One of the grimmest realities for hospitalized COVID-19 patients is that if they die, it's without the presence of loved ones.
Hospitals have responded to the contagion and subsequent shortages of personal protective equipment by barring visitors. On top of that, caregivers wear masks, face shields and gowns, diminishing the human connection they can establish with dying patients.
“We were all pretty struck by the way that our patients were dying and approaching the end of life,” said Dana Nelson-Peterson, vice president of nursing at Virginia Mason Health System.
Executives at the Seattle-based system wanted to do better for the patients and challenged nursing leaders in early April to find a way to safely allow families to visit dying coronavirus patients.
The new program, which has been in effect for about six weeks, relies on nurses who volunteer to escort, oversee and comfort visitors.
Nelson-Peterson said the idea arose after nurses in the ambulatory setting were furloughed in late March. Nurses said they wanted to help despite the furlough, so there was a workforce available for the program.
But the role isn’t for everyone, Nelson-Peterson said. It involves witnessing and comforting people during tough moments. The nurse also can’t be afraid to interrupt or stop someone from lifting their mask or touching their face during an intimate moment.
The nurse leaders asked managers to recommend nurses who they thought would be appropriate for the role. Rebecca Maxim, a nurse for 20 years at Virginia Mason, was one of them. She currently works in an infectious disease outpatient clinic at the system, but she has 18 years of hospice experience. She also tended AIDS patients in the early 1990s.
Six other nurses agreed to participate.
The process starts with a nurse calling the family to provide options for saying goodbye. Phone and video calls are encouraged. “It’s a high-risk area to go into even with your PPE on,” Nelson-Peterson said.
If a family member insists on coming in person, which nearly all relatives choose, the nurse directs them to a special entrance.
A nurse oversees the family member putting on and taking off their PPE correctly, a process called donning and doffing. Only if the patient has undergone an aerosolized procedure will the family member need to wear an N95 mask. In addition to a surgical mask, the family is given a face shield, gown and gloves to wear.
Nelson-Peterson said the program is only possible because Virginia Mason has an adequate supply of PPE, which has stabilized since the pandemic initially emerged.
In the patient rooms, the nurse stays nearby to observe proper PPE protocol and offer comfort to the grieving individual.
Usually it’s a tough sight for the family, Maxim said. Patients might be hooked up to a ventilator and heavily sedated.
When they are ready to leave, the equipment is removed under supervision and a nurse leads the loved ones out of the hospital with a mask on. Maxim said in her time as a hospice nurse she learned there are many ways people show grief, such as through anger or resentment. “You have to be ready for all of it,” she said.
Virginia Mason’s palliative-care group also follows up with the family member to see how they are doing.
Fewer than 10 families have gone through the program. Families are appreciative and nurses find it rewarding, said Jessica Dunn, director of the Virginia Mason Kaizen Promotion Office.
The nurses on furlough started going back to work last week, so the program will now rely on a shared pager that notifies nurse leaders when a patient is nearing the end of life. That group dispatches an available volunteer.
Maxim said even though she’s going back to the outpatient clinic, she’s going to be on call for the program.
Given projections for the pandemic, Nelson-Peterson said, “I don’t see this program going away. The pool of staff who want to participate will likely grow. We are in this for the long haul.”