Consents have become a prominent part of health care. We sign consents for visits, procedures, medication, privacy, release of information, care of minors … the list goes on and on. We must acknowledge and respect the patient’s autonomy in their care. This is never more apparent or more important than in end of life care. Physicians encourage everyone to have an end of life plan, a living will. It is not something that people like to think about. No one wants to think about their mortality. But we stress, if not slightly harass our older patients at every visit to consider deciding whether to become do not resuscitate or do not intubate to avoid unnecessary suffering. We urge them to have a living will. We document it in notes; we place orders in the EHR, we even make sure to verbalize it to the other staff taking care of the patient. This has probably become one of the more important questions we have had to ask during the COVID pandemic. Physicians have to diligently remember to check the status in the chart more than ever. But have we as a medical community considered asking our geriatric population their end of life plan outside of DNR/DNI? Because I think end of life in the geriatric population is much more than a living will. It is quality over quantity of life to them. Have we paused to ask them how they want to spend their “end of life?”
In addition to seeing geriatrics, I see outpatient teens and adults. I have seen a noticeable increase in patients who are suffering from anxiety, depression, and guilt. Not mild guilt but painful, intense guilt that they can do nothing to remedy. These patients are suffering because they have loved ones in nursing homes who are also suffering significantly. They are calling family, begging them to visit in person, or take them out of the homes. They feel as though they are in prison. They cannot go on being separated from the outside world and their loved ones. They have quit eating and participating in their care. They will no longer do their physical or occupational therapy. They have given up.
I find as a geriatric psychiatrist that sadly this population is often overlooked. Though in my opinion, they are the wisest and wonderful population to serve as a physician. I learn something every time I have the honor to treat them. But they often feel forgotten and never so more now during this pandemic. We know that they are our most vulnerable patients during this pandemic. The virus tends to be much more deadly in this population. And that is why the most extreme measures have been put into place in nursing homes.
Our nursing homes have now been on “lockdown” for months. No one in and no one out unless you are staff (which has not been very effective to this point). We understand that if one resident gets COVID, it will spread like wildfire. This has been seen in many nursing homes. But it is not just COVID that is spreading through nursing homes like wildfire; it is depression. Depression rates are soaring. Residents are dying. They are dying from depression. They are giving up.
I understand the initial regulations that were put in place to protect them. I respect them and think they were wise. After speaking to some of the residents in these homes, they too are genuinely thankful for the concern to protect them. But no one has taken the time to ask them what they desire in their end of life. We put the strictest regulations in place to avoid the massive number of cases, deaths, and damning headlines. But these regulations give us as health care providers comfort and a sense of peace because of our oath to take care of people. But it not giving those that the regulations were put in place the same sense of comfort and peace. They are struggling. Many have just given up. When asked about the regulations, so many have replied that they are end of life and would rather die of COVID then suffer from lack of contact with their family. It is about quality over quantity.
Now that numbers have begun to stabilize and hospitals are no longer overwhelmed, we must step back and take time to re-evaluate the regulations for visitation in nursing homes. There must be a middle ground. With the increase in available testing and the increased knowledge about this virus, we can find ways for this most wonderful population to see family. It can be done. If we do not make this a priority, we will see a new pandemic that will burn through every single nursing home. We will see a mental health pandemic that will cause unnecessary death. There must be a middle ground.
Katherine Gantz Pannel is a psychiatrist.
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