Last month, I watched a YouTube video with two physicians, ZdoggMD (Zubin Damania) and Vinay Prasad, both active on social media, discussing Prasad’s perspective that allowing patients “to die alone is a human rights violation.” He argued that clinicians should not accept blanket rules from administrators and believes there are ways around what seems to have been standard practice in hospitals during the COVID-19 pandemic.
So when we asked on AJN’s Facebook page (December 13), “Should hospitals allow patients with Covid-19 to have visitors?”, I was surprised that the comments were split. Many respondents supported the need for patients to be able to have loved ones with them, but many others felt visitors shouldn’t be allowed because PPE was scarce or because visitors didn’t follow rules and, as one commenter noted, “We don’t have time to be the PPE police.”
No one should die alone.
Nurses have been assisting patients to connect with family members by tablets or mobile phones, or in many cases filling in as surrogate family at the time of death. A colleague told me that in her ICU, nurses decided no one would die alone and made sure that one member of the staff was there with the patient. And while this was comforting to many families, I know from a recent initiative, Frontline Nurses Wiki Forum (you can read a summary of the report in the December AJN), that this has been a major source of distress for many nurses.
Some hospitals do seem to be loosening up a bit because of the recognized detrimental impact of isolation on patients and families and the stress on staff. And I’ve heard several stories of nurses who have worked around rules (as nurses have always done when they felt patients would benefit) and snuck family members in for quick goodbyes.
‘Limited visitation with compassion.’
The trend seems to be loosening up a bit. Terry Siek, vice-president of patient care/chief nursing officer at the University of Kansas Health System in Hays, Kansas, reported that his institution has developed a policy of “limited visitation with compassion” and allows family members to visit COVID-positive patients at the end of life. They have opened up visitation to other patients, too:
“We allow one visitor per day for non-COVID patients. They are required to wear a mask the entire time they are in the facility. They can switch out visitors but the switch out must occur outside the building.”
Maureen Swick, senior vice-president and enterprise nurse executive of Atrium Health in Charlotte, NC, notes:
“Emotional support is a vital part of the healing process and we have worked hard to make it possible for our patients to have one visitor with them during their stay with us. When we have patients who are COVID-positive, this becomes more challenging. As long as our personal protective equipment supplies remain stable, we are committed to helping our patients be with a loved one when the end is near.”
Planetree, a network of organizations and facilities that embody a philosophy of person-centered care (see AJN’s series on Planetree), has developed Guidelines on Family Presence During a Pandemic with input from myriad groups. It provides criteria for facilities to assess risk and safely provide for family visitation. These guidelines may be helpful to organizations seeking to develop evidence-based policies.
In the 20th century’s most influential booklet, the ICN’s Basic Principles of Nursing Care, the description of the unique function of the nurse includes a parenthetical phrase, ‘peaceful death’ as an objective for the end result of nurses’ care. That so many nurses struggle with how to operationalize this aspect of nursing care in a pandemic or more specifically in an ICU is evidence of lessons learned about end of life care. The work arounds described in the blog are welcome evidence that human service requires much more than strict adherence to rules and that many nurses seek solutions to problems they and their patients encounter. It is no wonder that nurses are trusted.