Comfort amid the chaos: How 4 systems are helping patients connect with loved ones during the pandemic

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COVID-19 visitor restrictions are forcing hospitals to find new ways for all patients — not just those with the virus — to connect with their loved ones and, in some cases, say goodbye.

These connections come in many different shapes and forms — a dying patient video-chatting with her incarcerated son or clinicians playing a family member's recorded voice message in a critically ill patient's ear — but they all have the same goal: to maintain patient-centered, holistic care, even amid the grim realities of the pandemic.

How four health systems are helping patients connect with their loved ones:

Note: Responses were lightly edited for length and clarity.

Stephanie Conners, RN, executive vice president and chief operating officer at Philadelphia-based Jefferson Health: Like most health systems, we have instituted strict no-visitor guidelines during this pandemic. However, we will do everything we can to allow a loved one in the room when someone may be near the end of life, including patients who are COVID-positive. We do not limit family members from coming in and saying goodbye, but do ask for one visitor at a time. Our percentage of patients at the end of life is small, so our personal protective equipment supply is robust enough to ensure those last goodbyes.

As crucial as all of our decisions are right now during the COVID-19 pandemic, this one was relatively easy. It was not made lightly, but it was made in the best interest of our patients and families. We feel that as life enters and leaves the world, we need to take care of the person — the person is far bigger than their medical events. Families should be able to say goodbye to their families. 

If patients are ill, but not critically, we use technology so they can communicate with their family. FaceTime and iPads are key resources.

Sunita Puri, MD, medical director of palliative medicine at Los Angeles-based Keck Medical Center of USC and author of That Good Night: Life and Medicine in the Eleventh Hour: Right now, no visitors are allowed at Keck Medicine of USC, regardless of if they want to visit a COVID-19 patient or not. But that does not include people who are at the end of life. We shouldn't be in the position where people who are in comfort care can't see their families. For other patients with laptops, tablets, etc., we encourage them to use FaceTime or Zoom to connect with their families if they are awake and alert. I just met with a family who has a sick loved one in the hospital they can't visit. We told them to make voice recordings, which we played in their family member's ear. There's no concrete proof, but I think things like this bring patients comfort and provide relief for loved ones.

The majority of our patients with COVID-19 are not in critical care right now. But some can take a turn for the worse fairly quickly and require intubation. If somebody comes in really sick and hasn't had a discussion about their care preferences before, we often are obligated to intubate them and then have a conversation with their families. Unfortunately, this means physicians must talk with families over Zoom or by the phone to give them tough updates or have difficult conversations about loved ones' wishes.

This pandemic is going to underscore the importance of advanced care planning. Healthcare is really feeling the effects of people not doing advanced care planning; it's getting put on physicians' shoulders to make these decisions. One thing I can't stress enough is having these discussions before patients get really sick. 

Naomi Tzril Saks, a clinical healthcare chaplain in the division of palliative medicine at University of California, San Francisco: Providers' security blanket has always been thinking, "Well, if I can't save a life, I can at least bring the family in and give them a gentle death." But that has been taken away due to COVID-19 protocols. We're still focused on how we keep the notion of whole-person care alive and best support people, even when we can't necessarily be there in person or pick up on the energy in the room. 

Technology is really taking a new place in our work. In some ways, it's become the touch, voice and connection that we can't have. Chaplains and social workers are using telemedicine to have individual counseling sessions with patients and their families. In one instance, we brought in about seven to 10 family members by Zoom to sit in a virtual vigil as their loved one with COVID-19 was dying. In another, we were able to reunite a patient with her incarcerated son on Zoom before she died.

We actually now don't have many COVID-19 patients on ventilators right now. But standard practice is that we have any patient connect with their family by phone or Zoom before they are placed on ventilators. We are also doing everything we can to allow visitors for end-of-life situations. We try to bring visitors in one at a time as safely as possible. Our team is so busy and overwhelmed trying to care for people, so we also want to be mindful of the balance between bringing visitors in and safeguarding clinicians' well-being. 

Jeanne Wirpsa, research chaplain for the department of spiritual care and education and program manager and clinical ethicist for the department of medical ethics at Northwestern Memorial Hospital in Chicago: The hardest thing is shifting to this new framework and really understanding why we have the visitor restrictions in place as we do. We need to make sure staff and the public at large understand restrictions are not meant in any way to be punitive toward families because we are afraid of them — it has to do with protecting the most vulnerable patients in our care. The visitor restrictions for COVID-19 and all patients are grounded in the moral obligation we have to protect as many lives as possible. The only way we can do that is social distancing and stopping the traffic of people through healthcare institutions. We don't know what exposure people have had in the real world [to the virus].

Patients are alone right now, and their anxiety is heightened. How do we help mediate that family presence to their loved one in the hospital, even when they can't be present? Our support services have been collaborating to make sure patients who are alone receive more virtual or in-person visits from chaplains, social workers and other members of the healthcare team. When they can't enter the room of a COVID-19 patient — because we're trying to limit the use of PPE — they interact outside the door or Skype the patient to provide that virtual presence in lieu of physical touch.

Patients and families have been grateful for the efforts we have taken to use technology to communicate. I've heard from our bedside staff, patients and families about the difference it makes to have someone pick up the phone and hold it to the patient's ear so they can hear the voice of their loved one. Our institution has also expanded the capabilities of our VRI interpreter machines so they have Zoom or FaceTime for family consults. We have purchased iPads for isolation units so they can remain in the patient's room and not have to be shared. Some of our nurses actually purchased or brought in chargers for patients' phones, which are easy to forget when leaving home for the hospital. Patient engagement services, patient relations, social workers, chaplains and volunteer services have also combined their efforts to address the gap in the physical presence of family members at the bedside.

The truth is none of the virtual technology replaces being able to be at the bedside, and I think we have to be honest about that. We are so used to being with our loved ones — seeing them, being able to whisper in their ear and say things in real time. It's hard to appreciate the level of suffering it causes to families when they can't have that in the flesh. But the risk we face if we don't limit exposure far outweighs that need. Some things we have suggested to families is to wear a piece of their clothing or sit in their loved one's favorite chair [when communicating virtually]. 

One thing that's really important doesn't relate so much to our visitor restriction policy, but has to do with the lack of family at the bedside. When somebody comes into the ER or is admitted to the general med floor with COVID-19, it is important that we know who they trust to make decisions for them. If they have any advanced directives, it's important we have those in our possession or at least know what they say. We have a conversation fairly early on with decision-makers, as we're seeing that breathing can quickly deteriorate and patients need support from mechanical ventilation. Before that happens, how do we plan for what patients want their loved ones to know and things they need to say to them? "I've lived a really good life. I'm 75 and I will be okay, and I know you will be okay if I'm one of those people who gets really sick and doesn't make it out of this." We have been proactive in ensuring people know who they want identified as their decision-maker so we don't have conflicts at the moment of crisis. That has been critically important. 

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