COMMENTARY

Let's Stop the Draconian Visiting Restrictions

Tom Alsaigh, MD

Disclosures

May 27, 2020

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As society grapples with the multifaceted devastation caused by the COVID-19 pandemic, patients and families worldwide are left to wonder what the path forward will be to mitigate the profound psychological fallout from visitor restrictions imposed by hospitals, nursing homes, and care facilities. As F. Scott Fitzgerald wrote, "The loneliest moment in someone's life is when they are watching their whole world fall apart, and all they can do is stare blankly."

His words capture the feeling around the deeply disturbing visitation policies in place from both the patient and the family perspective. Not only are patients with COVID-19 isolated and treated as social pariahs, but families are helpless in their efforts to touch and comfort a loved one in a time of exquisite need.

Consider non-COVID-19 hospitalized patients as well; their trauma is just as distressing as they live a digital nightmare with their families via blurry videochatting about risky surgeries and end-of-life care. The despair felt by forced separation of patients and families during this time is overwhelming. A meta-analysis showing loneliness as a key driver for all-cause mortality underscores the critical need for in-person social support for patients. Anecdotal sentiment from patients and family members suggests that while videochatting services help somewhat, they are inadequate at alleviating the consequences of physical isolation.

Families' descriptions of the intense trauma they experience because of these restrictions should also worry society about the unintended consequences of such draconian policies, including a widespread increase in post-traumatic stress disorder (PTSD) in both patients and families.

One particularly poignant moment shared by a colleague involves the desperation of a dying father—with a non-COVID-19–related illness—to see his son with autism one last time before passing away. Despite multiple attempts by staff to grant this dying wish, the request was ultimately denied due to a nebulous on-the-spot policy decision that a child with autism may not be able to appropriately wear a mask while in the hospital. The father died shortly afterwards without seeing his son. That same day, a hospital staff member whose father was intubated due to COVID-19 was agonized by the difficulty in obtaining updates about her loved one's medical status. It was gut-wrenching to watch.

[I]t is not impossible to imagine a scenario where the benefits outweigh the risks of reuniting family members, if done carefully and methodically.

The consequences of this are real and tangible. For example, in women, PTSD is associated with significantly higher total healthcare costs, even after controlling for depression, chronic medical illness, and demographic differences. Failure to address this visitation quandary will almost certainly mean a significant increase in PTSD and other psychological sequelae, the impact of which will last years if not decades.

Is society willing to accept this as the status quo until the crisis resolves?

Surely reconsideration of this policy requires a thoughtful approach in light of the dire consequences of continued societal spread of the virus. So, what is the solution? A measured policy based on compassion and scientific merit should be foundational and guide decision-making on visitation privileges. The devastating lack of personal protective equipment has made this prospect more difficult. Understandably, hospital systems cannot afford to distribute this equipment liberally to family members, as it is essential to protect the health of frontline workers. Because of this, any policy that eases visitor restrictions will undoubtedly invite risk to patients and family members, but it is not impossible to imagine a scenario where the benefits outweigh the risks of reuniting family members, if done carefully and methodically.

First, limiting the number of visitors is necessary. A one-visitor-per-patient rule will help minimize overall exposure. The visitor is screened at the entrance for fever and, if afebrile, is escorted directly to the patient's room by a dedicated staff member. The visitor may not leave the room for other purposes until ready to leave the hospital. Once ready, the visitor is given instructions to minimize contact outside the home environment and is escorted out of the hospital.

Next, face masks have garnered significant attention lately as a way to mitigate viral spread. Culturally driven opinion about face masks aside, the efficacy of these masks in reducing the emission of coronavirus in large droplets and aerosols is generally accepted. This has led to systemic societal change, with the CDC now recommending the use of cloth face coverings in addition to social distancing while out in public. This policy would accompany any visitor to a hospital or other healthcare center. Face masks must be worn at all times, without exception. Instructions on proper face mask hygiene, including not touching the front of the face mask directly, should be provided to both patients and family members.

Finally, appropriate social distancing, both in patient rooms and outside of the hospital, should be stressed to every visitor. Reminders of the importance of this in reducing viral spread should be reiterated at every opportunity.

I argue that this is a worthwhile risk which may significantly alter the trajectory of the unimaginable despair felt by family members affected by this crisis. We must care about this. We must address this issue and challenge the current dogma, if for no other reason than to prevent a significant portion of humanity from staring blankly as their whole world falls apart.

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