Reflections of the corona pandemic from a nursing home physician’s view

I work as a physician in two Galilee nursing homes. Since the pandemic outbreak, the effect on the content and nature of my work has been dramatic and all-encompassing. 

Conceptually, like many others, initially I was not convinced that this was different from the flu. My conversion to appreciating its severity though, came quickly. In addition to reports out of Israel, I followed journalist and physician reporting as they appeared in The New York Times. 

In particular, the first-person reporting out of Italy and New York City, where ICU departments in well-run hospitals were overwhelmed with dizzying numbers of patients, many of whom were dying, convinced me that we were dealing with a new dangerous disease of which we knew little about.

Fortunately, my administrators caught on early to its potential severity. We immediately instituted use of gowns, masks, hygiene and social distancing. This early adherence should not be taken for granted. It required the administrations to abruptly allocate unbudgeted funding and implement unpopular policies long before the danger had sunk into the public minds. 

In contrast, in following reports out of US nursing homes, some of the early examples of virus infiltration and associated multiple deaths emanated from homes in which the administrations refused to purchase the supplies nor implement policies necessary to contain the virus.

As the pandemic unfolded, we were intent on implementing Health Ministry national guidelines. Dealing with almost daily, often inconsistent and sometimes unimplementable new ordinances, was challenging to say the least. To do so, the director, head nurse and I would review each new ordinance and decide together how best to implement it. Somehow we succeeded in muddling through the early pandemic period.

Professionally, almost every change required to contain the virus contradicted the principles of providing compassionate care to the elderly. Forbidding family visits, wearing masks when talking with residents who some at the best of time are disoriented, and maintaining physical distance were all anathema to what I had been taught and practiced for decades.

The required changes encumbered our work. While each change was easy to take in stride, their aggregate was wearisome, especially mask-wearing for hours. At times when I felt sorry for myself, I would give myself a sobering perspective by thinking of my colleague, a physician friend, who was working in a hospital on a corona ward. Since he had to use even more burdensome protective material and was at risk of contracting the virus, I realized that my lot was relatively easy and safe.

The main problem was not the awkwardness of work but rather preventing the virus from infesting the nursing home. From vivid and livid reports out of the US, Italy, France and Spain, I knew of the nursing home havoc and death the virus could cause. Statistics the world over began showing that a disproportionate number of corona patients were from nursing homes, and the nursing home death rate was higher than that of the public at large. Consequently, doing what we could to prevent the virus infiltration was and remains our primary mantra.

THE PANDEMIC fundamentally changed my work, especially during the early period. Between hospital reallocation of other departments to corona departments, de facto closure of community specialty clinics, fears of residents and their families and the inability of family members to accompany their loved ones during medical care, there was immense pressure to handle all medical problems within the confines of the nursing home. While my overall approach to dealing with frail nursing home residents has always been to limit outside referral, the pandemic required taking even more lonely responsibility on myself.

Another issue to deal with was the separation of residents from their families. Our policy has always been to encourage family awareness in resident care. My typical policy was to keep a family member informed when the patient’s condition worsened or a change in treatment planned.

When the pandemic became rampant, the reports out of Italy and the US said that family members were often kept in the dark even when the virus had invaded the nursing home and residents were dying. I was determined to handle thing differently. 

I began calling the main family caregivers and providing them with routine updates, even when there was not a new problem. As an example, I would initiate a phone call and report to a family member that we had ordered routine lab work for Dad, and the results were about the same as before. 

The rest of the administrative staff augmented this family-involving approach by being available when family members phoned, facilitating video chatting with the residents, maintaining an active WhatsApp family group, posting video clips of nursing home activities, and sending frequent regular nursing home updates – more than was done in the pre-corona days.

Sometimes rules need to be broken. Early in the pandemic, we had a veteran resident – a lucid determined woman who had earned the respect of everyone in the home – who was finally dying from a non-corona-related incurable cause. It seemed simply cruel to let her die without family preset. We decided to bend the rules. 

Our nursing home has a rarely used side entrance which happened to be adjacent to the woman’s room. This meant that a person could enter the nursing home and her room without encountering anyone else. During the last 36 hours of her life, we allowed the family to freely visit, only insisting on use of masks and social distancing. 

We realized afterward that this decision, while against the rules, was particularly compassionate, since this was the first personal incidence where we could neither attend the funeral nor join the family during the shiva mourning period after her death. We felt that at least the woman had not died alone.

The corona pandemic has inflicted anguish and woe on nursing home residents and their families, even in cases where the nursing home is corona-free. It has been a clinical and humanistic challenge to try to prevent virus infiltration and minimize the damage as much as possible. I am grateful that we have been able to be effective so far.