This article was updated on 22 July, 2022.
This week the Aged Care Quality released a new fact sheet for aged care service providers titled ‘How prepared for a Covid-19 outbreak are you?’.
It comes as the inquest into Covid-19 deaths begins, with news reports focusing once again on the problems faced there.
The fact sheet is helpful but no doubt comes as little comfort to the families of those who lost loved ones in places like Newmarch House. As winter continues, some health experts warn of a fourth Covid-19 wave, revisiting this article from April 2020 is a timely reminder to ensure the mistakes of the past are not repeated.
We need lots and lots of answers about how it is that Newmarch House is expected to house so many patients sick with Covid-19, along with many who are not yet infected – and why worried families of residents report they have had so little communication.
By last night, April 29, Newmarch House, near Penrith in NSW, had 56 Covid-19 infections including 34 residents and 22 staff. Eleven residents had died.
Why weren’t the infected patients moved into nursing care at a major teaching hospital as soon as their Covid-19 was diagnosed?
After all, it can be predicted that the very elderly will get very sick with Covid-19 and are therefore the group most likely to need ventilators. And even if they don’t need ventilators many will still need ICU. Looking at all the deaths in Australia so far, of the 89, 75 were of people over the age of 70.
We’ve got the resources to think laterally
Is this a resource issue? Is it because the teaching hospitals need to be on stand-by to manage all the mainstream Covid-19 cases? Except they don’t. Australia’s success is such that our intensive care units are not overflowing with Covid-19 patients – in fact almost the opposite, since until only recently all elective surgery had been cancelled and it is only slowly getting back to full steam.
And due to our level of lockdown, and the timeliness of it, there are substantially fewer car accidents, there are fewer drunks bashing each other senseless after a boozy night then presenting themselves to A&E to be stitched up. There are even fewer sporting injuries, because no-one’s out playing sport.
It’s been almost embarrassing for our staff, who are treated as though they are managing the great crowds of patients of the UK, Italy and the USA. But they’re not. In NSW there are 28 active cases taking up hospital beds now, 17 of them in intensive care beds. This is in a country where we doubled the number of ventilators on hand from 2000 to 4000 (at least) and have stringently prepped all staff for an onslaught. We’ve solved the supply issues with protective clothing. We’re ready.
So why weren’t the Newmarch patients transferred, or why can’t they be now? A decision to do something like this, even if unprecedented, would need to be made by the NSW state government, since it’s their beds we’d be asking the patients to be transferred to. And the NSW government would have to negotiate a right to intervene with the Federal government because they have responsibility for nursing homes. It’s complex but doable.
How did ‘not for resuscitation’ get into this?
It’s been hypothesised in the media that the difficulty is the patient’s advance care directives that say they are ‘not for resuscitation’. There’s a lot of supposition in that. With a foreseeable death in old age you can plan not to resuscitate, especially if that is the wish of the person, especially if they’ve written it down.
I bet anyone filling in an advance care directive until now, didn’t explore the possibility of a pandemic of biblical proportions, the strange reality of now.
This is an extremely unusual circumstance. It is a pandemic disease, a 100 year event. Covid-19 is not going gently into that good night. It’s not ordinary pneumonia, called ‘the old man’s friend’ because the frail, very elderly patient with it develops a fever and delirium and then drifts into a state of unconsciousness, then slips into death.
It’s worth noting that in Australia, respiratory related deaths tend to be managed in hospital because they are frightening for the patient and the hardware to ease these symptoms is not generally transported to homes. So there’s a tradition of respiratory disease patients having good access to hospitals anyway.
Being locked in a place waiting for your turn to be infected by Covid-19 is more akin to being locked in a room with a caged bear than anything your planning documents might have foreseen before. Especially because of the fear factor. It’s true that even the elderly can survive Covid-19 lightly. But the trouble is, doctors can’t predict right now who that’ll be, so the Russian roulette creates fear.
The Covid-19 death is not an easy one. Acute Respiratory Distress Syndrome develops very rapidly and with it breathlessness and the sensation of drowning and a struggle for air. There are reports worldwide of the emotional trauma of staff nursing patients with it because of this.
If deemed as someone who needs hospital for Covid-19, this is an emergency. And when a patient goes into a teaching hospital as an emergency patient in Australia, their ‘not for resuscitation’ directive is void.
Advance planning thinking has to be adjusted for this. One emergency doctor said recently, “in a pandemic, there is no emergency because everyone is an emergency patient.”
So pre-pandemic thinking about advance care plans has to be chucked out the window.
Covid-19 is highlighting one of the limitations of ‘not for resuscitation’ clauses. If the patient does not have a realistic sense of the various scenarios that could play out, can they make an informed decision?
Can Covid-19 show us how to be better prepared?
The Covid-19 crisis is an ideal opportunity for us to educate people about the unexpected and to significantly upgrade advance care planning to show people that black swan events happen.
And for every one old lady who would not want to be resuscitated if she had a heart attack, or to be given antibiotics if she developed pneumonia, there is another one who thought she came into a nursing home to be protected from risk.
I don’t want to undermine the efforts we have made to make sure the elderly’s lives are not prolonged unnecessarily, especially when they have issued a clearly communicated directive.
But Newmarch House residents are being infected and Newmarch House is not a cruise ship out at sea, in international waters that can’t find a safe harbour. It doesn’t look like anyone’s got the right to leave, although maybe they have. This needs further exposition.
And this is not about access to social resources. Many nursing homes do a fine job these days, usually providing transparency, access to family, good ratios of carers, entertainment, electronic resources and a range of stimulating activities. The pandemic has confronted them with scenarios they’ve not had to deal with before.
So let’s chuck out the precedents.
Chucking out the precedents
Why can’t those who aren’t infected be put up in one of those fancy hotels where all the returning travellers were recently isolated for 14 days. Because they need care? The carers who aren’t infected can be brought in too.
That arrangement, between a hospital, health insurance providers and classy local hotels works well in Sydney maternity hospitals.
But back to advance care planning documents. Many elderly Australians don’t have an advance care directive. Nursing homes invite residents to fill them in, but many do not have capacity, so the point can never be pushed. Instead, by default, their families have to fill in ‘plans of care’. Many don’t fill them in but the family still ends up making the decision.
But in Covid-19 cases, where are the families, the people who would normally negotiate with medical staff? The family who we would normally hope would advocate for a confused, elderly person without capacity is not there.
There could be very few television scenes more horrible than watching desperately anxious Newmarch House families wishing they could have more information but collectively barred from access. That is absolutely barbaric. For those families and for those residents. The optics undermine confidence in aged care facilities.
Yes, of course we need social distancing and restrictions on numbers visiting a place infected with Covid-19. But can’t we come up with some lateral thinking so that we practice social distancing but still allow the families in this situation genuine connection? Can we make industrial grade protective equipment available, put the family and their loved one on a back field for the day? Maybe all these things are happening but that is not the impression we’re getting.
If, as the families have suggested, the aged care facility won’t let the families in, that’s another reason for the patients who have tested positive to be taken to a major teaching hospital, where the staff have been preparing to take Covid-19 patients for weeks, are trained and psychologically prepared for the risks of treating Covid-19 patients – unlike the terrified, anxious, frontline staff at the aged care facility, not usually registered nurses and not usually practising intensive care nurses.
And that leads to another important reason why it would be good if residents were moved out – some to a teaching hospital, some to a hotel. This would stop the risk of staff becoming infected.
Imagine the terror of being a worker who’s afraid of getting Covid-19 every time they go to work. This is not just happening at Newmarch House but all over the world. In Sydney it’s creating a mish-mash of protocols that differ from one nursing home to the next. This is a customer relations nightmare for nursing home managers, who have to explain why people are allowed into one facility and not the next.
A light is being shone on us
Every nation in this pandemic has had a searing light shone into its soul. Every nation’s weakest point is exposed; it’s as if the way it’s social contract with its people is conducted is the mechanism that enables the killer virus and visa versa: Covid-19 is exposing our killer flaws.
In Australia we’re doing well. But the light is shining on the troublesome, clunky, relationship between nursing homes, which fall under federal authority and teaching hospitals which fall under state authority.
The politics of this is always blamed when people, usually the weak elderly, fall through the cracks. When the review of management of Covid-19 in nursing homes is done, this politics problem needs to be fixed.
And let’s not blame the nursing homes. They work on small margins. They are a hard, much maligned business to be in. Maybe some of the federal budget currently and rightly put aside for the Business Improvement Fund for aged care providers in severe financial difficulty could be utilised for this bigger fix.
There have been 6,746 Covid-19 cases in Australia and only 89 deaths so far, quite remarkable. There have been 60 cases in residential care, and 22 deaths in them. Yes, those numbers are thankfully very small.
Therefore, it is financially and logistically, only a small problem to solve, although politically it appears to be a very big one. Because while the raw numbers are small, that ratio is high, something that we can approach as a problem easily solved, with all the federal and state money, resources, think tanks and national committees in play right now.