In response to the COVID-19 pandemic, most health-care organisations have implemented
policies to restrict visitor access. Although there are exceptions to some of these
policies, including limited visiting for patients nearing the end of life, they still
have profound effects on the dying and their family members. We are still in the midst
of the pandemic, but there are compelling reasons to expand access of family members
to their loved ones as they near the end of life, despite the risk of infection.
Hospital visitor policies represent an attempt to balance two competing priorities.
Restrictions reduce the chance of harm from infection, but increase the chance of
harm from isolation or separation. Exemptions can reduce isolation and allow for a
more compassionate response to patients nearing the end of life, but they potentially
increase the risk of COVID-19 transmission.
It is too early to assess the burden of complex grief of family members who endure
the loss of a loved one during the pandemic, and we have little bereavement data from
previous pandemics.
1
We know that restrictive visitor policies are associated with a higher frequency of
delirium and anxiety in patients.
2
We also know that separation from the patient, the absence of normal death rites,
and the disruption of social support networks are risk factors for poor bereavement
outcomes.
3
Virtual communication is not feasible for some family members, and might be distressing
if the patient is dyspnoeic, delirious, or intubated.
There are also little data on the harms of liberalising visitor policies. Liberal
visitor policies in intensive care units do not appear to be associated with an increased
risk of nosocomial infection, but they do increase the risk of burnout among staff.
2
Zhou and colleagues
4
studied rates of nosocomial infections in the early days of the COVID-19 outbreak
in Wuhan, China, before visitor restrictions and routine personal protective equipment
were implemented, and found that nosocomial infections accounted for a third of all
cases, but only 2% were due to people other than hospital staff.
The scarcity of good data is frustrating, but ultimately not relevant. Even if we
knew the precise risks of different approaches to visitor policies, we would not be
any closer to finding a balanced approach because the risks cannot be compared directly.
How much psychomorbidity is justified by the prevention of a single COVID-19 infection?
Neither the risk of transmission nor the harm of isolation can ever be reduced to
zero. Hospital outbreaks occur due to asymptomatic staff, even when there are no visitors,
and unrestricted visitor policies would not address isolation in individuals with
distant or no family. But the harms of isolation are clearly amplified for people
approaching the end of life. Faced with a choice between having acute hospital care
or having unrestricted access to family members, some dying patients choose to remain
at home, even if that means uncontrolled symptoms and an unsustainable burden on family
members and community care services that are already stretched by the pandemic.
Even end-of-life visitor exemptions can be harmful, if they apply only to people in
the final days of life. Prognostication is challenging, and patients can sometimes
deteriorate suddenly without any of the usual warning signs. Such occurences have
led to situations in which family members were forced to leave the bedside of patients
who appeared to have months to live, and were then unable to return quickly enough
after a sudden deterioration. Moreover, patients in their final days and hours are
often minimally responsive and unable to interact with family members; the opportunity
to spend so-called quality time has passed. Otani and colleagues
5
found that being present at the time of death was not associated with any difference
in the incidence of complicated grief among family members, but having the opportunity
for meaningful conversation (eg, being able to say goodbye) was associated with reduced
symptoms of depression and complicated grief.
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Limiting the number of visitors allowed at one time might seem a reasonable compromise,
but it can also lead to problems. Considering that cohabiting family members often
visit at the same time, separating them at the bedside does not reduce the chances
of transmission to each other or to the patient. Instead, they often choose to take
turns, cycling between being at the bedside and being outside the hospital multiple
times in a single day. Because the greatest risk of transmission occurs during the
removal of personal protective equipment and transit within the hospital (eg, encountering
other staff, travel in elevators), this cycling is likely to increase the risk of
transmission substantially more than simply allowing all visitors to remain at the
bedside for the duration of their visit (space permitting).
We have also found that inconsistent visitor policies among different sites can be
problematic. Patient transfers are very common as patients near the end of life and
are transferred from acute care to palliative settings. But if the receiving facility
has stricter limits on visiting than the sending facility, patients often refuse the
transfer, which increases the burden on the acute care facilities by adding to the
population of those classed in the so-called alternate level of care.
The broad visitor restrictions put in place by many health-care facilities at the
start of the pandemic were reasonable responses to a new and previously unknown pathogen.
With the benefit of experience, and provided that sufficient personal protective equipment
is available, we propose that health-care organisations adopt a new end-of-life visitor
policy (panel
) that would reduce restrictions overall without necessarily putting patients, staff,
and family members at a substantially increased risk of COVID-19 transmission. Elements
of this policy might be reasonable outside the end-of-life context, and Munshi and
colleagues
6
recently proposed more general relaxation of visitor policies. This proposal is not
intended as a criticism of those who recommended more rigid restrictions at the start
of the pandemic. But the threats of COVID-19 must be placed in context of other threats
to health, including those that are harder to appreciate in the short term.
Panel
Proposed elements of an end-of-life visitor policy
1
The policy would apply to anyone admitted to an inpatient palliative care facility,
or any inpatient with a plan of care focused on comfort, and when the patient is expected
to die in the coming weeks or short months. The policy should be applied consistently
across a given region.
2
Visitors should be allowed during normal visiting hours; when physical circumstances
allow, one family member can remain with the patient outside of these hours.
3
The number of visitors allowed at the bedside should be limited only by the size of
the room. In practice, this would mean up to four visitors in a private room, and
up to two visitors in a semiprivate room if another patient is present in that room.
4
Cycling of visitors should be avoided. Family members should be allowed to remain
at the bedside throughout visiting hours. However, once they leave the hospital, they
should not return to the bedside until the next day or unless they are remaining overnight.
If more than four visitors in a group wish to attend, the visit should be scheduled
in advance with the ward.
5
Visitors have a responsibility to observe proper infection prevention and control
procedures to limit the risks to patients, staff, and to themselves. Visitors who
are unwilling or unable to comply with these procedures would not be able to visit,
but would be offered virtual visits instead.
6
Although longer visits would be permitted, we recommend that family members limit
their visits to 1 h at a time, to reduce the risk of asymptomatic transmission of
COVID and to allow patients and family members to rest.