Ethical policy for visitors to long-term-care homes needed

In a pandemic, individual liberty is often restricted, with the ethical justification that we are preventing greater harm to a significant number of people.

After nearly 100 days of extreme restrictions on visitors in nursing and retirement homes, does this rationale still stand? In Ontario, directives on the restart of the healt-care system are guided by four ethical principles — proportionality, minimizing harm to patients, equity and reciprocity. And yet, these same principles are being violated in the ongoing lockdown of nursing and retirement homes.

Visitor restrictions should balance the current risk and circumstances, using the least restrictive measures. We are missing the mark on proportionality.

To date, more than 80 per cent of Canada’s COVID-19 deaths have been long-term-care residents. Our national shame in leaving these residents unprotected was caused by many factors, including a failure to secure personal protective equipment and delays in implementing universal masking of staff, restricting workers to one home, and widespread COVID-19 testing.

Now that many of these issues have been addressed, it is time for homes to cautiously welcome back visitors.

Minimizing harm. Many residents have died or deteriorated not because of acquiring COVID-19, but because of the collateral damages of the ongoing lockdown and visitor restrictions. When physical, social, spiritual and emotional needs are not attended to, residents decline. Many will never recover. Long-term-care physicians in France noted that the effects of the lockdown were causing more deaths than the virus.

Equity. Decision-makers are failing to appreciate that not all visitors are the same. Many are actually unpaid family and friend caregivers who could easily be trained in infection prevention and proper use of PPE.

Reciprocity. Currently, many homes in Ontario are moving to weekly, short, outdoor and physically distanced visits. This is not enough.

With competing perspectives about one issue, how do we reconcile all views and still make an ethical policy for visitors? We must strike a balance and support the wishes of all, recognizing it will be imperfect.

While we advocate for a more balanced allowance for visitors with greater attention to residents’ quality of life, we are not suggesting disregard for the importance of preventing COVID-19 transmission. Decision-makers must consider the breadth of perspectives of residents, and implement policies guided by the same four ethical principles underpinning the reopening of other sectors of our health-care system. Rebecca Greenberg is the senior bioethicist at Sinai Health System and an associate professor in the University of Toronto’s department of pediatrics. Dr. Nathan Stall is a geriatrician at Sinai Health System and a research fellow in U of T’s departments of medicine and Institute of Health Policy, Management and Evaluation.