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COVID-19: Why are dying seniors not being taken to hospital?

Posted: May 10, 2020

(May 9, 2020)

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“The hospitals ... are not in total crisis. The long-term care homes are in crisis and a significant number of retirement homes,” says Natalie Mehra, executive director of the Ontario Health Coalition.

Questions are being raised by unions and advocacy groups about why Ontario seniors with COVID-19 are not being sent to hospitals from long-term care and retirement homes struggling with outbreaks.

“I have been really concerned about this,” said Natalie Mehra, executive director of the Ontario Health Coalition. “The hospitals … are not in total crisis. The long-term care homes are in crisis, and a significant number of retirement homes.”

In Hamilton, one long-term care resident has died in hospital while five died in the homes. At Cardinal Retirement Residence on Herkimer Street, three residents died in hospital while five more died at the retirement home.

“If I were in that situation in long-term care and frail, I would rather die at home rather than in a hospital,” said Arthur Schafer, founding director of the Centre for Professional and Applied Ethics, at the University of Manitoba.

He says most long-term care residents are age 80 or more, physically frail with underlying health conditions, and many are cognitively impaired.

“They wouldn’t be admitted even in normal times let alone in pandemic times,” he said. “The decision not to send long-term care patients to a hospital for potential ICU admission would be understandable and reasonable.”

However, Schafer’s assessment is based on the home being able to provide end-of-life care and other supports to keep the resident comfortable.

“They’re entitled to palliative care and if they will not receive good palliative care in their long-term care facilities, that is a medical scandal and an ethical scandal,” he said.

The capacity of Ontario’s long-term care homes — particularly those with large outbreaks — to provide supportive care is precisely what is raising alarm among the coalition, the Advocacy Centre for the Elderly and the Canadian Union of Public Employees (CUPE).

“We agreed that we would be calling much more assertively for people to be transferred to hospital where they can be cared for safely,” said Mehra. She points to a report the coalition did with Unifor in January that found long-term care homes were at their breaking point before the pandemic.

“There was total consensus that every home was working short staffed all the time — every shift, worse on the evening and weekends — and that was prior to COVID-19. Now it’s indescribable.”

CUPE announced that it plans to launch a legal action next week on behalf of long-term care residents alleging discrimination on the basis of age.

“Not everybody has a do-not-resuscitate order and many of the people who do could be made more comfortable,” said Michael Hurley, president of CUPE’s Ontario Council of Hospital Unions. “There is lots of things that people could do for them in a hospital setting. From our perspective, people in long-term care are undervalued significantly and denied access to some of the quality care that the rest of the people enjoy.”

But the executive director of Dundurn Place Care Centre on Mary Street, where two residents died in April, says keeping them at the home is about compassion and a dignified death.

“Although hospitals may have more equipment, LTC staff are family to the resident and have been there for that resident for weeks, months, or even years,” said Danny Pereira. “This is the resident’s home and many wish to live out their days here. By staying in the residence at the end of life, not only are they provided with comfort measures but are also surrounded by the loving care of the people that have been there for them all along.”

He says the home is “capable of providing comfort measures to ensure that the resident is free of pain and suffering” despite having three infected staff as well as nine residents.

“The dedication and compassion that I’ve seen in recent weeks is invaluable,” he said.

Heritage Green Nursing Home, where four residents died — including three at the home — and Cardinal did not respond to requests for comment. Some residents from the Cardinal outbreak were sent to hospitals when the home could no longer cope.

The province says neither the Ministry of Long-Term Care nor the chief medical officer of health have directed homes to keep residents out of hospital.

“The decision of whether to send residents who have COVID-19 to hospital is made on a case-by-case basis by a physician in consultation with the resident and their family,” the minister’s office said in a statement. “If residents who tested positive for COVID-19 require medical attention that the long-term care home is unable to provide, these residents are transferred to hospital to meet the health-care needs.”

The Advocacy Centre for the Elderly has questioned when advanced directives were signed, indicating that residents don’t want to go to hospital.

“We’ve heard of homes — and I don’t know if there is any in your area — that the administrator has made a blanket policy that they are not sending people to hospital who has COVID and that’s just illegal,” said Jane Meadus, staff lawyer for the centre.

She also said directives signed when a person entered a long-term care home — long before COVID-19 — are also not informed consent.

“It’s meaningless,” she said. “They’re out of context.”

At Dundurn Care Centre, Pereira said discussions happen more than once — on admission, annually and with a resident’s status change.

“Decisions are fluid and not made in stone,” he said. “They adapt to the resident’s needs in consultation with family, palliative experts, doctors, nurses, nurse practitioners and the resident him/herself if able.”

CUPE says it has been a long-standing issue that residents of senior’s homes are not sent for hospital care.

“Even before COVID, there was a resistance to transferring long-term care residents who were acutely ill to hospital and that was linked to the lack of capacity in the acute-care system we believe,” said Hurley. “And now with COVID, you have to ask yourself how many of these residents in long-term care are being offered the opportunity to be cared for in hospital.”

Hamilton’s hospitals, which currently have resources available because they have not seen the expected surge of patients, did set up a 24-7 line during COVID-19 that connects long-term care homes to doctors and other health-care providers to help keep residents in their home.

“Since the beginning of the pandemic, we have received long-term care and retirement home residents with COVID-19 into our hospitals and will continue to do so as needed,” said Dr. Wes Stephen, chief operating officer at Hamilton Health Sciences. “In addition, LTC homes can now connect with ED physicians and other medical specialists 24-7 through virtual and telephone access, and we have started the process to deploy staff to LTC and retirement homes as the need arises in our community.”

Hamilton was back to having double-digit increases in cases for the first time in a number of days with 14 new confirmed cases Friday bringing the total to 483 plus five more probable.

Ontario also saw a larger-than-normal increase of 477 infected to 19,598 confirmed cases.

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