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

Outpatient Case Study

Prior to recommendations for social isolation given the pandemic, Aubree Baker, a 91-year-old woman with a history of neuropathy, pseudogout, fatigue, and pain, was referred to the outpatient palliative care clinic for ongoing management of symptoms, end-of-life planning, and anticipatory guidance. Aubree stated that she gained interest in palliative care after hearing an hour-long radio program about it, prompting her to request a referral from her primary care provider. The reason for the visit in the client's own words were that she was "tired of this" and elaborated that she wanted to stop going back and forth to the hospital, did not want to proceed with further diagnostic testing, and wanted to live out her last days in comfort with her family. She wondered if these desires classified her as suicidal and asked for reassurance that palliative care was not a form of assisted suicide. Aubree identified that her goals were to reduce hospitalizations, treat her neuropathic pain, improve sleep quality, maintain involvement with family and grandchildren, and manage other symptoms as they developed. Aubree's children accompanied her to the visit, and the client clearly stated that she would not make any decisions without their input. Overall, Aubree's family was supportive of her desires and previously stated goals.

In terms of symptoms, her burden was relatively low. Aubree expressed that she did not currently have any symptoms of anxiety or depression, but stated that she intermittently experienced symptoms of depression related to "traumatic life events," including the death of her mother and sister. It should be noted that after the visit, Aubree's daughter pulled the nurse practitioner aside to state that she did, in fact, believe her mother to be actively depressed, wondering if this could be addressed over time with palliative care. Aubree admitted to being fatigued, but related this symptom to difficulty sleeping. She noted that she was "bone tired" after dinner and usually went to bed early. She would easily fall asleep, but found that the pain made it difficult to sleep restfully through the night.

Aubree reported independence in most activities of daily living and lived with her daughter in a 2-story home equipped with a motorized chair lift for the stairs. Aubree ambulated with the use of a walker as needed. She had an unintentional 50-lb weight loss over the last year and reported one fall within the last 6 months.

The client noted that her children were supportive and had 3 who lived locally and 3 who lived out-of-state. She had several grandchildren who visited regularly and found much joy in these visits. Aubree stated that she "used to be Catholic" but no longer identified as such and simply considered herself to be a spiritual person.

After an initial discussion with the nurse practitioner of her symptoms, overall goals, and what palliative care could offer to her and her family, Aubree confirmed that she would like to change the medical order to a do-not-resuscitate status and limit her trips to the hospital. The client and her family felt comfortable with moving forward with a comfort-focused plan of care and discussing hospice initiation as she approached eligibility.

Over the course of several months, Aubree was seen monthly for ongoing discussion, symptom management, and continued evaluation as she approached her end of life. A minimum of 2 children were present with her at every visit, and regular family meetings were conducted with 3 children physically present and 3 children present by phone. After each meeting, a representative from the children would meet separately with the provider to clarify any questions or concerns and to communicate specific thoughts and anxieties from the children's perspective.

Pandemic Challenges to Outpatient Palliative Care

With the onset of COVID-19 regulations and reduction of in-person visits, the number of people allowed to attend visits with patients was severely limited. Prior to the pandemic, the client and family had developed a relationship with the provider and clinic staff and had a specific routine for discussions and relaying of information. Not only had the client benefitted from having her children physically assist her to the office, but also having 2 or more present allowed Aubree to hear their perspectives on difficult discussions. The client and family were able to transition to telehealth and video visits during COVID-19 restrictions; however, they expressed a sense of loss for the in-person connection and feeling of caring that has come to be synonymous with palliative care.

While this client lived with a child, she still experienced feelings of isolation. Like other clients, her physical connection and ability to visit with family were limited to the immediate household. This is exceptionally difficult as patients approach their end of life. Aubree had expressed one of her overall goals was to spend quality time with all family members, but found this to be severely limited because of quarantine and stay-at-home restrictions. In addition, Aubree expressed feelings of isolation from her provider who had previously been a strong source of support. The client and family had concerns about moving forward with hospice, as they were worried that they would not be able to experience the full benefit and robust services offered by the hospice agency because of local and national restrictions. Ultimately, with planning and communication between the client, provider, and hospice agency, Aubree was admitted to home hospice and able to die with dignity and comfort at home surrounded by family.

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