COVID-19 Shines a Spotlight on the Age-Old Problem of Social Isolation

Karen Harden, DNP, AOCNS; Deborah M. Price, DNP; Heidi Mason, DNP, ACNP-BC; April Bigelow, PhD, AGPCNP-BC, ACHPN

Disclosures

Journal of Hospice and Palliative Nursing. 2020;22(6):435-441. 

In This Article

Inpatient Case Study

Tom and Lila Doane, married for 64 years, had served as missionaries and traveled extensively worldwide until about 2 years ago, when they settled back in the United States into a retirement community. At 83 years old, Tom was robust and healthy and had no medical history except for requiring an abdominal aneurysm repair 7 years ago, from which he recovered well. Per follow-up, Tom was instructed to report the occurrence of abdominal pain to his physician. About 6 months ago, he began to experience lack of appetite, persistent acute abdominal pain, and a 35-lb weight loss for which the physicians could find no etiology. After several delays within the medical system, his physician confirmed per biopsy that he had an aggressive form of lymphoma surrounding his aorta. The consulting oncologist directed him to be admitted to the hospital and receive curative chemotherapy. Because of the current COVID-19 pandemic, Lila was not allowed to stay with her husband at the hospital, which left Tom hospitalized and alone. The Doane's daughter traveled from out-of-state to assist her parents through this medical crisis and provide support with health care team communication and medical decision-making. Honoring Tom's wishes, Lila and her daughter delivered advance directive paperwork in-person to the hospital social worker that indicated he did not want to be resuscitated.

Pandemic Challenges During Hospitalization

Once hospitalized, Tom rapidly declined in health. He did not tolerate the chemotherapy well and became very frail and deconditioned, suffering intractable pain and lack of appetite. His daughter had phone conversations with the oncologist to determine if there were other options rather than chemotherapy with the intention of curative treatment, but was met with strong resistance from both the oncologist and social worker who repeatedly indicated that there were no alternative treatments or options. No discussions between the family, social worker, or oncologist included quality of life or what Tom would want. Family members were left feeling helpless and unsupported and particularly distressed that their father/husband was in agony, and alone. The bedside nurses provided some emotional support to the family and were especially apologetic that Lila could not be at her husband's bedside.

Within the 10 days that Tom was hospitalized, family were allowed to come briefly to his bedside following 2 medical emergencies, one in which cardiopulmonary resuscitation was performed against Tom's wishes as identified in his advance directives, and the other when he was moved to the intensive care unit for life-threatening bleeding. At this time, Lila, supported by her faith, bravely informed the oncologist that the family wanted Tom moved into hospice care and brought home. She expressed that she felt like she was disappointing the physician by not accepting his care, but wanted to honor her husband's wishes. The medical community reluctantly complied with the family's wishes and provided access to hospice care, which streamlined Tom's transition home.

Transition to Hospice Care

Once home, medical equipment and pain medications were rapidly obtained, and for the first time, Tom was made comfortable with tolerable pain levels. Hospice nurses recognized appropriate goals of care and supported the family as they lovingly cared for their father/husband. In approximately 1 week, Tom died peacefully at home, with limited family members at his bedside because of the pandemic travel restrictions. His family decided to limit visits of extended family as he approached his end of life. This was not related to COVID-19, however, but was a conscious choice in an effort to maintain a more peaceful environment for Tom. Other disconcerting challenges for the family in the midst of the COVID-19 pandemic included not being able to have an immediate memorial service for family and friends following Tom's death, although they plan to do so in the future.

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