A recent report notes that more than 50,000 US nursing home residents have died from COVID-19. The authors are quick to add that the number is likely actually higher due to the differences in reporting from state to state. As grim as this number is and as devastating the loss involved, it represents the impact of underlying chronic conditions, compounded by frailty, rendering the residents susceptible to the virus and likely to have complications, deteriorate quickly, and not return to their baseline health status, if they survive.
From the outset of the pandemic, the CDC has warned of the increased risk associated with several chronic conditions – always present in the nursing home population. Research published during this time period has also confirmed that coronavirus patients, aged 70 or older, with heart disease, diabetes, or lung disease, and frailty are more likely to succumb to the virus than those without chronic illness and frailty.
This high mortality rate has left families, nursing home personnel, and communities traumatized, surprised, and looking for answers. Poor care is always assumed, and in some situations, poor care has contributed, but more often the residents, being stalked by a novel virus, are succumbing to the COVID-19 virus because they have chronic conditions and are frail. While death is not inevitable, the risk is increased and our need to be vigilant greater in the nursing home setting.
In the day to day care of the nursing home resident what might this mean? Obviously, infection control, always a priority, must be taken to a higher level during the pandemic. CMS and the CDC has offered much guidance and when protective personal equipment is available residents and staff are better protected from harm. The next level of infection control, often harder in the nursing home, is the isolation of positive or infected residents and in older homes, with multiple residents sharing a room, that has been problematic. Nevertheless, it remains part of the ideal and shielding or cohorting will be an important issue to address going forward. Finally, knowing the risk for adverse outcomes imposed by frailty, should guide the approach to care even before COVID-19 but especially since the devastating results for those who are frail are known.
Communicating this level of risk to families, along with information about all the approaches to care taken to reduce the risk of infection, will help prepare them for an adverse outcome. Often when informed of the risks and potential outcomes families will choose a less aggressive, yet appropriate, approach to care and take comfort in the knowledge that they have chosen well for their loved one. This also helps to remove the element of surprise if their loved one does not do well. Identifying the risk, managing the risk, and communicating the risk to families can be part of a more comprehensive approach to alleviate suffering – a key part of the response in a pandemic.