Perspectives in Hospital Medicine

To Suffer Alone: Hospital Visitation Policies During COVID-19

© 2020 Society of Hospital Medicine

When my grandfather, who speaks limited English, was admitted to a hospital following a stroke amid the coronavirus disease 2019 (COVID-19) pandemic, my family was understandably worried. Sure enough, within just hours of his admission, we were told our normally very calm and beloved Nana was experiencing significant agitation and delirium. He did not understand nurses’ efforts to calm him down, became even more confused, and was eventually sedated and placed in physical restraints. Even though my family’s presence might have prevented some or all of this terrible series of events, the hospital’s visiting policies during the wave of COVID-19 admissions meant that we were forced to wait in the parking lot as they transpired. The hospital’s policy at the time only allowed visitors for pediatrics, end-of-life care, or labor, not for patients with delirium or altered mental status. We were given the option to make a video call, but my grandfather’s stroke had almost completely taken away his vision. Instead of sitting by his side, comforting him, providing explanations in voices he knew and a language he understood, we were left imagining how difficult it must be to suddenly wake up in an unfamiliar environment, with strangers speaking a different language, limited vision, and your arms and legs tied. Intellectually, I understood the hospital’s goals to minimize transmission, but spiritually and emotionally, it felt very cruel and very wrong.

The next day, we successfully petitioned administration to make an exception for one visitor. We argued that our presence would allow for removal of the sedation and restraints. The clinical team agreed that video calls were insufficient in his situation; he was allowed a visitor. We decided that it should be my mother. As soon my grandfather heard her familiar voice, there was a dramatic improvement. He immediately became calmer and restraints were no longer necessary. The team was grateful for a better physical exam and my grandfather was more cooperative with physical therapy. A few days later, unfortunately, the hospital let us know that they had reevaluated their position on my mother’s visits and that she posed an unnecessary COVID-19 risk to medical staff and other patients. And as soon as she left, my grandfather was again agitated and confused for the remaining 3 days of his hospitalization. Although we are grateful that his delirium resolved once he returned home, delirium also has the potential to lead to long-term cognitive impairment.1

The COVID-19 pandemic has required hospitals around the world to make difficult decisions about how to balance minimizing disease transmission with continuing to provide compassionate and high-quality patient care. Of these many dilemmas, developing flexible visitor policies is particularly difficult. Currently, the Centers for Disease Control and Prevention and many state health departments encourage limiting visitation in general but recognize the need for exceptions in special circumstances such as in end-of-life settings or altered mental status.2-4

At the hospital level, there is substantial variation in visitation policies among hospitals. Near our family home in San Jose, California, one hospital currently allows visitation for pediatric patients, pregnant patients, end-of-life patients, surgical patients, and patients in the emergency department, as well as those with mental disabilities or safety needs.5 A mere 10 minutes away, another hospital has implemented a very different policy that allows only one visitor for pregnant patients and in end-of-life settings; there are no exceptions for patients with cognitive or physical disabilities.6 Other hospitals in the United States have gone even further, not permitting visitors even for those at the end of life.7 These patients are forced to spend their last few moments alone.

From an infection control perspective, there are certainly valid reasons to limit visitation. Even with temperature screenings, any movement into and out of a hospital poses a risk of transmitting disease. Infected but asymptomatic persons are known to transmit the disease. Additionally, hospitals still treat non–COVID-19 patients who are most susceptible to severe illness should they develop COVID-19 infection. Early in the COVID-19 pandemic, limitations in testing capacity, personal protective equipment (PPE), and staffing made it challenging to ensure safe visitation. In many cases, it was almost impossible to mitigate the transmission risk that visitors posed. Because many hospitals did not have the capacity to test all symptomatic patients, they could not reliably limit visits to COVID-19–positive patients. Additionally, without enough PPE for healthcare workers, hospitals could not afford for visitors to use additional PPE.

Now that testing is more readily available and some aspects of the PPE shortages have been addressed, we should not forget that visitation has significant benefits for both patients’ psychological well-being and their overall outcomes.8 Putting aside the emotional support that the physical presence of loved ones can offer, a large body of research indicates that allowing visitors can also meaningfully improve other important patient outcomes. Specifically, the presence of visitors is associated with less fear,9 reduced delirium,10 and even faster recovery.8 In many cases, family members can also help improve hospital safety surveillance and catch medical errors.11

I saw firsthand how these benefits are particularly true for visitors who are also a patient’s primary caretaker. When my mother visited my grandfather, she was not simply a visitor but instead served as an active member of the care team. In addition to providing emotional comfort, my mother oriented him to his surroundings, successfully encouraged oral intake, and even caught some medication errors. Particularly for patients with cognitive impairment, caretakers know the patient better than anyone on the clinical team, and their absence can negatively affect the quality of care.

As a family member who also has familiarity with the healthcare system, I share hospitals’ concerns about wanting to minimize disease transmission. I recognize that, even with PPE and screenings, there is still a chance that visitors unknowingly spread COVID-19 to others in the hospital. On a personal level, however, it feels inhumane to maintain this policy even when it affects particularly vulnerable patients like my grandfather. As some hospitals are already doing,12 we can take steps to allow visitors for such patients while minimizing the likelihood of COVID-19 disease transmission from visitors. Arriving visitors can be screened and required to wear PPE. While these measures may not eliminate the risk of COVID-19 transmission from visitors, they will likely reduce it significantly when implemented properly and make possible a more humane experience for all.13

Fortunately, my grandfather is now recovering comfortably at home, surrounded by his loved ones. To this day, however, he has not forgotten what it was like to be confused and alone in the hospital after his stroke. Even with loved ones around, a stroke is a profoundly distressing experience. To go through such an experience alone is even worse. Because of our petitioning, my grandfather was at least allowed a visitor for part of his stay. Other patients are not even allowed that. As we plan for the pandemic’s next waves, hospitals should reevaluate their visitor policies to ensure that their most vulnerable patients do not have to suffer alone.

Acknowledgment

The author sincerely thanks Dr Allan Goroll (Massachusetts General Hospital/Harvard Medical School) for his mentorship and critical review of this manuscript.

Disclosure

The author has nothing to disclose.

References

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