Visitor Restrictions During COVID-19 Pandemic May Impact Surrogate Medical Decision-Making

Abstract

I was recently rounding as a hospitalist on a general medical floor. A patient who had been in the hospital for nearly three weeks showed up on my list. His chart was dense; it was surprising he had survived thus far, in and out of intensive care to intermediate units with hemorrhagic shock, respiratory issues, and sepsis. At baseline, he was on chronic ster-oids for an autoimmune disease and was tracheostomy and dialysis dependent. He had also had a Roux-en-Y gastric bypass years before. During the course of his hospitalization, he was found to have severe dysphasia, and despite efforts of our speech and swallow therapists, he was unable to regain any safe swallow function and was made strict nothing by mouth status. While he was mostly lucid, but he had pulled out at least 3 naso-gastric tubes during periods of confusion and frustration and refused to have another placed. Surgery was consulted for a possible feeding tube. Given his poor overall functional status and his history of having gastric bypass, the surgery team felt he was not an appropriate candidate for this surgery and raised the question of initiating total parental nutrition (TPN). This patient was in his late 60s but he appeared to be in his 90s and on death's door. His body mass index could not have been more than 13 or 14 and he was covered in ecchymoses and had more skin tears than I could count. He was extremely weak; even to hold his tracheostomy tube closed so that he could speak seemed to take great effort. When I examined him I did so with great caution because it seemed like I could break his bones if I pushed my stethoscope in too deeply to listen to his rhonchus lungs. Also, he was a full code. Palliative care was already on board when the patient was transferred to my floor. There had been questions about the patient's capacity to make decisions at times, but he mostly seemed extremely anxious but cognitively intact. However, when he received small doses of lorazepam to treat his anxiety , he would become nearly unresponsive for hours. Family was included in all decision-making, but the patient seemed to just agree with whatever his daughter, who had power of attorney, said regardless of his cognitive status at the time. A complicating factor was that visitor restrictions had been put in place due to COVID-19 while the patient had been admitted. His family was able to visit early in his hospital stay, but once restrictions were placed, they were unable to visit him. This was not a COVID-positive patient, but COVID was certainly affecting his care. Family would primarily talk on the phone with the patient, but again, speaking seemed to take a great deal of effort for him and so the conversations were short. In addition, the palliative care team had arranged multiple video family meeting calls using FaceTime. Despite being updated by providers regularly and the direct communication she had with her father, the daughter did not seem to comprehend, or perhaps did not want to, her father's poor functional status and prognosis. A fourth FaceTime call was arranged with myself, the patient, palliative care, and his family on a late afternoon. He tended to be calmer and more alert in the afternoons and I had changed his as-needed medication for anxiety to low-dose quetiapine, which he tolerated much better than lorazepam which I believed was causing symptoms of hypoactive delirium in this patient (1). The patient was mentally clear during this time, and given my psychiatric background , I made sure to assess his capacity during the conversation as well. We discussed his full code status and the unlikelihood he would survive resuscitation. We also discussed the risks of TPN and that it also meant the patient would probably never be able to enjoy his favorite salty snack foods again. Many tears were shed, but ultimately, the journals.sagepub.com/home/jpx Creative Commons Non Commercial CC BY-NC: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).