Thanks to: Bill Kubat, V.P., Resident, Community and Quality Services and Chief Quality Officer and Laura Tubbs, Director, Resident Services/Clinical
The Evangelical Lutheran Good Samaritan Society is the largest not-for-profit provider of long term care in the United States. Good Samaritan has 21,000 staff members and 27,000 residents/clients in 230 locations in twenty-five states. Good Samaritan is a Social Ministry Organization of the Evangelical Lutheran Church in America and a Recognized Service Organization of the Lutheran Church — Missouri Synod.
Introduction
[1] Seniors who need skilled nursing and who are admitted to a nursing home face a number of challenges. While most other options for care and services allow seniors to continue to exercise some choice about their lives, being institutionalized in a long-term care setting necessarily infringes on one’s ability to make choices about a whole array of activities that most people take for granted. These activities include: when one gets up in the morning, when one eats, where one spends the day, what activities are available, who one interacts with, even when one goes to the bathroom — all these things and many more are impacted by one’s entry as a resident into the world of long-term care.
[2] Many nursing home residents enter the world of the nursing home briefly to receive rehabilitation. They come, get well, and go home. Many nursing home residents, however, come and stay, often for the duration of their lives. The quality of life they experience depends on many things: the progress of any mental or physical disease they are living with; relationships — or lack of them — with family; relationships with nursing home staff members; their living environment; the quality of their food service; religious activities in their nursing home; opportunities to leave the nursing home for community outings; and other meaningful activities available to them on a regular basis.
[3] Add to these common factors of nursing home life a pandemic flu outbreak and resident fears and vulnerabilities quickly escalate. (For the purposes of this article, an “epidemic” occurs when a disease affects a greater number of people than is usual in a particular locality, and a “pandemic” is an epidemic of world-wide proportions.)
Good Samaritan’s Pandemic Influenza Plan
[4] An outbreak of the flu in a long-term care facility is defined as one or more laboratory confirmed cases of residents with influenza or three or more cases of residents with influenza-like illness all on the same floor or unit and diagnosed within a 48 to 72 hour time period. When an outbreak occurs, the leadership staff members of a Good Samaritan nursing home respond by putting a number of procedures into effect. These procedures reflect commonly held standards of clinical practice. Some of these procedures that directly impact residents include:
· All public areas are closed.
· Family visits are minimized and/or suspended.
· All residents remain in their rooms for the duration of the outbreak.
· Hall way fire doors are closed to minimize cross contamination from hall to hall.
· Staff members are assigned to specific halls for the duration of the outbreak.
· Dietary delivers the meals to the command station. Disposable containers are used when possible. The meals are delivered to residents by the staff members working on their unit or hallway.
· Housekeeping will provide continuous disinfecting of all areas as needed.
· The activity staff members provide recreational activities in the resident’s room if appropriate for the duration of the outbreak. If contraindicated, the activities staff members will provide supportive services to nursing staff members (i.e. hydration, feeding, answering call lights, etc.)
· Social services staff members — along with the help of activities staff members, chaplains and lay ministry staff members — provide psychosocial, emotional and spiritual support to residents, family members and other staff members.
[5] In addition to these suggested measures, the facility pandemic planning committee also discusses and considers the necessity of changes in the standard of care, closure of units, closure of the entire facility to new admissions, and limitation of outside visitation when pandemic influenza has been identified in the facility.
Some Consequences for Nursing Home Residents
[6] What happens to residents in a nursing home where an outbreak of influenza occurs? To begin to answer that question, we can divide the residents into two categories: those who contract the flu and those who don’t. While all residents will be impacted by a flu outbreak in their nursing home, those who actually become ill with the flu will face serious consequences that those who are not sick will not face.
[7] Residents who contract the flu face a life-threatening situation. Because they are already compromised physically, the flu — and especially a strain of the flu like H1N1 — has greater potential for killing them. Residents might experience, then, increased emotional and spiritual anxiety. All of the concerns and questions that typically accompany the dying process — What will happen to my family? What difference did my life make? What, if anything, lies beyond the grave? — come crowding into the sick resident’s consciousness.
[8] Making matters worse—in terms of the resident’s vulnerability—are the clinical directions for appropriate treatment of a resident in this situation. There are a number of procedures—maintaining appropriate distance between residents; the use of gloves, gowns and surgical masks to help prevent the transfer of the flu virus; social distancing (defined as encouraging people to stay away from those who have the flu)—that serve to underline for the resident his or her status as both vulnerable personally and dangerous to the community
[9] Residents who do not contract the flu also experience additional challenges because of an influenza outbreak. Many of the supportive relationships that help to encourage and sustain nursing home residents are curtailed or eliminated during the outbreak. Family members, other visitors, and even staff members with whom a resident has grown close may all be kept from seeing the resident. Socialization in public areas and during meal time is discontinued. Activities that the resident has found meaningful—whether bingo or bowling, devotions or watching television in a lounge with other residents—are all stopped as a way of preventing the spread of the virus.
[10] The physical and mental diminishment of seniors leading to their entry into a nursing home, the outbreak of influenza, and the institutional response seeking ways to confront and combat the outbreak all help to create a situation in which vulnerable adults with limited choices are made more vulnerable and experience even less freedom.
Some Ethical Considerations in the Face of an Influenza Outbreak
[11] There are a number of ways a faith-based organization might begin to ask important questions about the ethical implications of this situation. The overarching ethical dilemma leaders in a faith-based long-term care setting face is balancing the rights of individuals with the rights of the community within which they live.
[12] The many precautions the institution takes in the face of a pandemic flu outbreak constitute a hardship for residents. For some time — days or weeks depending on the duration of the outbreak — a host of supportive relationships are curtailed or eliminated. In fact, all contact is reviewed and regulated in order to minimize the potential spread of the virus. Social events, formal and informal, are canceled. Residents and staff members are strongly encouraged to keep their distance from those who are sick. And “keeping your distance” becomes a central strategy for dealing with the outbreak. This is critical from a medical and practical standpoint. The pandemic creates a very real risk of a shortage of staff and a shortage of access to other health care services which in turn heightens this need for containment.
[13] But it is precisely here at the edge of life with older people grown frail with age — especially when they are additionally weakened physically, emotionally and spiritually by the flu — that contact is so vital. Strict clinical practice and medical interventions may provide an environment within which people’s bodies can better fight the flu. But if they become increasingly lonely and discouraged in this environment, how might this very environment constitute a detriment to their wellbeing as well as their ability to recover from the sickness they are fighting? And if, in addition, a sick resident is struggling with dementia, how might their inability to understand their sudden isolation deepen their social, emotional and spiritual suffering?
[14] A second question has to do with resident’s choice about accepting or rejecting these precautions. The perceived urgency of combating an influenza outbreak encourages nursing home leaders to implement on their own authority and without consulting resident or resident’s family opinion a wide range of strategies that literally change the whole way life happens in the nursing home. So residents whose choices are already severely limited by virtue of their living in a nursing home must confront with these sudden changes the recognition that their perspectives are not valued.
[15] Finally, there is the question of what criteria are used for decision making. Decision making about responding to an outbreak of influenza is determined along medical guidelines. These guidelines suggest what to wear, what distance to keep people apart, what strategies to implement in terms of addressing a variety of resident needs and/or wants. But while clinical guidelines are central to dealing with an outbreak, should they so dominate the discussion that other areas of concern are marginalized? What about psycho-social concerns? What about religious perspectives? In a host of clinical guidelines, is one statement about the role of these other disciplines in the “Pandemic Influenza Plan” adequate?
Conclusion
[16] Although safeguarding individual rights and choices is becoming increasingly important to providers of long-term care in the United States, the imperative of keeping the nursing home community free of infection during a pandemic flu outbreak overrides individual rights. The mandated practices by the government create a strong bias toward a medical model of dealing with the flu with an emphasis on protecting the community. Faith-based providers of long-term care must abide by government standards while acknowledging the interdependence of all who live in community with the resulting necessity of individuals sacrificing for the common good.