No easy choices: COVID-19 in residential aged care

OVER the past few weeks, we have seen a rapid increase in the incidence of coronavirus disease 2019 (COVID-19) in residential aged care facilities (RACFs) in Victoria. Understandably, this is causing growing anxiety in the community, and particularly for the families of residents of RACFs. Here in Queensland, we have been watching events with some trepidation, knowing that we are but one asymptomatic carrier, or a trio of thoughtless travellers, away from similar challenges.

As has been laid bare by Australia’s Royal Commission into Aged Care Quality and Safety, there is a wide range of long-standing flaws and failings in our aged care system that will need to be addressed in coming years. However, while understanding the origins for these issues is important, and some may wish to sheet home responsibility, the identification of long term solutions will not have any impact on how to deal with the immediate challenges posed by the current pandemic.

There are many things that cannot be known about a new infection, and we will only gain a useful understanding of how COVID-19 plays out in our community after it has happened. Our leaders, scientific experts and decision makers are facing some very difficult choices on a background of great uncertainty about the best, or perhaps we should say the least worst, option.

What we do know:

• strict social isolation can control spread;
• lax behaviour, asymptomatic carriers and superspreaders can cause rapid outbreaks, with many cases remaining undiagnosed;
• hospitals and health systems can be overwhelmed, and even with the best personal protective equipment, health workers can become infected;
• many frail, sick and elderly people with and without known illnesses have a very poor prognosis, even with the best of technology, although the majority do not die (here and here);
• moving frail older persons from their place of residence is associated with a significant risk of harm, particularly due to confusion and delirium (here, here and here);
• young people can also get very sick and die;
• COVID-19 causes multisystem disease and may well have long term, perhaps lifelong, impacts on the health of some of those infected;
• some people experience no symptoms (here and here) whatsoever and it is not yet known why – it seems likely that this may be genetically determined;
• difficult triage decisions have been necessary in other countries and may also be required in Australia;
• there are many things that we don’t know.

You will note that I have not addressed the broader economic and social issues that compound the complexity.

So where does this leave our decision makers?

When we are not in the throes of a disaster, the interests of the community generally do not conflict with those of the individual members. Equally, at all times our leaders have a duty to maintain a balance between the interests of individuals and the broad interests of the community of individuals, particularly when considering the allocation of a significant proportion of finite resources to single or small groups of individuals.

Disasters, including pandemics, change everything. When faced by broad threats to the stability and security of society, the duty of leaders is to shift the emphasis of their actions from the immediate needs of specific individuals towards the broader intermediate and long term interests of the community. In some circumstances, that can mean withdrawing or withholding resources from some individuals; actions that may upset some people.

Every disaster requires a different response. Most of the disasters that have befallen us over recent times have been of limited duration, lasting hours to days – cyclones, fires, floods, earthquakes etc. The COVID-19 pandemic, however, must be managed as an event without boundaries, either geographic or chronologic. So far, most of the responses have been founded on the uncertain, but not unreasonable, expectation that a vaccine will allow the pandemic to be extinguished. The appropriate response to a pandemic that cannot eventually be aborted is a very different prospect that I will not address here.

The dilemma faced by our leaders is that identifying the best solutions that reflect the broad needs of the community and respect individual choices depends on information that cannot be known at the time when decisions must be made. Even just within the challenges posed by clusters of COVID-19 in RACFs in Victoria, we face a range of things that we cannot know:

• the proportion/numbers of members of the community who will become seriously ill;
• the impact of a policy of transferring some or all of the residents of RACFs where COVID-19 is identified to hospitals or other facilities;
• the vulnerability of the physical and workforce capacities of hospitals to the pressure of the pandemic and mass admissions;
• the longer term impact on frail older persons of being uprooted from their homes in RACFs, not to mention the consequences of social and physical isolation;
• the vulnerability of our hugely complex health system to the pressures of providing care for the unknowable numbers of people with COVID-19 and other serious illnesses who live in the community;
• that there are sufficient staff with the skills for caring for people with severe COVID-19 in addition to other serious illnesses;
• the impact on staff of the stress of caring for those with COVID-19 on top of the baseline care needs of others, along with the risks to them and their families;
• how to decide which patients will be likely to benefit from intensive treatment (although the harsh experiences of other countries have improved our knowledge);
• how to weigh the dynamic balance between individual autonomy of choice to accept or refuse treatment with the community’s power, and the need to limit supply and choose who to treat.

None of these uncertainties will be resolved until long after decisions about them will have been made. We all have opinions on the appropriate response, but these commonly reflect our individual parochial perspectives and relationships. We expect our leaders to create a plan from this dog’s dinner of interdependent variables and unknowns – and they only get one go at it.

Every solution creates winners and losers; some who will die of COVID-19 and other diseases, and others who will not. For a few examples:

• A decision to transfer elderly people from their home in an RACF to a hospital would kill some but prevent others from contracting and dying of COVID-19.
• Closure of RACFs that are not equipped to care for large numbers of people who are sick with a pandemic disease and admitting their residents to hospital and other facilities may overwhelm the receiving institutions.
• With about 60 000 people in RACFs in Victoria, it is not possible to transfer everyone, or even just the sickest, to hospitals without compromising the operation of facilities that are necessary for the care of others in the community with COVID and non-COVID illnesses.
• Health care workers in hospitals, and their families, are also at risk of COVID-19, and mass exposure to infected patients increases the risk to them and other patients, as well as to others, increasing the demands on the health care system.
• If the admission to hospital of residents of RACFs is restricted too tightly, and hospitals are not overstretched because the numbers of patients from the community at large is not as great as feared, then some people will die unnecessarily. If too many are admitted, then hospitals may be overwhelmed and other people might die from both COVID-19 and non-COVID-19 conditions, and complex triage decision making would become much more challenging.

Such decisions must be made not knowing the numbers of patients who will require hospital care, nor the intensity of or duration of the care that they will require.

As discussed elsewhere (here and here), the dilemmas of the COVID-19 pandemic should be explored publicly in order to help the community to better understand why this is all so difficult. I believe that we can deal with these harsh realities, which should be explained honestly, along with a clear exposition of the choices that are being made. Our leaders will earn our respect by candour in their explanations of the challenges and uncertainties, transparency in their descriptions of the basis of the decisions that they are making, and openness about the likely benefits, and the potential harm, of the course that we are taking together.

No governments have a fix for this pandemic. It is a storm to be weathered and we all own the responsibility for the solutions. I highly recommend reading a speech that the federal Chancellor Angela Merkel made to the German people earlier this year.

I do not envy our leaders who have the duty, and must find the courage, to make so many difficult decisions in the face of so much uncertainty. They need our ongoing support and respect for what they are doing on our behalf. And even though we may subsequently find, after the fact, that some of the choices that we have made as a community were wrong, we all share the responsibility for the outcomes. We should never forget, there are no win-win situations in a global pandemic.

Dr Will Cairns is a palliative medicine specialist based in Townsville and an adjunct Associate Professor at James Cook University.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.