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“Do not cast me off in the time of old age; do not forsake me when my strength is spent.” (Psalm 71:9)
Today, Dr. Merrillee Fulerton, Minister of Long-Term Care, announced that the provincial government is launching an independent commission into the province’s long-term care system. The commission will start in September, hoping to give some answers to families who lost a loved one residing in a long-term care home. NDP Leader Andrea Horvath has been calling for a public inquiry into the situation, saying, “Families with loved ones in long-term care are demanding answers. They deserve those answers, and they deserve a full public inquiry that is non-partisan to give them those answers.” Expressing similar frustration, Charles C. Camosy, Associate Professor of Theological and Social Ethics at Fordham University, in a recent opinion piece for the New York Times, writes: “We tend to see this as a public health failure, but it is also a moral failure.” Our Church’s moral teaching calls us to affirm the dignity of the person at all stages, challenging any practice or ideology that compromises the integrity of the person created in the image and likeness of God. Our God-given conscience should prompt us to ask questions regarding past and present living conditions in long-term care homes.
During the recent virtual 2020 National Mass for Life, Archbishop Prendergast of Ottawa reminded Canadians that the March for Life is a celebration to “witness the God given dignity of the human person from the moment of conception until natural death.” He went on to affirm the “right of care for elders” and the need for compassionate palliative care. No doubt, the concern over end of life issues applies to the current COVID-19 crisis happening in many long-term care facilities.
This past April Canadians and people from around the world, remained in shock, horrified at the discovery of 31 deaths at Montreal’s Herron Nursing Home. Reports indicate that just two nurses were left to care for 130 elderly residents after caregivers left their workplace amid a coronavirus outbreak. Various reporters discovered that residents were found dehydrated, “lying listless in bed, unfed for days, with excrement seeping out of their diapers.” Upon hearing about the condition of their loved ones, family members became sick to their stomachs. The horror of these tragic deaths has prompted an investigation into allegations of extreme neglect.
Over the past few months access to long-term care facilities and other senior residences has been restricted, leaving many to wonder about the living conditions of their loved ones, with or without COVID-19, perhaps wondering if neglect fuelled the perfect storm that took their loved ones. Have the very restrictions put in place to create an “iron ring” of protection for the vulnerable contributed to this perfect storm?
Many people have expressed concern for seniors who are shut-in, lonely, living alone at home or living in a retirement residence or in a long-term care facility. Day by day we receive troubling reports of seniors and other hospital patients dying alone, without the presence of loved ones or someone to speak on their behalf. Although we have focused so much of our attention on protecting physical health, has anyone thought of the collateral damage caused by loneliness, emotional, and spiritual isolation? Dr. John Cacioppo, a researcher from the University of Chicago, has found that loneliness is harder on the body than smoking, drinking, and obesity. It would be interesting to study whether loneliness and isolation are harder on the body than some of the symptoms related to COVID-19.
Notwithstanding the excellent efforts put forward every day by dedicated health care workers who are battling on the front lines of the COVID-19 crisis, they too have suffered greatly. Regrettably, their ability to publicly express concern over the management of COVID-19 in their place of work might be impacted by the recent actions of the Provincial Government issuing an Order under the Emergency Management and Civil Protection Act on March 21, 2020 that applies to hospitals and other “Health Service Providers” and which effectively allows Health Service Providers to suspend certain provisions in collective agreements with trade unions.
On March 23, 2020, an additional Order was enacted by the Province with respect to licensees within the meaning of the Long-Term Care Homes Act, 2007 and, to a municipality or board of management that maintains a long-term care home. This order extends the right of employers to suspend certain collective agreement obligations as in the earlier Hospitals’ Order. While the intention of the Orders is to contain the spread of the virus, employers are challenged by the requirement that part-time employees choose to work at only one facility, making it difficult to replace workers who choose to work elsewhere. The very Orders created to protect the vulnerable may have created a new scenario, reducing the number of available health care workers or personal support workers. Unfortunately, the attempt to control outbreaks in the community has left us with the unexpected—collateral damage, including mental anguish and loneliness, not to mention the economic devastation experienced by small and large business owners, and workers in a variety of sectors.
There are numerous accounts circulating on social media and various news feeds regarding the care of the elderly and other vulnerable persons during this period of restrictions:
- Family members lament the lack of access to their loved ones who are patients in hospitals or are seniors living in retirement residences or long-term care facilities. Reporters from various news outlets have shared stories regarding patients who are left feeling vulnerable, making decisions without the good counsel of loved ones who are able to speak on their behalf, monitor their level of care, and question policies and procedures that raise doubt. Are advanced health care directives being followed? People are frustrated because, for many, so much is unknown regarding the care of their loved ones. Of course, the situation will vary from institution to institution, with some having more access to their loved ones than others.
- It appears fewer individuals/patients are seeking help for emergency situations or other medical issues. Some have expressed fear of contracting COVID-19 by visiting an emergency department of a hospital. On a daily basis tweets and announcements from local hospitals encourage people to seek medical assistance if they are experiencing physical distress.
- Some physicians, local and abroad, have voiced concern regarding economic uncertainty and the future of their clinics, whether they will survive the lengthy period of restrictions and billing limitations brought about due to the reaction to COVID-19.
- Others have expressed frustration due to the inability to see their family physician in person. Elective surgeries have been canceled, leaving many stressed by conditions that are not being treated.
- Some of our elderly relatives who live alone have expressed concern over the restrictions on public and private gatherings. One mother reportedly said this to her adult daughter: “I’m going to die of loneliness, not COVID-19.”
- Many people of faith have lamented the limited access to the spiritual care needed to support them during this difficult time.
- Advocates for homeless persons have raised awareness regarding the harm done by physical distancing by-laws
- Recently, reporters have wondered why cleaning services and babysitting services are allowed access into Ontario homes, but seniors cannot have members of their own families visit and care for them in their own homes. Where’s the common sense?
The Need for Common Sense
A recent visit to a local grocery store magnified the need to approach these restrictions with common sense, justice and mercy. I observed an encounter involving an elderly woman, struggling to manage her scooter, her puppy, groceries and the coffee she had just poured into a cup, and a “Good Samaritan” watching a few metres away, physically distancing, yet fully engaged in the moment. A few store employees were standing in the distance, staring, seemingly paralyzed with fear, not knowing what to do. Finally, the “Good Samaritan” asked the senior if she needed any assistance, asking permission to approach, re-sanitizing her hands in her presence. The woman welcomed the help, telling the lovely lady who helped her that she was not worried about her touching the lid for her coffee cup, sharing more concern over the lack of medical attention she has received due to restrictions resulting from the province’s response to COVID-19. I overheard her saying she had suffered a stroke, resulting in blindness in one eye and problems walking. She lamented that she has gone several months without any proper care or access to specialists, including her family physician. She said this angered her more than the virus. No doubt, she was expressing the pain associated with the collateral damage of COVID-19. She thanked the woman for noticing her need and offering to help. This same woman approached the manager who was standing by, observing the interaction, and told her she was given permission to approach and touch the lid to seal the coffee cup, to which the manager replied, “Thank God you helped her. I am happy you did. We don’t know what to do in these circumstances. We are struggling to follow the by-law regarding physical distancing.” The woman used her common sense, the same common sense Premier Doug Ford has advised us to use in similar situations.
The woman managing her scooter and her grocery needs is not alone. Sadly, there are many other individuals who have lamented the lack of common sense when it comes to the care they have or have not received when they are in need of medical assistance, especially when their medical needs are deemed non-essential. Although everyone is in agreement we need to protect the vulnerable, these same restrictions are creating more vulnerability. Others who have fallen ill and have needed emergency assistance have complained about being left alone in the hospital, without any support or anyone to speak on their behalf. Surely, there are exceptions with the dying, or with childbirth, but accounts abound regarding seniors and other vulnerable individuals with language or other social barriers, left alone to struggle.
I felt similar distress over the past few months watching the anguish on my daughter’s face when she could not be present with her husband who had been admitted to hospital on several occasions due to kidney stone complications. He expressed his desire to have her accompany him and she expressed her pain, not being able to be present and assist him with any interactions with health care staff. Although he received excellent care, it is frightening to think people are left all alone, possibly unconscious, or palliative, without the support of loved ones. I’ve heard horrifying accounts of children and spouses not being allowed to say goodbye to loved ones who are terminally ill, or others being reduced to limited access to loved ones in the final hours of life.
The cancellation of non-essential medical treatment has left patients anxious over the postponement of procedures deemed “non-essential”. In the first weeks of CBC’s coverage of COVID-19, a reporter interviewed a woman diagnosed with breast cancer. I watched with horror as the woman sobbed on national television, expressing fear of the cancer spreading, feeling abandoned and helpless. Some of the procedures considered non-essential are considered essential, life-saving procedures for those who need them. People in need of organ transplants come to mind. Apparently, these procedures were put on hold as well, decisions leading to more collateral damage. Case in point, Chris Walcroft, a 50 year-old man from B.C., father of two, died on April 15 after a scheduled surgery to prepare for kidney dialysis was canceled. Clearly, someone determined that his procedure was non-essential, a procedure that would have extended his life, giving him more time with his wife and children.
Sadly, the very restrictions put in place to protect the vulnerable are putting them at risk for other issues: mental and spiritual distress, sickness or possibly death due to canceled or postponed procedures, lack of touch and physical intimacy that would have been provided by loved ones permitted to visit and accompany seniors and other patients in hospitals or homes. Many surviving family members and close friends are left with many questions, possibly anger and regret over not having been given the opportunity to care for their loved ones. Policies regarding access or visitation remain confusing, robbing many people of the opportunity to say good-bye to their loved ones.
Moreover, questions remain regarding the quality of care received by loved ones living in long-term care homes.
The Need for Accountability and Transparency
On April 15, 2020, the Ministry of Health published version 2 of “COVID-19 Outbreak Guidance for Long-Term Care Homes (LTCH). Here’s a link to the document: http://www.health.gov.on.ca/en/pro/programs/publichealth/coronavirus/docs/LTCH_outbreak_guidance.pdf
There are a few alarming details in the document, including details on page 4 regarding the regulation of medications, calling for the “switching of medications to less frequently dosed formulations or reducing dosing frequency, if safe.” And, “reassessing the need for non-essential medications.” Who is determining what is essential or non-essential? Do the family members know this is going on? Concerned about transparency and access to loved ones, I read over the document searching for any references to external visitors. Page 5 of the document refers to “essential visitors.” Although these facilities remain closed to visitors, there seems to be some allowance for people deemed “essential visitors.” The following is an excerpt from page 6 of the document regarding directives and precautions pertaining to essential visitors:
Managing Essential Visitors
As LTCHs are now closed to visitors, accommodation should be considered for essential visitors who are visiting very ill or palliative residents, or those who are performing essential support care services for the resident (i.e., food delivery, phlebotomy testing, maintenance, family or volunteers providing care services, and other health care services required to maintain good health).
- Essential visitors must be screened on entry for symptoms of COVID- 19, including temperature checks and should not be permitted to enter if symptoms are present.
- Essential visitors must wear a surgical/procedure mask during the entire duration of their visit to the LTCH.
- Essential visitors must attest to not experiencing any of the typical and atypical COVID-19 symptoms.
- Essential visitors should be limited to one person at a time for a resident.
- Essential visitors must only visit the one resident they are intending to visit and no other residents. Visitors providing essential support care services for more than one resident should consult with the home.
- Staff must support the essential visitor in appropriate use of equipment for source control (i.e. mask) and PPE if required, based on the health status of the resident:
- For source control, essential visitors must wear a mask while visiting a resident that does not have COVID-19.
- Essential visitors in contact with a resident who has COVID-19 or suspected COVID-19, must use PPE as required in Directive #1 for droplet and contact precautions.
(End of excerpt)
It sounds like there are possibilities for family members to be considered “essential visitors.” Who is monitoring this policy? Are loved ones being made aware of this policy? Does it vary from institution to institution?
I am not aware of the policy in Quebec regarding visitation, but it’s been a few weeks since military personnel were deployed to long-term care homes. See https://montreal.ctvnews.ca/military-deployed-to-care-homes-in-quebec-to-help-curb-spread-of-covid-19-1.4904742
Would it not have been easier to ease some restrictions and allow loved ones to visit with their elderly relatives? Is there any guarantee military personnel are healthier than the family members of the residents?
In Ontario, Education Minister, Stephen Lecce, announced that the provincial government reached an agreement with Ontario school boards and unions, allowing for the “voluntary” redeployment of education workers to long-term care homes, hospitals, and shelters struggling with the novel coronavirus pandemic. Would it not be helpful to include family members who wish to be voluntarily deployed? Although it is obvious that those who are invited to consider this deployment are qualified to offer specialized care, family members can help ease the load by sitting with loved ones overnight or assist with feeding and other tasks that are permitted.
If some family members can be considered “essential visitors” why not ask family members to volunteer to sit with their loved ones, monitoring their quality of care, including the ratio of personal support workers to residents. Will the new commission investigate whether family members were informed regarding the recommendations made in the Ministry of Health document? Did anyone investigate whether the long-term care homes followed through with recommendations regarding “essential visitors?” What was the ratio of care before and after COVID-19?
Ratio of Care
In 2017, Dr. Jill Aitken prepared a handy fact sheet for families considering long term care options for elderly relatives. You can find that document here: https://retireathometoronto.com/5-answers-about-long-term-care-homes-in-ontario/
She reports that the ratio of personal support worker to residents is 1:10 during the day and 1:14 for overnight care. The ratio may vary from home to home.
Will the new commission ask the following questions?
- What is the current ratio?
- Can these institutions verify this level of care?
- Do family members have access to this information?
- Are they dying due to COVID-19 related symptoms or is it due to neglect, resulting from health care workers who have been asked to stay home, following the direction of their union representatives expressing concern about their safety?
- Is it possible that some residents have COVID-19, but as in the Montreal case, it is the consequences of neglect that could be the alleged cause of death?
- Who is monitoring this tragic situation, especially if family members cannot access their loved ones nor assess their living conditions? The perfect storm has been created for residents, concerned family members, and health care workers. Justifiably fearful, health care workers are worried they will get sick, possibly feeling overworked, without proper support or supervision.
Residents and staff are dying without any accountability or answers for loved ones. Health care workers are demanding answers as they struggle to understand the number of deaths among residents and staff. A few recent actions are sounding the alarm for transparency and inquiry into long-term care home environments.
Demands for a Public Inquiry
No doubt, recent demands for a public inquiry have inspired the recent announcement regarding the creation of a new commission. Recently, it was reported that the Ontario Nurses’ Association wants an inquiry into COVID-19 outbreaks at long-term care homes. See https://barrie360.com/ontario-nurses-association-wants-public-inquiry-into-covid-19-outbreaks-at-long-term-care-homes/
Moreover, the union representing more than 60 000 health care and community service workers is calling for a public inquiry into the rising number of deaths of residents and workers in long term care homes. (https://www.cbc.ca/news/canada/toronto/union-long-term-care-inquiry-1.5556136)
The CBC reports (see article above) that the union is calling for:
- A public inquiry by the provincial government into the rising number of deaths of residents and front-line workers at long-term care homes, to be commissioned immediately.
- Criminal negligence investigations by Toronto and Peel Regional Police at a yet-undisclosed number of long-term care homes and home care providers.
- An investigation into the deaths by Ontario’s Office of the Chief Coroner.
On a daily basis, reports of family members joining class action law suits against long-term care facilities are growing in numbers.
Similarly, orders of nurses and physicians will be calling for an investigation into the horrors discovered in some Quebec long-term care homes. See https://montreal.ctvnews.ca/orders-of-doctors-and-nurses-to-investigate-long-term-care-centres-in-quebec-1.4905054
Health care professionals, concerned citizens, and loved ones of the deceased want answers. Steve Paikin, in a recent article, expresses similar frustration when he asks, “Is it too much to ask for a direct answer to a direct question?” See https://www.tvo.org/article/is-it-too-much-to-ask-for-a-direct-answer-to-a-direct-question
On the issue of transparency and accountability regarding answers to direct questions and the request for a public inquiry into the rising number of deaths of residents and workers in long term care homes, he writes:
But the premier’s (Premier Doug Ford) most questionable moment came earlier this week when the official opposition and journalists asked a simple and direct question: Given that most of the COVID deaths have come in the long-term-care sector, would the government please call an independent, full-scale public inquiry to get to the bottom of why the system has failed so badly?
For the first time since the pandemic hit, Ford blatantly obfuscated in his response. He promised an investigation. He promised change. But he pointedly declined to commit to an independent public inquiry. That’s his prerogative. But he consistently refused to explain why. And the awkwardness of his tap dancing was noticeable for all to see.
It became painful to watch when CBC Queen’s Park reporter Mike Crawley asked the coup de grâce question during one of the premier’s daily briefings. Crawley had done his homework: one Indigenous protestor was killed at the Ipperwash Provincial Park in 1995; six died from tainted water in Walkerton in 2000; eight seniors died at the hands of a serial-murderer nurse named Elizabeth Wettlaufer between 2007 and 2015; and 44 died during the SARS outbreak in 2003. In all those cases, independent public inquiries were called. Why, when we’re approaching 2,000 deaths in Ontario from COVID-19 are you, premier, resisting calling a public inquiry?
It was a devastating question, and Ford didn’t help himself with an answer that was utterly non-responsive.
Surely, senior lives matter and deserve more than this response. Hopefully, the new commission will give us some answers.
Who will be held accountable?
The Long-term Care Utilization Report (February 2019) prepared by the Ontario Ministry of Health and Long Term Care reports that of the 626 homes licensed and approved to operate in Ontario, 58% of homes are privately owned, 24% are non-profit/charitable, and 16% are municipally owned. Who are these owners? Are they accessible? Who’s holding them accountable?
On Tuesday, May 12, 2020, Dr. Theresa Tam, Canada’s chief Public Health Officer, reported that roughly 20% of all confirmed cases of COVID-19 in Canada are linked to long-term care facilities, but 80% of the people who have died from COVID-19 were seniors living in these homes. The next day, Premier Doug Ford announced the Ontario government now has the power to take over management of long-term care homes. Will this new management improve the quality of care of our seniors? Similarly, will the new commission consider the following questions?
- Was it a mistake to isolate seniors, limiting access to loved ones willing to sit at their bedside, assisting with feeding, offering comfort and care, advocating on their behalf?
- Were family members made aware of the policy regarding “essential visitors?”
- Were loved ones advised of the recommendation to modify doses/medication that was deemed non-essential?
- Who determined what was to be considered non-essential medication?
- What were the criteria?
- When some health care workers were advised to stay home by their union representatives or employers, avoiding contact with COVID-19 or self-quarantining, what was the remaining ratio of personal support worker to residents?
- What was the ratio after part time workers were told to choose one place of employment?
- The Employee Standards Act (2000) was amended to give employers/employees flexibility regarding self-isolation, absenteeism/care for loved ones at home due to COVID-19. What was put in place to ensure the ratio of one personal support worker per 10 residents continued to be in place?
- Were family members informed of any new ratio?
- Were there any inspections that took place regarding alleged reports of neglect?
- Are loved ones encouraged to seek legal recourse?
- Will loved ones be allowed more access to sick relatives in hospitals or long-term care facilities?
- Will the government guarantee transparency?
- Will the rights of vulnerable persons, including the homeless, be respected?
What would the Good Samaritan do?
On April 3, 1968, the day before Martin Luther King was murdered, he gave his last speech, “I’ve Been to the Mountaintop.” He referred to the parable of the Good Samaritan (Luke 10:31-37) to make a point regarding the support needed by sanitation workers in the Deep South. He spends some time giving context for the scene of the parable, reminding the crowd that the road to Jericho is a “winding, meandering road. It’s really conducive for ambushing.” He proposes that the priest and the Levite are aware of the possibility of ambush and say to themselves, “If I stop to help this man, what will happen to me?” But then the Good Samaritan came by. And he reversed the question: “If I do not stop to help this man, what will happen to him?”
Let us apply the lesson of the parable to today’s current crisis with COVID-19 and long-term care homes. If we do not speak up and call for accountability, transparency, and a public inquiry, what will happen to the most vulnerable among us? If we do not allow access to loved ones in hospital or other settings, what will happen to the most vulnerable? If we do not supply an “iron-ring” of people inspired by common sense, truth, and courage to protect our loved ones, what will happen to us in the future?
“Religion that is pure and undefiled before God, the Father, is this: to care for orphans and widows in their distress, and to keep oneself unstained by the world.” (James 1:27)
Here are some quick facts from the Long-term Care Utilization Report (February 2019):
Ontario’s long-term care homes (February 2019)
- 626 homes are homes licensed and approved to operate in Ontario
- 58% of homes are privately owned, 24% are non-profit/charitable, 16% are municipal
- About 40% of long-term care homes are small, with 96 or fewer beds
- Of these small homes, about 45% are located in rural communities that often have limited home care or retirement home option
- 77,257 long-stay beds are allocated to provide care, accommodation and services to frail seniors who require permanent placement
- 669 convalescent care beds are allocated to provide short-term care as a bridge between hospitalization and a patient’s home
- 321 beds are allocated to provide respite to families who need a break from caring 24/7 for their loved one
- Approximately 300 of the province’s long-term care homes are older and need to be redeveloped (more than 30,000 beds)
- The average time to placement in long-term care, as of February 2019, is 161 days
- The waitlist for long-stay beds, as of February 2019, is 34,834
Sources: Long-Term Care Utilization Report, February 2019, Ontario Ministry of Health and Long-Term Care; Ontario Long Term Care Association, internal database, 2019.
Josephine Lombardi © 2020
May 19, 2020, Personal Support Worker Day