Investigating the impact of remote visits on patients in hospitals with restricted visiting conditions

Abstract

Objective

Following the novel coronavirus disease 2019 (COVID-19) outbreak that began in 2020, contact between hospitalized patients and their families was significantly restricted to prevent infection. In May 2023, COVID-19 was classified as a Class 5 infectious disease by the Japanese Ministry of Health, Labour and Welfare. Although restrictions have gradually been lifted in some areas, at the time of writing this report, our hospital has not lifted all visit restrictions. Understandably, patients in this situation experience mental distress due to a lack of support from family, friends, or partners. Although remote visits have been introduced as an alternative to in-person visits, their effectiveness remains unclear. In this study, we report three cases in which we examine the impact of remote visits via electronic devices on patients who were unable to receive in-person visits.

Patients

Among the inpatients referred to our hospital’s palliative care team from April 2022 to March 2023, three who requested remote visits due to psychological distress caused by the inability to see their families were enrolled in this study.

Results

The degree of psychological distress in all cases reduced after conducting remote visits. However, cancer-related pain (in two patients) and postoperative wound pain (in one patient) showed no significant differences in severity. In one patient, anxiety was evoked following a remote visit. This was attributed to the patient’s realization of their isolation from their family.

Conclusion

For patients whose family members are unable to conduct in-person visits due to visit restrictions for various reasons, remote visits may help alleviate psychological distress. Since remote visits can cause adverse emotional reactions in some cases, monitoring the mental status during and after remote visits is necessary.

Introduction

In palliative medicine, including end-of-life care, it is crucial to understand the patient’s background and personality to address holistic distress. Holistic distress refers to the physical, mental, social, and spiritual distress.

The basic policy of Japan’s Ministry of Health, Labour and Welfare regarding the outbreak of coronavirus disease 2019 (COVID-19) stated: “In order to prevent infection from visitors at medical institutions and elderly care facilities, visits should be temporarily suspended except in emergencies”¹⁾. This led to significant restrictions on contact between hospitalized patients and their families in Japan. According to a survey by the Japanese Society for Palliative Medicine and three other medical societies, 98% of palliative care wards had restricted visits as of May 2020²⁾. At the time of this report, restrictions on in-person visits remained in varying degrees. While essential and necessary contacts may be made via telephone or e-mail, patients may feel a lack of support from their families, friends, or partners. According to a survey by Hospice Palliative Care Japan, 77% of the respondents reported that the quality of palliative care had declined due to the COVID-19 pandemic, with visit restrictions being the primary cause³⁾.

One of the measures introduced is remote visits via electronic devices. However, it is yet to become widespread, and there is still no strong evidence to support its effectiveness in patients. We surveyed 15 hospitals with active palliative care teams in Akita Prefecture in September 2020. Only one of the 15 hospitals conducted remote visits using their own equipment. Many hospitals without remote-visiting services allow patients to use their own devices for phone calls. Although the spread of smartphones has allowed patients to communicate with their families via videophones or other means, some may hesitate to use such devices because of privacy concerns, noise (especially in multi-bed rooms), or unfamiliarity with the devices, particularly among the elderly. Moreover, many elderly patients either lack devices compatible with videophones or have little experience in using them, making it difficult to utilize them.

This report presents three cases to examine the impact of remote visits on patients whose family members were unable to have in-person visits because of visitation restrictions. We also discuss the effectiveness and challenges associated with remote visits.

Patients and Methods

Inpatients referred to our palliative care team between April 2022 and March 2023 were asked whether they wished to undergo remote visits with their families during their hospital stay. For those who requested remote visits, we asked both hospitalized patients and their family members to prepare a smartphone or tablet with communication capabilities. Remote visits were conducted using widely used videophone applications such as Facetime™ (Apple) or Skype™ (Microsoft). We then assessed the changes in psychological and physical distress before and after the remote visits.

For psychological distress, the Hospital Anxiety and Depression Scale (HADS) was used to measure changes before and after remote visits. The HADS, developed by Zigmond and Snaith, is widely used as a screening tool for depression and adjustment disorders in cancer patients, particularly in those with physical symptoms. It is known for its ease of scoring and the minimal time required for completion, thus reducing the respondent’s burden⁴⁾. The HADS has been translated into Japanese, and its quantitative psychological properties, such as reliability and validity, have also been confirmed^5,6,7).

The HADS questionnaire was translated into Japanese. Among the 14 questions, seven assess anxiety (HADS-A), while the remaining seven assess depression (HADS-D). Each item is scored from 0 to 3, and a total score of 8 or more on the odd-numbered items indicates anxiety, whereas a total score of 11 or more on the even-numbered items indicates depression. A combined score of 20 or more on both the HADS-A and HADS-D (HADS-T) is considered indicative of both anxiety and depression. These criteria have been previously reported by Kugaya et al⁸⁾.

For physical pain, we used the Numerical Rating Scale (NRS) and the Face Scale (FS), which are widely used and easy to assess in our clinic. We also monitored changes in the medication regimen, such as increases or decreases in analgesic use.

The devices were used after confirming that they were positioned at least 1 meter away from medical devices to prevent malfunction. Additionally, the visits were conducted in a hospital visit room, ensuring that there were no postings or other items that could lead to the exposure of personal information, to protect patient privacy and minimize noise disturbances.

Case 1

A 63-year-old woman visited her doctor because of pain while swallowing. She was referred to our otolaryngology department for a thorough examination. Endoscopy revealed a neoplastic lesion in the posterior wall of the pharynx, and a biopsy confirmed squamous cell carcinoma. Subsequently, the patient underwent multiple rounds of chemoradiotherapy with various regimens. Cervical vertebral metastasis occurred during treatment, and the patient underwent posterior fusion surgery. The patient was subsequently admitted to the hospital for chemotherapy.

No particular medical history was noted.

Her family consisted of her husband and daughter.

Her performance status (PS) was 0.

From the first day of hospitalization, the patient experienced lower limb pain due to edema. On day three, the palliative care team was asked to intervene. The patients’ HADS-A, HADS-D, and HADS-T scores were 8, 13, and 21, respectively. She stated, “I worry whether my family is doing okay”. Her leg pain was rated at NRS 5. Owing to edema associated with poor nutrition, spironolactone (50 mg/day) and furosemide (20 mg/day) were prescribed, along with albumin replacement. Immediate-release oxycodone (2.5 mg) was initiated as a rescue analgesic for the lower extremity pain. She was advised to wear elastic stockings, and rescue doses were administered twice daily.

On the day of referral, a remote visit was conducted with her husband. The following day, her HADS-A, HADS-D, and HADS-T scores decreased to 2, 9, and 11, respectively. She stated, “I am glad that my husband seems to be managing well with our daughter”. Following the addition of diuretics, the edema in her lower extremities gradually decreased, although her NRS score remained 4 upon discharge. The patient was discharged on the 11th day and no longer required rescue medication. She eventually passed away from a hemorrhage due to a cervical tumor during chemotherapy.

Case 2

A 49-year-old man underwent medical examination, and computed tomography (CT) revealed an 11 mm hypervascularized mass in his left kidney. He was referred to our hospital with a suspected diagnosis of renal cell carcinoma. After further examination, the patient was admitted to our hospital for surgery.

His medical history included hypertension and chronic hepatitis B.

His family consisted of his wife and daughter.

His PS was 0.

On the second day of hospitalization, the patient underwent robot-assisted laparoscopic partial nephrectomy. Pathological examination revealed papillary renal cell carcinoma, leading to a diagnosis of T1aN0M0, p Stage 1. His postoperative course was uneventful. However, on the seventh day of hospitalization, he requested intervention from the palliative care team because of emotional distress due to being unable to see his family. His HADS-A, HADS-D, and HADS-T scores were 4, 4, and 8, respectively. He expressed sadness over not being able to see his wife and daughter. A remote visit was conducted with his wife on the same day. On the following day, his scores improved to 0, 2, and 2, respectively. He stated, “I couldn’t talk to my daughter, but I am looking forward to leaving the hospital”. His wound pain was rated NRS 1 before the remote visit and remained stable until discharge, with no need for analgesics. The patient was discharged 10 days after admission.

Case 3

A 25-year-old woman presented to a local hospital with nausea and anorexia. The patient was treated by her primary care physician; however, her abdominal distension and gagging sensation gradually worsened.

The patient was diagnosed with gastric cancer after an upper gastrointestinal endoscopy. She was referred to our hospital for further examination and treatment. The patient was diagnosed with por2 >sig, T4b, NxM0, stage IVa gastric cancer invading the pancreas and esophagus. Despite receiving chemotherapy with multiple regimen changes, the tumor continued to enlarge, and metastasis to the lymph nodes was observed. The patient was admitted for palliative radiotherapy for the enlarged cervical lymph nodes.

No particular medical history was noted.

Her family consisted of her parents and sister.

Her PS was 2.

The patient underwent 30 Gy/10 Fr irradiation of the cervical lymph nodes. However, as the main tumor remained difficult to control, she chose to focus on palliative care. On the 18th day of hospitalization, the patient requested palliative care for abdominal distension and emotional distress. Her HADS-A, HADS-D, and HADS-T scores were 16, 19, and 35, respectively. Her FS score was 2 because of hepatomegaly associated with liver metastasis, and abdominal distension was suspected to be due to abdominal lymph node metastasis. Stenosis of the esophagogastric junction and nausea due to obstruction were also contributing factors. A remote visit was conducted with her mother on the day of referral.

On the following day, her HADS-A, HADS-D, and HADS-T scores improved to 5, 5, and 10. She commented, “Seeing my mother’s face made me feel at ease”. “However”, she continued, “I am afraid that I may not be able to meet her remotely again. I am anxious that this may be my last remote visit”. On the following day, the patient requested daily remote visits. Although the pain did not change immediately after the visit, her abdominal distension gradually worsened as her general condition deteriorated. The patient died on the 33rd day of admission.

Results

The HADS scores for the three cases are shown in Figures 1, 2, and 3, and the pain scale scores are shown in Figure 4.

Figure 1.

Changes in the HADS-A scores before and after intervention. HADS-A: hospital anxiety and depression scale-anxiety.

Figure 2.

Changes in the HADS-D scores before and after intervention. HADS-D: hospital anxiety and depression scale-depression.

Figure 3.

Changes in the HADS-T scores before and after intervention.

HADS-T: hospital anxiety and depression scale-total.

Figure 4.

Changes in the pain scale scores before and after intervention. NRS: numerical rating scale; FS: face scale.

Two of the three patients were anxious and depressed prior to the intervention. These patients showed improvement in their scores after the remote visit and were no longer classified as anxious or depressed. The remaining patient, who was negative for both anxiety and depression before the intervention, also showed an improvement in HADS scores after the remote visit. Although all patients showed improvement in their HADS scores after a single visit, only one patient requested daily remote visits for mental stability.

Among the three patients, two had cancer-related pain and one had postoperative wound pain. Pain was evaluated using an NRS. However, one of the patients with cancer pain experienced difficulty with the NRS assessment and was instead evaluated using the FS. In both cases of cancer pain, no significant improvement was observed immediately after the remote visit. However, one case of cancer pain improved with therapeutic intervention, whereas in the other case, the pain gradually worsened as the disease progressed, leading to death. The postoperative wound pain resolved naturally over time.

Due to the small number of cases, statistical analysis was not performed.

Discussion

The most important finding of this study was the reduction in psychological distress following remote visits.

In a meta-analysis by Mitchell et al., 16.5% of patients with cancer in a palliative setting had depression, while 15.4% had adjustment disorders. In a non-palliative care setting, 16.3% had depression and 16.3% had adjustment disorder⁹⁾. Lack of social support is a known risk factor for depression and adjustment disorders¹⁰⁾. From this perspective, the recent restriction of visits to hospitalized patients to prevent COVID-19 infection could be a risk factor for depression and adjustment disorders.

Although none of the three patients examined in this study had been diagnosed with depression or an adjustment disorder prior to the intervention, they all expressed emotional distress because of being unable to see their families. They also wished that the situation would improve, suggesting the need for methods that would enable patients to meet their families. In all cases, the HADS scores improved after the remote visit, suggesting that having face-to-face conversations with family members, even remotely, could positively contribute to reducing emotional distress under conditions of restricted visitation. However, in case 3, the patient became anxious following the remote visit, as she thought the remote visit might have been her last, and requested daily remote visits thereafter. As seen in this case, remote visits may make the patient realize the physical separation from their family and cause mental distress. Therefore, patients’ mental states should be closely monitored during and after remote visits, especially in circumstances that require prolonged isolation from their family, friends, or partners.

Regarding physical pain, there was no significant change in either case after the remote visits. In Case 1, who experienced lower limb pain due to edema, there was no immediate change in pain following the remote visit; however, the symptoms improved as the edema was managed with therapeutic interventions such as diuretics. In Case 2, who experienced postoperative pain, the pain had already decreased by the time of the intervention, and no medication was required. In contrast, in Case 3, who experienced cancer-related pain, the symptoms worsened as the disease progressed, requiring adjustments to opioid dosages. In cases where the cause of pain is unclear, such as psychogenic pain, we sometimes observe that relieving psychological distress leads to an improvement in physical symptoms. However, in all three cases presented in this study, the causes of pain were clearly identified as physical, and remote visits did not alleviate the pain. Instead, interventions targeting the underlying causes contributed to the improvement. Appropriate treatment based on the cause is necessary for the physical symptoms of identifiable causes. Further studies on psychogenic pain involving more case studies are required to evaluate the potential impact of remote visits on such symptoms.

Special attention was paid to privacy issues and the risk of information exposure, and no major post-implementation problems were observed at the time of submission. However, establishing a standardized protocol for remote visits remains challenging. There are concerns about the safety of using certain tools over the internet, and the responsibility for their use is left to medical personnel and patients. In the future, it will be necessary to establish standard protocols for safely conducting remote visits to ensure that patients’ social connections remain uninterrupted, even when issues such as infection control or physical distancing are a concern.

In this report, we compared a patient whose condition was expected to be incurable but who could still be discharged from the hospital (case 1), a patient who was expected to be cured and scheduled to be discharged (case 2), and a patient whose condition was expected to be incurable and difficult to discharge and who may die without meeting her family under visitation restrictions (case 3). In all cases, remote visits were considered to have a certain effect on the mental distress of not being able to meet with their families. However, the HADS scores of patients in cases 1 and 3, whose conditions were incurable, varied greatly from those of case 2, who was discharged from the hospital after undergoing curative resection. The more severe the disease, the more likely the patient is to feel that they might never return home or be able to see their family again, which may result in greater mental distress.

Study limitations

This report was limited to cases in which a palliative care team was involved at a single hospital and to patients who already had a certain level of understanding of remote visits, were accustomed to them, and had requested them. Therefore, although remote visits showed an effect on mental distress in all cases, there may have been a selection bias toward patients who were already inclined to seek psychological support.

We also consider it important to acknowledge patients who may have experienced psychological distress but were unable to express it, those who declined to participate because of a limited understanding of remote visits or unfamiliarity with the technology, and those who were not seen by the palliative care team. Considering these limitations, additional cases are required for further investigation.

Conclusion

Patients whose family members are unable to conduct face-to-face visits due to visitation restrictions may benefit from remote visits, as they can help reduce psychological distress. However, since remote visits can cause adverse emotional reactions in some cases, monitoring the mental status during and after remote visits is necessary.

Conflict of interest

The authors declare no conflicts of interest related to this study.

Funding information

This work was supported by the Japan Society for the Promotion of Science (JSPS) KAKENHI Grant Number JP21K17222 (Grant-in-Aid for Young Scientists).

Ethical approval

This study adhered to the Declaration of Helsinki and was approved by the Ethical Review Committee of Akita University Hospital (Approval No. 2727). All participants signed an informed consent statement prior to participation, consent for publication, and a data availability statement.

Consent for publication

All authors consent to the publication of this article in the Journal of Rural Medicine.

Author contributions

Sugimoto contributed to the conception and design of the study, the collection of the study data, the interpretation of the study data, and the drafting of the manuscript. Chiba and Andoh contributed to the interpretation of study data and critical revision of the manuscript for important intellectual content. All authors agree to the final version of the manuscript for submission and publication and take responsibility for the integrity of the manuscript.