The corona virus disease- 2019 (Covid-19) crisis is facing society, citizens, and experts with a number of troubling challenges in Germany as well. One of these, which is so far still receiving too little public attention and support, is the risk that many senior citizens’ homes and care institutions may become contaminated. On 7 April, the German TV channel ZDF's ‘Fakt’ program reported that Covid-19 cases had been diagnosed in 331 care homes. In the state of North Rhine – Westphalia, more than 40% of Covid-19-related deaths are said to have taken place in care homes. This problem now needs to be addressed in order to cushion the damage -- above all for the sake of the residents of homes themselves. It will not be an easy task.
The latest news has been providing us with horrifying pictures of the way in which the coronavirus pandemic is leading to catastrophic mortality and care conditions in senior citizens’ homes in other countries -- in Spain, for example. Here in Germany, too, however, the residents of the country's 14 000 or so senior citizens’ homes are at high risk, as protective measures are particularly difficult to implement there. In addition, the infection is particularly dangerous for the residents, who are already often ill and frail.
According to experts, research groups, and specialist societies and associations -- some of which are currently working on recommendations and guidelines -- there are four main problems that need to be overcome in order to assist the residents of senior citizens’ homes.
Firstly, the introduction and spread of the coronavirus must be prevented as far as possible. This is achieved by ensuring high hygiene standards, equipping nursing staff with protective clothing and face masks, early testing and spatial separation, the widest possible implementation of the physical distance requirement and -- unfortunately -- also by prohibiting visitors. Implementing all of this politically and institutionally is a difficult and arduous task.
Secondly, the social isolation that can result from residents being prevented from receiving visitors or leaving the buildings needs to be countered in imaginative ways. Particularly toward the end of life, aspects of medical care are important but they are not always the most important consideration. Being left alone, perhaps without understanding why; having to do without the usual meetings and routine activities in common rooms; and missing visits from loved ones -- all of this can be much more painful for those on ‘the inside’ than we on ‘the outside’ like to think. Individually adapted alternative means of communication and entertainment -- ranging from streamed radio in rooms to phone support -- would be just as important and welcome here as the use of volunteers who are already immune to the coronavirus. Help and imaginativeness on the part of the community are required here.
Thirdly, it needs to be clarified -- now at the latest -- for each individual resident of homes whether in the hypothetical case that they develop more serious Covid-19 disease they would like to be transferred to a hospital and receive intensive medical care. And in addition, before hospital admission: whether there is any chance of the patient surviving such treatment, from the medical point of view. More on this below.
Fourthly, precautions have to be taken for a situation in which a very large number of patients in some institutions might fall ill and die of Covid-19 pneumonia simultaneously. For this, they require reliably provided care that is of good medical quality and shows human sensitivity. More about this below as well.
Even before the Covid-19 epidemic, many patients have already decided in advance how they wish to be treated at the end of their lives (through a living will or precautionary power of attorney). In view of the growing technical options for prolonging life despite multimorbid conditions and infirmity, these questions have become increasingly urgent for many people. The poor prospects for intensive-care treatment of very severe pneumonia of the type that Covid-19 can cause -- particularly in frail patients with very debilitating prior conditions -- certainly represent a paradigmatic case in which the decision to waive intensive care would be justified. Would the affected patients themselves even want to try intensive care and ventilation therapy?
To clarify precisely this question regarding each individual patient's current, already recorded, or presumed wishes, it is necessary for action to be taken immediately. Would he or she want to undergo intensive-care treatment for Covid-19 pneumonia at all? The moment to obtain clarity here on a precautionary basis is right now at the latest, if respect for the patient's self-determination is to be more than just lip service. A final patient veto, one should remember, has to be respected independently of physicians’ advice. Patients who are able to provide consent must be informed and asked about this, living wills need to be interpreted, and relatives have to be consulted. Such concerted activities might seem insensitive -- as if they were trying to encourage the answer ‘no’ in order to reduce the risk of supply shortages. But this approach is not insensitive. It is extremely helpful for patients and has only indirect effects on shortages. Beyond the question of self-determination, it would be wrong and unfair to treat patients who are willing to accept death at the expense of those who wish to live. Sensitive relatives, trusted nursing staff, family physicians, and palliative care physicians are needed in order to communicate this background in a credible manner. And this needs to be done as soon as possible. In a preliminary step, the physicians concerned would also have to clarify whether the patient has a realistic chance of surviving intensive-care therapy. Otherwise, the treatment would be pointless and palliative goals ought to be aimed for instead.
In a subsequent step, the results of this clarification process would have to be clearly documented -- in such a way as to ensure that, even in emergency or stress situations, no unwanted hospital admissions are made and ambulances are not ordered. As a tool for clarification and documentation, what is known as the ‘palliation traffic light’ system could be used here, as developed by the German Palliative Foundation and made available on its home page under the keyword ‘Pipip’ (Pilot Project on Palliative Care in Care Homes; www.palliativstiftung.de). At present, those who are calling for the right course of action to be chosen and the right assessments to be made are above all palliative physicians who are concerned with the topic on the basis of their experience with dying, very elderly, and seriously ill patients. Tragic though the Covid-19 epidemic is as a whole, death from pneumonia at an advanced age does not have to be fought against in every single case. Instead, the specific patient's wishes can be followed, in the same way that any other case of fatal pneumonia can be tolerated if it occurs without pain or shortness of breath. For this purpose, reliable and good palliative care must be made possible on site, perhaps even for numerous people dying at the same time. In the same way as in hospices: with opiates, oxygen, and well-trained staff -- unlike the horrifying scenarios in Spanish retirement homes. It is urgently necessary to take the steps needed to achieve this. We need to open out the tunnel vision in which every single Covid-19 death is regarded as a catastrophe that needs to be avoided at all costs and is managed helplessly.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.