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The COVID ‐19 Pandemic: Experiences of a Geriatrician‐Hospitalist Caring for Older Adults

2020; Wiley; Volume: 68; Issue: 5 Linguagem: Inglês

10.1111/jgs.16481

1532-5415

Liron Sinvani,

COVID-19 Pandemic Impacts

In the last few weeks, New York has become the epicenter for the COVID-19 infection. This novel virus, while infecting young and older indiscriminately, takes its most dangerous toll on older adults. Medicare patients now occupy more than 50% of all hospital beds in the United States. As a hospitalist with geriatrics training practicing in the greater New Yok area, I am witnessing in the trenches the immediate impact of this pandemic on geriatric patients and their family members who long for one final good-bye. I have also seen some amazing acts of selflessness and empathy by frontline healthcare practitioners. Identifying details have been altered to protect the patient's confidentiality, but the essence of the stories remains the same. Patient 1: Mr. J. is an 82-year-old man with interstitial lung disease for which he requires 4 L of oxygen at home. He lives with his wife of 50 years. Given his high-risk profile, they have been completely isolated home for the last 3 weeks. His son, the only outside contact, has been bringing groceries once a week. Three days before admission, Mr. J. developed low-grade fever and increasing dyspnea. He was admitted to the hospital and tested for COVID-19. Overnight, his oxygen requirements escalated and a rapid response was called; the patient was deemed to be a poor candidate for intubation. I met Mr. J. the following morning. After putting on my full protective gear, I slowly entered the room. He was lying in bed with his eyes closed, the face mask covering most of his face, taking shallow and rapid breaths. I heard the telephone ring. I assumed it was a worried family member denied visiting rights. I gently woke up Mr. J. and held the telephone to his ear. In between breaths, I could hear Mr. J. softly telling his son that he loved him and that they should keep safe at home. Once they hung up, I spoke to Mr. J. about his wishes, and he stated clearly that he would not want to be kept alive on machines. An hour later, his COVID-19 test returned positive. I called his son and daughter who cried, and they asked my advice on bringing their mother to the hospital. They wondered if they were at fault for perhaps contaminating them during their weekly grocery shopping visit. The daughter also asked about potential risks to her husband, currently undergoing chemotherapy. I listened and felt their pain. I went back to Mr. J.'s room and sat with him a little longer, knowing I would probably be his only visitor that day. The patient died the following morning. The COVID pandemic has built an unsurmountable physical barrier between our patients and their loved ones at the most vulnerable time of their lives. We hospitalists often become the last human connection between our dying patients and their loved ones. Patient 2: Mr. B. is a 78-year-old man with a history of atrial fibrillation, congestive heart failure, and chronic kidney disease. Before admission, Mr. B. ambulated independently with a cane, drove, and had a full life with friends and family. He was brought in to the hospital by his daughter after experiencing fever and shortness of breath. He was admitted to the hospital with hypoxia and found to be COVID-19 positive. On his third day, he was now requiring 100% oxygenation with a non-rebreather mask. The nurse informed me that he had gotten more confused. Shaken from my last encounter, I put on my protective gear and entered the room. Mr. B was lying in bed, restless, trying to position his oxygen mask with one hand and holding his phone in the other. He looked at me and I could see the fear and frustration in his eyes, the only part of his face visible under the mask. With his hearing impairment, my mask, and the noise of the oxygen blowing through the non-rebreather, he could barely hear me. He held his phone up to my face and told me to read his message aloud. He was in the middle of writing his daughter a message indicating that he could not handle this situation any longer. I placed the telephone down and asked him if we could talk. I yelled as loudly as I could, explaining I was his doctor and came to see how he was feeling. He sighed in frustration and told me that he could handle the shortness of breath and the fevers but not another day in the hospital. Due to his oxygen needs, he had been in the same position in bed for the last 3 days and was stiff throughout his whole body. He spoke about his inability to use the bed pan and his dependency. In addition, the noise of the oxygen blowing in his eyes, nose, mouth, and ears all day and night was "driving him crazy." He then apologized and told me that normally he is a wonderful man, funny, smart, always making jokes, "the type of person the nurses love." I promised him that together we would address his concerns. The first thing we did was to dangle his legs off the bed. It took about 10 minutes of slowly working his muscles again to get him in a seated position, and he immediately felt better. I encouraged the staff to let him use a commode or at least find a larger bed pan for comfort. He apologized again and told me that he would hold off on sending the message to his daughter. Mr. B. continued to decline over the next few days. He became more confused and died 2 days later. Hospitalized older adults with COVID-19 infection are at a high risk for developing delirium. Although multicomponent nonpharmacologic interventions have proven efficacious in decreasing rates of delirium, these programs are nearly impossible to implement in the face of isolation and visitor restrictions. Patient 3: Mrs. R. is a 76-year-old woman with advanced Alzheimer's disease, who has lived comfortably for the last 4 years in a dementia unit of an assisted living facility. Mrs. R. was transferred to the hospital with suspicion for COVID-19 after displaying decreased oral intake and low-grade fever for 1 day; a few other residents were hospitalized and tested positive for COVID-19. In the hospital she was indeed found to be positive for COVID-19. I was seeing her on the fourth hospital day. Although her symptoms had mainly resolved, she could not go back to the assisted living facility due to concerns that she might still be contagious. Earlier in the day I received a call from the nurse that the patient has been extremely agitated and hitting the staff; she could be heard yelling throughout the entire unit. It seemed that the new environment was increasing the behavioral symptoms associated with her dementia. I carefully put on my protective gear waiting to hear the screams, but all was quiet. I entered the room and to my amazement, I saw the nurse assistant hold the patient's hand and slowly start to wash her face with warm water. He spoke to her gently, reassuring her. Once he was finished, he started feeding her patiently. The patient was calm and happy. He smiled as he noticed me watching. He explained to me that although he was of course concerned about being susceptible to the infection, he knew it was his responsibility to take care of this patient the way he would want his mother taken care of. Caring for hospitalized patients with COVID, especially those with cognitive impairment who require personal care, can be extremely challenging. We speak about physicians and nurses as heroes in the face of this pandemic, but it is important to remember the role of nurse assistants. Nurse assistants are often the ones who are tasked with bathing, feeding, and general care. They must place themselves in close proximity to the patient for prolonged periods of time. Healthcare systems must recognize and advocate for the invaluable contribution of the nursing assistant personnel, so they receive the compensation and benefits they deserve. As we battle the COVID pandemic, which disproportionately affects our older adults, all healthcare practitioners, whether physicians, nurses, nursing assistants, social workers, sanitation workers, or food and dietary personnel must join together and support each other. Now more than ever, we depend on each other as humans, if we want to overcome the first universal health challenge this world has ever faced.