Michael Kelly
St Mary’s Hospital in Dublin’s Phoenix Park Ireland has been quick to congratulate itself on the response to Covid-19, but for all the rhetoric there is precious little evidence that talk of solidarity extends to nursing homes, writes Michael Kelly
When this current pandemic passes – and pass it will – undoubtedly many people will breathe a sigh of relief. Those unable to exhale such a relief, of course, will be those who have lost their lives in residential care where the coronavirus has been particularly devastating.
From day one, the information – such as it was – being released by the communist authorities in China indicated that Covid-19 was having a bigger impact on older citizens.
As The Irish Catholic went to press this week, the Health Protection Surveillance Centre reported that of the 610 Covid-19 related deaths in Ireland, the median age of those who died is 83. This is despite the fact that the median age of confirmed cases is 48 years.
Nursing homes are bearing the brunt. Coronavirus has infected roughly a third of all such facilities across the State with 335 outbreaks in residential care settings.
A prominent doctor appointed by Health Minister Simon Harris to the Medical Council two years ago has resigned in protest at what he has described as the Government’s alleged “blunder” in regard to nursing homes.
Management
Dr Marcus de Brun, who runs the Rush Family Practice in Co. Dublin, accused Mr Harris of failing in his obligations to the people of Ireland. He described the management of the Covid-19 crisis as “the biggest political blunders in the history of the Irish State”. Dr de Brun said those most at risk have “featured as something of an afterthought” to the Government in the pandemic.
“Unquestionably the most vulnerable cohort of patients in Ireland are those residents of nursing homes. This fact should have been entirely obvious to all involved in the management of the crisis,” he wrote in his letter of resignation.
“Most of these individuals are of course elderly and most have significant underlying health conditions. Nursing home residents cannot or could not be expected to avail of the same measures applied to the general public,” Dr de Brun said.
“It beggar’s belief, and remains an evolving tragedy, that these vulnerable people were not considered as the first priority for the State, rather than being the last to be considered.”
He also revealed that guidelines were used to refuse elderly people being tested in nursing homes. He said that until April 9, “nursing home residents were refused testing in nursing homes where Covid-19 had already been detected. Nursing home staff were advised ‘to presume everybody has it’. Residents who had been booked for testing by their GPs were summarily removed from the queue for testing, without the requesting GP even being informed.”
He said that only “after an outcry from some GPs and nursing home managers, was this rule/guideline changed”.
****
One in five residents of nursing and other care homes believed to have died of Covid-19 were never tested for the disease, new figures reveal.
Nursing and other long-term residential facilities now account for almost 60% of virus-related deaths, according to the figures released by the National Public Health Emergency Team (NPHET).
Of the 406 deaths linked to care homes, 77 are classified as “probably or suspected” and were not confirmed by laboratory tests, according to a breakdown provided for the first time by NPHET.
Nursing homes specifically account for almost half of all deaths in the current outbreak – 337 out of 687 total cases, of which 61 have now been classified as probable or suspected.
Emergency departments
In St Mary’s Hospital in Dublin’s Phoenix Park, there have been 15 Covid-19 related deaths. Many other service providers tell a similar story.
But, is this a case of bad luck or were some of our most vulnerable citizens failed?
All of the evidence is that nursing home operators acted swiftly. In early March, many reported that they had restricted visiting in a bid to stop residents contracting the virus. On March 10, they were advised by public health officials that this was unnecessary.
For Aontú Leader Peadar Tóibín, the shift is hard to fathom. “We have been analysing the situation in nursing homes from the very beginning of this crisis, and it’s difficult to now to comprehend that on March 10 the Government advised that ‘socially restrictive actions around hospitals and nursing homes are not necessary’.
“As the situation quickly escalated, little action was taken,” according to Mr Tóibín.
It was March 30 before Minister for Health Simon Harris met with Nursing Homes Ireland – the body which represents over 450 private and voluntary nursing homes providing care for some 25,000 citizens.
This has been a crisis that has been long in the making…it relates back to policy issues around the Department of Health over the past 20 years”
Following that meeting Tadgh Daly of Nursing Homes Ireland said that he had “informed the minister of the considerable challenges for hundreds of nursing homes in meeting the care needs of our most vulnerable during Covid-19.
“The challenges presented to the minister centred around timely access to PPE equipment and testing within nursing homes, the necessity for the State to recognise the essential need for nursing homes to be supported around the critical area of staffing, and the need for enhanced staffing and logistical arrangements during this emergency to be recognised in Fair Deal,” Mr Daly said.
That same day the Health Minister told the National Public Health Emergency Team to “examine the issues in nursing homes” and the following day Mr Harris announced that the HSE would work “to identify measures to strengthen support for staff”.
Mr Tóibín remains unimpressed. “Let’s be clear, by the end of March, while the Department [of Health] were busy thinking and brainstorming, nothing practical was actually reaching the frontlines.
“Finally, on April 1, the department banned nursing home visits. This decision was three weeks late”.
****
Prof. Des O’Neill, a consultant geriatrician at Tallaght University Hospital in Dublin is adamant that what is playing out now is the failure by successive ministers for health to prioritise care for older citizens. He is adamant that blame for the failure to prevent the catastrophic spread of the virus in care homes rests squarely at the doors of the Department of Health.
“This has been a crisis that has been long in the making,” Prof. O’Neill told Brendan O’Connor on RTÉ Radio One at the weekend.
“It relates back to policy issues around the Department of Health over the past 20 years.” He said senior officials who make policy have overseen privatisation “without due attention to adequate support systems or engagement with the HSE or the nursing home sector”.
Linkage
Prof. O’Neill warned that there is “not enough appropriate linkage into the public health system.
“What we have are a range of small to large businesses that do not have this clarity of leadership,” he said.
“The issue is around policy-making in the DOH, which has not adequately put into place linkages with the public health system…this has been absent in the nursing home sector, and not through any fault of the HSE or its staff.”
According to Prof. O’Neill – who wrote the Leas Cross report that revealed substandard living conditions in that home leading to the deaths of some patients – “They [staff in nursing homes] are working in a system that is not actually a system…This system has not been set up with any clarity in leadership or expectations”.
This is not just about Covid-19, although it has brought it into sharp focus. It is not just about rationing. It is about us as a society, doctors with their patients and families and individuals, discussing end of life”
On the tragic Covid-19 deaths in nursing homes, he insisted that “this is a reflection that we really, badly, need to rethink pay, conditions, support structures and engagement with the public health service and leadership in the nursing home sector.”
He contrasted the situation in Ireland with that of the United States where each care home is required by law to have a medial director to take charge of the clinical needs of residents.
****
Another point of unease is whether some older patients are being given a fighting chance to beat coronavirus. In the North, a member of the assembly has claimed that he knows of a case where a patient and their family were not consulted before a do not resuscitate (DNR) notice was issued by a Belfast hospital.
Some elderly residents have voiced fears over the use of such measures during the coronavirus pandemic when doctors are having to make difficult ethical decisions while allocating ventilators.
Some patients could have acute treatment withdrawn to instead offer it to those with a greater chance of survival, guidance has said.
Arrangements
Alex Easton, a DUP Assembly member on Stormont’s health committee, alleged neither family members nor patient were consulted before a DNR notice was issued for someone who was conscious at the Ulster Hospital near Belfast.
Elsewhere, a senior medic has urged frail patients to discuss end-of-life arrangements with their families while they are still well.
Dr Hamish Courtney, from the Royal College of Physicians, said it is important that those dying from coronavirus do so peacefully.
Stormont’s Health Committee was taking evidence on decisions whether to ventilate and the use of DNR notices for the weakest.
Dr Courtney said: “This is not just about Covid-19, although it has brought it into sharp focus. It is not just about rationing.
“It is about us as a society, doctors with their patients and families and individuals, discussing end of life,” he said.
Talk of rationing when it comes to the lives of vulnerable elderly citizens will leave most people cold. There’s also the fact that many frail patients may have considered end-of-life care in the context of a terminal diagnosis or when they are considered to be suffering from a fatal pathology.
Catholic principles do not dictate that life is sustained at all costs, but do provide a moral framework where patients are given a chance to survive and thrive.
Church teaching explicitly affirms that a patient or, if the patient lacks competence, his or her proxy can rightly refuse treatments that do not offer a reasonable hope of benefit or entail an excessive burden, or impose excessive expense on the community.
But, what is the role of a DNR in the context of coronavirus?
“Significantly many residents of nursing homes have ‘do not resuscitate’ and not for transfer directions on their end of life plans,” Mr Tóibín says. “But these directions were decided upon before anyone had heard of Covid-19.
“Questions must be asked with regards how many of these residents would have survived Covid-19 if they had the benefit from hospital treatment and ICU care,” he said.
****
The failures to support nursing homes and other residential facilities is also part of the broader pro-life context.
Pro Life Campaign spokesperson, Maeve O’Hanlon said that “the fact that almost half of all deaths to date from Covid-19 in Ireland have occurred in nursing and residential homes is a devastating statistic. It was always going to be an immensely difficult challenge to protect the elderly and most vulnerable once the virus took hold, but a clear picture is starting to emerge that protecting residents of nursing homes was not given the priority it deserved when the HSE and others were planning their response to this crisis,” she said.
Ms O’Hanlon also raises the uncomfortable issues of whether or not the State was hindering homes from getting vital staff, equipment and supplies. “The claim from nursing home representatives that the HSE were also actively poaching frontline staff from nursing homes to reassign to hospital settings as the Covid-19 crisis started, is very troubling. So too is the claim that acute hospital beds were freed up by moving patients to nursing homes, which in turn likely contributed to the spread of Covid-19 in these homes.
My sister is not a statistic…and neither is she or anyone who dies because of Covid-19 or who has tested positive”
“It is clear from these and other decisions taken that nursing home residents were effectively abandoned by the Government at the early planning stage, leading to the catastrophic situation we now find ourselves in.
“The Government and National Public Health Emergency Team (NPHET) must be held more accountable for their actions. And that accountability needs to happen immediately. With each passing day more and more lives are being lost. No stone should be left unturned to assemble the expertise needed to protect the lives of our beautiful and beloved elder and dependent citizens, who deserve nothing but the very best care and protection from this State.
“It is a terrible indictment of our society that our elderly and most vulnerable citizens became the forgotten people when they should have been a top priority,” she said.
The available evidence would certainly point that these vulnerable citizens were far from the top priority. And news broke late last week that eight patients with Covid-19 died over the bank holiday weekend in a Co. Laois facility. All were residents of the Maryborough Centre for Psychiatry of Old Age located in the St Fintan’s Campus in Portlaoise.
The local bishop Dr Denis Nulty said that the devastating news “brings home to us in a very dramatic way the huge need for special care for those who are grouped together in similar centres or in homes for vulnerable or older people.
“We pray for those who have passed away in such distressing circumstances. We offer our deepest sympathy to the families and friends of the deceased. We give them and all who have worked to care for their loved ones the assurance of our prayers,” the Bishop of Kildare and Leighlin said.
“A very special word of thanks to all who work in any capacity in caring for those who have contracted or are threatened with this terrible virus – management, medical and nursing staff, carers, general workers in those centres and hospitals, suppliers and those who deliver those supplies to meet the many varied needs at this time of crisis.
Treatment
“The hearts and hands of the staff are the hearts and hands of family to many, many patients at this time. It is imperative that the best possible treatment is made available to those who are most vulnerable to Covid-19 and that staff working in these homes and facilities are equipped with a sufficient and proper supply of PPE. Every life matters. Every life counts. Every life is precious irrespective of age or potential productivity,” Bishop Nulty said.
“In the nightly news reports, we hear many statistics that may confuse us. I am conscious that we might lose the person that is behind every statistic – this is someone’s mother, father, grandmother, grandfather, brother, sister, son, daughter or friend. I am reminded of the very evocative poem composed and recited by a listener in memory of her recently deceased sister, on Joe Duffy’s Liveline, broadcast on RTÉ Radio One, earlier this week. My sister is not a statistic.
“And neither is she or anyone who dies because of Covid-19 or who has tested positive,” the bishop added.
As Fine Gael and Fianna Fáil prepare for what is being described as an historic deal to enter coalition government, those who were desperately failed during this crisis and their families must have accountability. The rush to don the green jersey and join in the national effort – particularly by journalists – must not stop the excavation of failures that have had the most devastating of consequences.