Alone, the hardest part

Of all the harrowing images of the COVID-19 pandemic, perhaps none is more heart-wrenching than that of a patient dying alone, without loved ones at their side, amidst chaos and fear. The pandemic has led to drastic changes in how we provide intensive and end-of-life care to patients and their families [1,2,3]. Age-old cultural and religious traditions surrounding death that comfort the dying and sustain the living, have also fallen victim to the pandemic.

How can we exercise our duty to care while humanizing the dying experience under such extraordinary circumstances?

Worried families, exercising social distancing, desperately seek information, reassurance, and opportunities to be with their loved ones. Front-line clinicians often feel unprepared and overwhelmed with these emotionally intense responsibilities yet try their best to provide impromptu virtual calls with family. These brief interludes offer the chance to utter what needs to be said, to affirm love, and to act as witness to unexpected grief. Clinicians experience extraordinary pressure multi-tasking care while holding mobile devices, listening to one-sided conversations. Although clinicians struggle with fatigue, trauma, and fear for their own safety; it is the dying alone befalling their patients that often breaks them.

Drawing on our pediatric experiences, steeped in traditions of family-centered care [4], we suggest an alternative pathway. Parent presence, even during invasive procedures and resuscitation, is the norm [5]. Throughout hospitalization and sometimes during a child’s death, parents are helped to be present for their child in new and different ways. Nurses help parents transition from parent-of-a-well-child to parent-of-a-critically-ill-child by providing knowledge, skills and support [6]. Witnessing the transformation of parents capable of providing comfort and care to their critically-ill and sometimes dying child is among the most rewarding aspects of pediatric practice. Facilitating human capacity is a core driver of professional satisfaction.

There are reasons to justify limiting family access to patients with COVID-19. The disease is poorly understood [7], diagnostic testing has been unreliable [8], and personal protective equipment (PPE) has been in short supply [9]. The balance outlined in Table 1 will certainly change with the acquisition of new knowledge about SARS-CoV-2, its transmission, tenacity and resultant immunity.

Table 1 Comparison of in-person contact during COVID-19 pandemic

We believe that infection control, public health concerns and family-centered care can coexist and urge reconsideration of adult family member presence at the bedside of patients during COVID-19. We believe this can be accomplished safely with beneficial effects to patients, family, and staff. With careful screening, preparation, and support, we believe many family members would be motivated, grateful, and capable of involvement in their loved one’s care. Moreover, family members who feel strongly about exercising their duty to be present for loved ones will likely experience more positive grief resolution and less post-traumatic stress, if afforded such opportunities [10]. If permitted, patients could be calmed by a familiar person at their bedside. The family member could assist with meaningful comforting and care activities that might otherwise require repetitive nurse donning/doffing.

Planning includes thoughtful consideration. Questions to consider include whether the family member has been infected or recovered from COVID-19, is capable of upholding safe practices to prevent the spread of infectious pathogens, and can be helpful to the patient [11, 12]. Not all families will be able to meet these criteria, but when they do, we should strive to make this option possible. At minimum, hospitals need rapid COVID-19 testing, adequate PPE, and a cadre of family facilitators. Rapid COVID-19 testing could confirm which family member could possibly be the patient’s designated family person [12]. Family facilitators, drawn from experienced psychosocial support staff, relocated pediatric or non-ICU adult nurses, and/or palliative care staff can constitute a team working hand-in-hand with clinical staff to liaise with each family [13].

We have learned that family members can provide what is needed for their loved ones under the most unfortunate circumstances [14]. Further, these opportunities can mitigate angst and regret, and promote positive coping and grief. Providing options while clearly outlining expectations and boundaries is essential. Family facilitators can screen and educate families while serving as the primary contact for those who cannot be present. Orientation would require information about donning/doffing and entering/leaving the room. Designated hours and the amount of time spent in the patient’s room could be individualized and pre-determined, during periods when facilitators are available, to encourage family members to return home for rest and refreshment.

We believe front-line clinicians may experience some peace-of-mind knowing that the needs of family members are being sensitively addressed by family facilitators, experienced in communication skills and anticipatory grief support and counseling. Knowing that patients are not alone but have family present to provide comfort and care can serve as a source of relief for extended family. Given that typical bereavement support, spiritual/religious customs, and funeral services are not available during COVID-19, the psychological benefit of family presence becomes that much more compelling.

In the interim, providing consistent virtual visits with families on hospital-provided mobile devices is important. Of note, virtual visits may perpetuate disparities in care; as low income and elderly family members may have decreased access to these technologies [15]. Virtual and in-person visits are a false equivalent; virtual contact inherently limits the human connection that provides meaningful elements of end-of-life decision-making and care.

In conclusion, the added value of family caregivers in the context of critical illness should not be overlooked amidst the COVID-19 pandemic. We urge clinicians to think differently during these extraordinary times and consider a decision-making framework that minimizes infection risk, honors patient/family relationships, upholds culturally important rituals of dying, and mitigates potential psychological harm precipitated by the trauma of family separation. With careful screening, education, pragmatic psychosocially oriented facilitation and teamwork, we can accommodate the very real needs of patients to not be alone, for families to fulfill their sense of responsibility and duty, and for staff to uphold the tenets of family-centered care. More than ever, it behooves us to facilitate loving relationships and genuine connections in our clinical worlds, as we continue to practice social distancing and isolation in our personal worlds. Dying alone, despite adhering to social distancing, should not be part of dying at all.

References

  1. 1.

    World Health Organization (2020) COVID-19 Dashboard. https://covid19.who.int/. Accessed 22 May 2020

  2. 2.

    Truog RD, Mitchell C, Daley GQ (2020) The toughest triage—allocating ventilators in a pandemic. N Engl J Med 382:1973–1975. https://doi.org/10.1056/NEJMp2005689

    CAS  Article  PubMed  Google Scholar 

  3. 3.

    Sayeed S (2020) The psychological toll of health care rationing should not be underestimated. Opinion. Newsweek. https://www.newsweek.com/2020/04/24/psychological-toll-health-care-rationing-should-not-underestimated-opinion-1496321.html

  4. 4.

    Hill C, Knafl KA, Santacroce SJ (2018) Family-centered care from the perspective of parents of children cared for in a pediatric intensive care unit: an integrative review. J Pediatr Nurs 41:22–33

    Article  Google Scholar 

  5. 5.

    Curley MAQ, Meyer EC, Scoppettuolo LA et al (2012) Parent presence during invasive procedures and resuscitation. Am J Respir Crit Care Med 186(11):1133–1139

    Article  Google Scholar 

  6. 6.

    Curley MAQ (1997) Mutuality—an expression of nursing presence. J Pediatr Nurs 12(4):208–213

    CAS  Article  Google Scholar 

  7. 7.

    (2020) Severe Outcomes Among Patients with Coronavirus Disease 2019 (COVID-19)—United States, February 12–March 16, 2020. MMWR Morb Mortal Wkly Rep 69:343–346. https://doi.org/10.15585/mmwr.mm6912e2

  8. 8.

    Sethuraman N, Jeremiah SS, Ryo A (2020) Interpreting Diagnostic Tests for SARS-CoV-2. JAMA. 10.1001/jama.2020.8259. https://jamanetwork.com/journals/jama/fullarticle/2765837

  9. 9.

    Gondi S, Beckman AL, Deveau N et al (2020) Personal protective equipment needs in the USA during the COVID-19 pandemic. Lancet 395(10237):e90–e91. https://doi.org/10.1016/S0140-6736(20)31038-2

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  10. 10.

    Lobb EA, Kristjanson LJ, Aoun SM, Monterosso L, Halkett GKB, Davies A (2010) Predictors of complicated grief: a systematic review of empirical studies. Death Stud 34(8):673–698

    Article  Google Scholar 

  11. 11.

    World Health Organization (2020) Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected. https://www.who.int/publications-detail/infection-prevention-and-control-during-health-care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125

  12. 12.

    Wong SC-Y, Kwong RT-S, Wu TC et al (2020) Risk of nosocomial transmission of coronavirus disease 2019: an experience in a general ward setting in Hong Kong. J Hosp Infect. https://doi.org/10.1016/j.jhin.2020.03.036

    Article  PubMed  PubMed Central  Google Scholar 

  13. 13.

    Back A, Tulsky JA, Arnold RM (2020) Communication skills in the age of COVID-19. Ann Intern Med. https://annals.org/aim/fullarticle/2764314/communication-skills-age-covid-19

  14. 14.

    Broden EG, Deatrick J, Ulrich C, Curley MAQ (2020) Defining a “good death” in the pediatric intensive care unit. Am J Crit Care 29(2):111–121

    Article  Google Scholar 

  15. 15.

    Velasquez D, Mehrotra A (2020) Ensuring the growth of telehealth during COVID-19 does not exacerbate disparities in care. Health Aff Blog. https://www.healthaffairs.org/do/10.1377/hblog20200505.591306/full/

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Curley, M.A.Q., Broden, E.G. & Meyer, E.C. Alone, the hardest part. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-06145-9

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