up to separate symptomatic residents from those who showed no symptoms: " ‘That's the reason why we actually have the space now. Because we've lost ... residents,’ said Sarah Gardiner, who has worked at the Pinecrest Nursing Home for 12 years.” (you can view Sarah Gardiner’s interview here). It is not just the residents of Pinecrest in Bobcageon that were endangered by the administrative decisions made from a distance. Over two dozen staff and volunteers from Pinecrest were infected with COVID-19 and one volunteer, Jean Pollock a spouse of one of the residents also died. Her husband Ted died a week later. An elderly woman Ruth Sheppard and her daughter with Down Syndrome, Tami Louise Sheppard (56) are among those residents who died at Pinecrest. When Tami Louis Sheppard’s father passed away her she was sent to live at Pinecrest because her mother could not care for her and then her mother eventually joined her at Pinecrest. A loving obituary for Tami Louise Sheppard can be found here.

Let’s step back and recognize that a 65-bed unit with bedrooms holding up to 4 people is far from an ideal long-term living situation. For anyone. Under any circumstance. It is not really a living situation at all, more like storage.
 Though many people move to residential facilities, urged to do so by family members, believing that such places are safer than their own homes, this is patently untrue. Just like any total institution as outlined by Erving Goffman in his book Asylums, such facilities limit individualized care, feature a lack of privacy, and increased vulnerability to physical and sexual violence. The increased risk of infection is merely one currently prominent sign of the vulnerabilities inherent in such institutional settings. In another layer of the structural inequalities of such places, the front-line workers are often face exploitationand unfair work conditions -- low-pay, given limited hours so the agencies don’t have to pay benefits. Capping hours below the levels where payment of benefits is required means that workers must work in multiple settings for multiple employers to make ends meet, extending the risk of infections as staff move between multiple facilities. Facilities with working and living conditions such has these are places particularly vulnerable to COVID-19.

Not only are some people in nursing homes not being given access to the hospital but less-acute patients are being released to long term care facilities to open up hospital beds, potentially exposing residents to people who have had COVID and who might still be contagious. This is also true of staff, who, at least at first, were being allowed to return to work after recovering but without any testing to confirm that there was no risk they might still be contagious. There has been some critique of the front-line staff, the ones who did not abandon the residents, the ones who worked crushing hours and experienced extreme understaffing – sometimes therewere as little as 4 people available to care for 60-something residents. Staff report they were not given appropriate nor sufficient protective materials and it is obvious there was inadequate leadership in this crisis situation until after far too many people had died. In addition, they faced backlash from people in the town – understandably frightened by the risk of infection but reacting initiating a kind of profiling. For example, in Bobcaygeon no one who was thought to have traveled abroad or worked in the nursing facility was allowed in the local grocery store. Someone from the store stood out front and refused admittance to anyone who they didn’t want to enter the store. Instead, a store employee was sent to retrieve groceries.

       "Immediately, we put someone at the front of our store, and we screen,” says Jessica    

       Strang, who runs the store with her husband Ken, whose parents owned it before        
       them.  “We ask them if they’ve been out of the country, near anyone who’s been out of 
       the country, or if they’ve been in contact with anyone from Pinecrest. And we got 
       backlash, saying, you can’t discriminate that way. And my defence (sic) there was, if 
       appropriate PPE (personal protective equipment) had been used, half their staff 
       wouldn’t have it. And it’s unfortunate, and it’s not their fault. But I am going to do 
       everything in my power to protect my staff, and my community that’s shopping in the 
       store. And that’s just how it is. I’m a firefighter. I run into medical calls myself, and we 
       have very strict PPE protocols in place. We have plenty of EMS and firefighters and 
       nurses who shop in our store. I’m not denying anyone. Unfortunately, Pinecrest did not 
       have those protocols in place. If someone from Pinecrest comes here, tell me what you 
       want, I will go in and shop it personally for you, and bring it to wherever. Call me."

Some of community members interviewed want to find someone to blame, and they call for investigations and inquests: “’Somebody brought it in from somewhere,’ said Pat Dunn, a City of Kawartha Lakes councilor.” Others focus on the extraordinary commitment of the Pinecrest health care workers and strategize best ways to support and help them and to advocate for better care and resources for residents and front-line workers. For example, City of Kawartha Lakes Councillor Kathleen Seymour-Fagan said “The PSWs and nurses that I’ve spoken to said there’s going to be PTSD afterwards because it’s so stressful,” she says. “It was such a mess because there was no staff there.” Miranda Ferrier, the president of an association representing personal support workers, emphasizes that staff needed training on presenting spread of infection but were not given adequate equipment. However, Pinecrest administrator Mary Carr stated that Pinecrest staff had proper protective equipment from the very beginning: “All staff, especially new team members, have been trained and oriented on the correct use of personal protective equipment (PPE) and our home has been fully stocked with PPE from day one. I want to thank our staff for being diligent and prioritizing the health and safety of our residents.” Whatever the status of protective equipment and it’s use, it is obvious is that the facility was severely understaffed during much of this crisis and this led to inadequate care for critically ill residents. Pinecrest eventually received outside assistance to ensure including extra staffing as from contracted workers from an agency called Extendicare Assist.

This leaves so many questions. Why were sick people not removed from the facility either to a hospital or even to a temporary hospital space that could have been erected outside the facility? Why was the attending physician advised not to go to the nursing home in person? ( you can see his interview here) Why were none of the residents ever removed to a hospital that would have enabled them to receive critical care including ventilation? In his interview, the attending doctor said the only thing that could be done was make people comfortable during their last days, but this is obviously not true, there were lots of things that could have been done to try to keep people alive. Removal to a hospital, intubation, and ventilation would be terrifying to someone with dementia, but isn’t this true for anyone no matter what the age and cognitive status? Isn’t that what those medications “to keep people comfortable” can be used for? To tranquilize people and minimize anxiety? We are seeing images all over the world of elderly people recovering and leaving hospitals. Why were the residents of the Pinecrest being refused hospital treatment that could include ventilation and resuscitation? Why were family members of people in Pinecrest told that hospitals had nothing to offer their loved ones? Why in other parts of the Canada are people being informed they are being preemptively denied the right to hospital treatment? One family in Calgary was told by the doctor that if their elder got sick “ ‘She would be denied emergency transfer in the event that she was deathly ill from COVID,’ ... ‘She would be denied access to an ICU. She would be kept in the care facility and treated to the best of their abilities there.’”

Pinecrest medical director Michelle Snarr: “emailed families on March 21, warning them they may have to decide on sending a loved one to the hospital or placing them on a ventilator — the latter of which Snarr said would likely cause a patient to ‘suffer a great deal,’ adding that they ‘may not survive.’" This is not a value-neutral statement, but rather one that appears to be discouraging family members from moving their loved ones to hospitals. Even though ventilation is certainly scary and uncomfortable, why was it was presented to family members as being something scarier than death, making the choice to fight for a loved one’s life equated with causing extreme suffering and emphasizing that that suffering would likely be in vain. I do not mean to minimize the risks or the realities of the questionable efficacy of ventilators for many COVID-19 patients. Most people with COVID-19 who are put on ventilators do not survive. Some would not survive and some may survive but be unable to exist without a ventilator in the future. It is also true that the quality of life of even those who were extubated may not be equal to life before experiencing ventilation, but again this is something that would vary according to individuals and should not be presented as the same blanket truth to all. Note that the people describing life on and after ventilation have not personally experienced either of these things and there are thousands of people who live their lives, sometimes for decades, while ventilated. Research has shown that nondisabled people, including medical professionals consistently underestimate the quality of life that disabled people experience. The notion that a life with ventilation is not worth living is an ableist imaginary, not something based on the actual experiences of people who use ventilators.

Why are elderly people and family members being told something so patently in contradiction to medical ethics and legalities of care? If people are not requesting Do Not Resuscitate orders (DNRs), indeed if people are refusing DNRs, why are they preemptively being refused care? This has been documented as occurring in both Canada and England. It has been threatened in the United States as well. In England people are getting letters letting them know that, should they need it, they will not be granted critical care. In the US, some states have announced their intentions to implement such policies but the Department of Health and Human Services warned medical professionals that this was an ethical and legal violation.

This has been referred to as medical triage but this term is misleading. Triage is defined as something that happens in emergent or battlefield situations where doctors assess patients one by one and make individual decisions that seem best at the moment based on resources available at the moment. This is something that has been reported to have taken place at the high of the pandemic curve in Italy and Spain. However, telling people who are not even sick that they will not be allowed access to a hospital or critical care or refusing to transport sick people, who did not sign a DNR, to hospitals is not triage. If it is not an individual or a designee making an individual decision about a single life – If it is an administrative decision being made at a distance and in advance to decide who deserves a chance at life and who does not, then it is not triage or even rationing. It is social engineering -- It is eugenics.


Acknowledgements: My thanks to Mary Egan, Ravi Malhotra and others who don't wish to be named for their comments and suggestions.

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