Journal of Gerontological Nursing

Editorial Free

Public Health and Ethics Intersect at New Levels With Gerontological Nursing in COVID-19 Pandemic

Heather M. Young, PhD, RN, FAAN, FGSA; Donna M. Fick, PhD, RN, FAAN, FGSA

Amelia cares for her parents, who live nearby. Her father, Samuel, has dementia and develops a dry cough, a fever of 100.8°, shortness of breath, and increased confusion (delirium superimposed on dementia) and agitation. Amelia and her mother, Sarah, take Samuel to the local hospital where he is met at the door by staff dressed in masks, gowns, gloves, and face guards. He is swept into the emergency department (ED), screaming at Amelia to take him home. Amelia and Sarah are told the hospital has restricted visitors and they must wait at home for an update. They leave, distraught and worried about Samuel. Amelia is concerned about her mother's health and potential transmission of the virus to her young family. They return to their homes, under state orders to shelter in place, at a loss for what to do next.

The United States and other countries are currently facing a pandemic of respiratory disease spreading from person to person caused by a novel (new) virus—coronavirus. Corona-viruses are a large family of viruses that are common in people and many different species of animals, including camels, cattle, cats, and bats. Th e disease has been named coronavirus disease 2019 or COVID-19. A pandemic is a global outbreak of disease. Pandemics happen when a new virus emerges to infect people and can spread among people sustainably. Because there is little to no pre-existing immunity against the new virus, it spreads worldwide (Centers for Disease Control and Prevention [CDC], 2020).

At the time of this editorial, the complete clinical picture with regard to COVID-19 is not fully known. Reported illnesses have ranged from very mild (including little or no reported symptoms) to severe, including severe respiratory illness requiring intubation and even resulting in death. Although information to date suggests that most COVID-19 illness is mild, what we know about this disease is rapidly evolving as we learn more and study the data that are becoming available from cases in the United States and beyond. There are some reports that the number of serious symptoms related to COVID-19 may be higher than previously reported (McMichael et al., 2020). Importantly, individuals of all ages with severe chronic medical conditions (e.g., heart disease, lung disease, diabetes) are at higher risk of serious illness with COVID-19 (Zhou et al., 2020). All 50 states have reported cases of COVID-19 to the CDC. The virus that causes COVID-19 is infecting people and spreading easily from person-to-person. Th e virus appears to spread much easier than influenza. For up to date information on COVID-19 from the CDC, including current cases, how to protect yourself, and what to do if you are sick, visit their website (access https://www.cdc.gov/coronavirus/2019-ncov/index.html).

The predominant focus of health system readiness has been on ramping up hospital services from more available and rapid testing to caring for critically ill patients on ventilators. Emergency plans are in play for addressing supply chain issues, personnel, surge capacity, and protecting the safety of health care workers. Given the interrelatedness of all health services and the general community, community- and state-level planning are essential to address collective strategies that minimize transmission, expedite care in the appropriate setting, assure adequate human and material resources, and promote physical and mental health in the face of this crisis. Health systems are establishing ethical guidelines allocating scarce resources, particularly in light of the current projected shortage of ventilators and staff to support critically ill patients requiring intubation. Th ese discussions bring to the fore the value of life in the context of distributive justice (White & Lo, 2020). Clinicians face difficult conversations and may require additional preparation for these encounters, such as that provided by VitalTalk, a nonprofit that works to help clinicians communicate better and more compassionately with seriously ill patients and their families (Back et al., 2019).

Many hospitals have established policies to limit visitors, many barring all visitors to protect the health and safety of these individuals and to allow staff to focus on prioritizing care. This policy has created tension and sorrow for many caregivers who play such a vital role in supporting older adults' health and well-being, including minimizing adverse effects of hospitalization, such as falls and delirium. With hospitals focusing on bed capacity, EDs and inpatient units triage admissions and discharges, reserving the space for those most likely to benefit from critical care services. Th erefore, many older adults are either not admitted or discharged early to nursing homes, assisted living, and home. Community settings may not have the capacity and readiness to accept patients who are ill with COVID-19, as they must protect other vulnerable residents.

Furthermore, many community-based long-term care settings and families themselves recognize that hospital transfer would not be feasible or helpful for frail or older adults with cognitive impairment who are infected by the virus. Nursing home and assisted living settings are facing challenges at a number of levels—adequate preparation of staff to care for persons affected by COVID-19, adequate staffing to meet increased care needs, adequate supplies to protect staff and limit spread of the infection to other residents, managing isolation and mental health issues for staff and residents, and insufficient programmatic support for palliative care in this crisis. Due to the shortage of staff (worsened by the pandemic) and need to decrease contact time with residents, facilities may consider an individualized approach to eliminate unnecessary medications or medication passes by reviewing the medication frequency and temporarily discontinuing medications based on standards and the person-centered care approach. Some settings are also designating sections of the facility for residents who have COVID-19 to limit their exposure to other members of the community.

The families of older adults in nursing homes and assisted living are also limited in visiting at a time when they most want to provide comfort. Staff are using creative ways to connect older adults with those who mean the most to them through FaceTime, Zoom, and other technology-enabled approaches. Staff can also benefit from virtual training on topics such as infection control and palliative care.

On the home front, caregivers may become ill themselves and certainly face the challenges of caring for older adults with underlying conditions already requiring care. Now they also must prepare for limiting the spread of the virus, managing symptoms, assuring adequate supplies of food and medication, and managing social isolation. Many caregivers lack knowledge of basic infection control, including handwashing, cleaning of household surfaces, appropriate use of masks and gloves, and practices to limit transmission. A number of resources are available to provide this guidance to caregivers (Table 1). Home health and home care agencies face greater demand for their services to support acutely ill older adults and to replace care usually provided by family members who become ill. These agencies share the challenges faced by others in the health care system.

Resources for Coronavirus (COVID-19)

Table 1:

Resources for Coronavirus (COVID-19)

Ambulatory care settings are frequently the first point of contact for a person with symptoms. Testing resources have lagged, hampering the ability of primary care clinics to identify individuals with the virus. Th ese settings also face shortages of supplies and staff. Many have ramped up tele-health as an alternative to in-person visits, facilitating social distancing and protecting the health and safety of their patient population and personnel. For primary care practices that serve frail older adults, COVID-19 occurs on top of all the usual demands and complexities of managing multiple comorbidities, including responding to symptom exacerbations, fear and anxiety, medication refills, and routine monitoring of chronic conditions. Many clinicians are new to the use of telehealth and are learning how to assess and support older adults in real time. With the triage in effect around health system resources, other medical treatments can be delayed or deferred, creating a secondary effect of the virus.

At the community level, this pandemic is a wake-up call for ongoing public health education for professionals and the lay public. Influencing all members of the community to adopt public health guidance is essential to flatten the curve and limit the impact of the pandemic. This is a time for clarifying our wishes for end-of-life care, having the difficult discussions in families to formalize advance care directives so that appropriate decisions are made. The seriousness and spread of COVID-19 also highlight the importance of palliative care in assuring that even when decisions to not seek heroic measures are in place, older adults receive compassionate care (Powell & Silveira, 2020). The widespread loss of life and the fears over the pandemic, coupled with social isolation in confined quarters, increase the probability of mental health problems, taking the form of increased depression and anxiety, potential for domestic violence and elder abuse, falling prey to financial exploitation, and increased agitation and difficulty for persons with cognitive impairment.

COVID-19 also brings attention to how we talk about older adults and persons with chronic disease and disabilities in our public health messaging when faced with a public health crisis and difficult decisions about the allocation of resources. As the fear of COVID-19 increases, we hear messages such as “it only kills old people or people with underlying sickness or disabilities.” Words are powerful and how we talk about older adults may impact their care. Louise Aronson (2020), a geriatrician and author wrote about this recently in the New York Times, telling stories of the profound impact of isolation and fear on older adults and the tremendous benefits to having older persons in our world and caring for them as part of our future. She warns us, “... if we look at people as nothing more than amalgams of age and diagnosis, we miss their humanity” (Aronson, 2020, para. 15). The Alzheimer's Association and several disabilities groups have also raised concerns about limiting access to care for persons with dementia and disabilities in violation of non-discrimination laws.

The pandemic also offers new opportunities for local organizing in neighborhoods to provide mutual support (e.g., well-being phone calls, food and medication delivery). An example at the national level is AARP's list of mutual aid organizations (which can be found on their website [access https://www.aarp.org/home-family/friends-family/info-2020/coronavirus-volunteer-delivery.html]) that guides people around the country to find or create a group that can support the most vulnerable people in their community amidst the coronavirus pandemic or to get assistance themselves. Many organizations have made their resources temporarily free to the public and health systems to increase preparedness and to give families and facilities creative ideas of how we can support and better care for older adults (Table 1).

Finally, the current pandemic presents many challenges for older adults and their caregivers and opportunities for us to learn how to better prepare for future public health issues. As daunting as all of this is, there have also been many creative solutions, innovations, and flexibilities created to care for older adults as a result of COVID-19. The Centers for Medicare & Medicaid Services has issued unprecedented regulatory changes and flexibility, including (but not limited to) the expansion of the scope of practice for clinicians and advance practice nurses; expansion of tele-health; modification of the observation status rules; and increased testing for COVID-19 at home and in nursing homes.

The pandemic exposes many questions and leaves us with many difficult lessons but also positive ways that our health care system and world will be forever changed. We welcome our readers to join us in tweeting or writing what you are learning and how we can improve the care of older persons with COVID-19 and ultimately our world. We appreciate the many ways our readers contribute to the health and well-being of older adults, with courage and compassion, particularly during this challenging time.

Heather M. Young, PhD, RN, FAAN, FGSA
Public Policy Section Editor
Professor and Founding Dean Emerita
Betty Irene Moore School of Nursing
National Director
Betty Irene Moore Nurse Fellows in
Leadership and Innovation Program
UC Davis
Sacramento, California

Donna M. Fick, PhD, RN, FAAN, FGSA
Editor
Elouise Ross Eberly Endowed Professor
Penn State College of Nursing
Director, Center of Geriatric Nursing Excellence
University Park, Pennsylvania

References

  • Aronson, L. (2020, March22). ‘Covid-19 kills only old people.’ Only? Why are we OK with old people dying?https://www.nytimes.com/2020/03/22/opinion/coronavirus-elderly.html
  • Back, A. L., Fromme, E. K. & Meier, D. E. (2019). Training clinicians with communication skills needed to match medical treatments to patient values. Journal of the American Geriatrics Society, 67(S2), S435–S441 doi:10.1111/jgs.15709 [CrossRef]
  • Centers for Disease Control and Prevention. (2020). Coronavirus. https://www.cdc.gov/coronavirus/2019-ncov/index.html
  • McMichael, T. M., Currie, D. W., Clark, S., Pogosjans, S., Kay, M., Schwartz, N. G., Lewis, J., Baer, A., Kawakami, V., Lukoff, M. D., Ferro, J., Brostrom-Smith, C., Rea, T. D., Sayre, M. R., Riedo, F. X., Russell, D., Hiatt, B., Montgomery, P., Rao, A.K. & Duchin, J. S. (2020). Epidemiology of Covid-19 in a long-term care facility in King County, Washington. New England Journal of Medicine. Advance online publication. doi:10.1056/NEJMoa2005412 [CrossRef]
  • Powell, V. D. & Silveira, M. J. (2020). What should palliative care's response be to the COVID-19 epidemic?Journal of Pain Symptom Management Advance online publication. doi:10.1016/j.jpainsymman.2020.03.013 [CrossRef]
  • Price, D. (2018, March23). Laziness does not exist: But unseen barriers do. https://human-parts.medium.com/laziness-does-not-exist-3af27e312d01
  • White, D. B. & Lo, B. ( 2020). A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. Journal of the American Medical Association. Advance online publication. doi:10.1001/jama.2020.5046 [CrossRef]
  • Zhou, F., Yu, T., Du, R., Fan, G., Liu, Y., Liu, Z., Xiang, J., Wang, Y., Song, B., Gu, X., Guan, L., Wei, Y., Li, H., Wu, X., Xu, J., Tu, S., Zhang, Y., Chen, H. & Cao, B. (2020). Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet, 395(10228), 1054–1062 doi:10.1016/S0140-6736(20)30566-3 [CrossRef]

Resources for Coronavirus (COVID-19)

ResourceDescriptionURL
AARP Community ConnectionsWebsite to aid communities in organizing mutual assistancehttps://bit.ly/3bJ5Cb4
AARP Coronavirus Tele-Town Hall seriesProvides updates and topical discussions for older adultshttps://bit.ly/39zexuf
American Geriatrics SocietyProvides resources and tools for professionals and older adultshttps://bit.ly/2UOzQTk
Center to Advance Palliative CareProvides resources for crisis communication and symptom management protocolshttps://bit.ly/340jjje
Centers for Disease Control and PreventionProvides information for professionals and caregivers at homehttps://bit.ly/3dLeIpA
Older adults and COVID-19https://bit.ly/348Ikcb
Interim guidance for implementing home care of people not requiring hospitalization for COVID-19https://bit.ly/2Uyl1oR
Centers for Medicare & Medicaid ServicesEmergency response and guidance for coronavirushttps://go.cms.gov/2Jt8sov
The John. A. Hartford FoundationProvides resources for improving the care for older adultshttps://bit.ly/346PJcc
Johns Hopkins University Coronavirus Resource Center Interactive MapCOVID-19 global cases by the Center for Systems Science and Engineering at Johns Hopkinshttps://bit.ly/2xDT4TJ
National Council on AgingResources for senior centershttps://bit.ly/2wKPqHP
TimeSlipsEngagement with nursing homes in a time of quarantinehttps://bit.ly/2JtEv7N
VitalTalkOpen source primer for COVID-ready communication skillshttps://bit.ly/2UUbojp
World Health OrganizationProvides global situation reports and web-based courses to prepare professionals to respond to COVID-19https://bit.ly/2X085K5
Authors

The authors have disclosed no potential conflicts of interest, financial or otherwise.

10.3928/00989134-20200403-01

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