Fahad Razak is a general internist at St. Michael’s Hospital and an assistant professor at the University of Toronto. Laveena Munshi is an intensive care physician at Mt. Sinai Hospital and an assistant professor at the University of Toronto. Gerald Evans is an infectious disease specialist at Kingston Health Sciences Centre and a professor at Queen’s University. All are members of Ontario’s COVID-19 Science Advisory Table.
Decades of advocacy from patient groups have made hospitals more welcoming to families and patient caregivers. According to a 2015 report by the Canadian Foundation for Healthcare Improvement (CFHI), only 30 per cent of Canadian hospitals had policies that were accommodating to visitors; the CFHI released another study in June that found that number had risen to more than 70 per cent, immediately before the start of the COVID-19 pandemic.
However, as concerns around COVID-19 escalated, hospitals enacted a marked reversal in visitor policies. The CFHI’s April survey of 35 adult-care hospitals across Canada found that every hospital studied had implemented a near-complete restriction on visitors, except in very limited circumstances.
As frontline physicians, we have never before witnessed the kind of sustained anguish that has emerged with the separation of patients from their loved ones. We’ve spent many hours on the phone trying to bridge these gaps, relaying information on prognosis or the nuances of medical updates. But virtual communication technologies can only do so much. The worst pain came when our patients died without loved ones to provide comfort in their final moments.
Being a placeholder for a family member is a heavy responsibility. A French study published in the American Journal of Respiratory and Critical Care Medicine found that critical-care clinicians expressed deep regret and symptoms of depression around visitor restrictions during the COVID-19 pandemic.
We believe that overly restrictive visitation policies do not reflect the most up-to-date science about either COVID-19 transmission, or the crucial role of family and caregivers in medical care.
First, it’s important to acknowledge that restrictive visitation policies were created with good intentions. Canada was facing a novel coronavirus with unknown lethality and potential for spread. Hospitals were a known failure point in other health systems that had been overwhelmed by COVID-19. Additionally, there was concern early in the pandemic about personal protective equipment supply and visitor restrictions were one way to maintain capacity.
Today, we know a lot more about this disease. COVID-19 has been the focus of historically intense study. And reviewing this literature suggests that at most, hospital visitors play a small role in disease transmission. For example, a study of more than 9,000 hospitalized patients in the United States found only one instance where a pre-symptomatic visitor with COVID-19 resulted in a patient becoming positive.
In contrast, there is overwhelming evidence supporting the role of family and caregivers in providing the best possible medical care. They facilitate communication and decision-making, and act as patient advocates and substitute decision-makers when patients are no longer capable.
Surgical patients exposed to visitor restrictions during the pandemic experienced delays in receiving medication, had greater difficulty getting out of bed, and were more likely to be discharged without their wishes being considered. The presence of family and caregivers decreases the rate of delirium, an acute state of confusion that can occur during hospitalization.
After the 2003 SARS crisis, the Campbell Report argued that Canadian healthcare providers should adopt the Precautionary Principle: “…that action to reduce risk need not await scientific certainty.” This was prudent advice at the time, given that more than 40 per cent of all SARS cases were among healthcare workers. But have we over-learned this lesson? The risk-benefit ratio of existing science now clearly favours allowing family and caregivers to visit hospitalized patients. It’s also the humane thing to do.
Hospitals have reflected on the lessons of the first COVID-19 wave and some are loosening visitor restrictions, but much remains to be done. We must reintroduce families and caregivers in a carefully staged manner, while remaining humble about our evolving understanding of COVID-19. That means monitoring carefully for disease transmission, and reacting nimbly if it does occur.
Safe and transparent policies will be required. For example, the number of visitors will need to be limited in order to make physical distancing feasible. Rapid testing, when it becomes available, may be crucial for screening. And circumstances – such as large-scale hospital outbreaks or high rates of community spread where visitor restrictions are required – might evolve.
We have many months to go before enough Canadians are vaccinated to break the transmission chain of COVID-19. During this time, tens of thousands of Canadians will be hospitalized. We owe it to them to allow their families and caregivers to be at their bedsides.
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