Are nursing home residents expendable?

Our leaders have told us to stay home- to shelter in place. Yet for many of the 1.5 million elderly nursing home residents, the home has become an unsafe and sometimes dangerous place. 

To be sure, the SAR Cov-2 or COVID-19 virus is rampant in the United States. As of this writing, more than 800, 000 persons have tested positive in the United States, thousands of whom are nursing home residents. While a relatively fierce war is underway against COVID-19, its parallel war in the nursing home is weak and disjointed with plans of action that are underdeveloped and confusing. 

Daily, public health pundits and media spoke-persons talk pithily about the vulnerability of the elderly, but not about what we can do for the elderly in our nation’s long-term care facilities, including nursing homes, assisted living, and veterans’ domiciles. Television and radio stations continue to interview pulmonologists, infectious disease specialists, talk show hosts with medical credentials, and epidemiologists. Still, no one speaks to the geriatricians — the small and highly educated team of physicians singularly committed to and most knowledgeable about older adults and the facilities to whom many have retired.

Undoubtedly, COVID-19 virus testing is lacking in the congregate long-term care (LTC) domain, making it difficult to quantify the magnitude of the infection and the number of lives lost. Because of the communal nature of these domiciles and the fragile physiologic state and attendant comorbidities of these residents, the odds of survival is low. Kirkland, Wash., the previously designated epicenter of the virus in March 2020, saw many elders from a local nursing home succumb to COVID-19.

The Coronavirus Aid, Relief, and Economic Security Act (CARES/ H.R. 748) passed in the Senate on March 25, 2020, and allocated $200 million for the Centers for Medicare and Medicaid Services (CMS) to help nursing homes fight the spread of COVID-19. Still, there’s no executed national policy focused on the elderly nursing home resident who lives in the shadows, forgotten and abandoned.

The CDC’s checklist for long-term care facilities includes a recommendation that “The facility has a system to monitor for, and internally review, development of COVID-19 among residents and healthcare personnel in the facility.” How can LTCs execute this recommendation and many of the others on the CDC’s list when these facilities lack virus-testing abilities, have rampant staffing shortages that pre-date COVID-19, and insufficient personal protective equipment (PPE).

In every state across the Union, residents of nursing homes are dying alone. Given that every state in the Union has infected persons, why is there no accurate accounting of the number of deaths? With the patchwork of systems and lack of a cohesive military plan, LTCs remain open and vulnerable to viral invasion. In a war, the likelihood of victory increases when one knows the profile of the enemy and its modus operandi, yet nursing home staff receive very little education as to the ever-changing treatment recommendations. The ability to resist the enemy with speed and efficiency is crucial to victory, yet nursing facilities are anemically staffed and desperately lacking in PPEs. 

A sampling of incomplete virus numbers across the country is alarming, with cases in every single state and county. Against the backdrop of these cases is the absence of concerted federal and state policies to protect nursing home residents. To be sure, individual nursing homes are struggling to care for residents in a physical environment akin to a dry forest surrounded by lit matches and no fire engines in sight. Clearly, the nurses and nursing home assistants are unsung heroes on the frontline. 

These facilities are overwhelmingly staffed by people of color who themselves are at high risk for the COVID-19 infections; they are overworked and under-resourced heroes making less than minimum wage; workers who feel forced to work when sick, or forego paying rent and buying food for their families. In Chicago where African Americans comprise only 30 percent of the population and account for more than 50 percent of cases and 72 percent of deaths to COVID-19, they are also the ones who provide most of the frontline care in nursing homes.

What can patients and their advocates do? Ask your mayor and governor to implement nursing home-wide testing immediately. Advocate for double negative testing of all hospital discharges entering your nursing homes. Maintain a strict “no visitor” policy. Demand more transparency in reporting of numbers of new cases and of deaths from COVID-19 in nursing homes. Facilities must immediately notify patients and families of status or status change in nursing homes. A hospital must do its part by ensuring COVID-19 rule out is done and must use more reasonable criteria to determine who to test. For many elderly, a change in mental status will be the primary indicator of infection, not whether or not they have traveled recently to New York. Furthermore, fever, the cardinal sign of infection, may be absent or blunted in the elderly 20-30 percent of the time. 

It has been said that a unified army is important in battle, but in this fight against COVID-19, we lack such an army. Given the lack of a cohesive battle plan on the federal level, we are poised to lose this terrifying war. Aspirations to flatten the curve and regain some vestiges of normalcy will fail unless universal testing begins immediately in nursing homes. To be sure, without such a strategy, nursing homes will become the greatest contributor to our country’s rising death toll. 

June M McKoy, M.D., MPH, J.D., MBA, is an associate professor at Northwestern University Feinberg School of Medicine. Anna Liggett, M.D., is a Fellow in Geriatric Medicine at Northwestern University Feinberg School of Medicine. Fernanda Heitor, M.D., is an instructor in Medicine at Northwestern University Feinberg School of Medicine.