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CW: COVID19 mortality, elderly. Thread. 
I was conflicted about writing this, but after a week of reflection, I decided I had to.
We’re going to lose a significant percentage of our elderly family members in skilled nursing homes, and there’s not much we can do about it. 1/
I was conflicted about writing this, but after a week of reflection, I decided I had to.
We’re going to lose a significant percentage of our elderly family members in skilled nursing homes, and there’s not much we can do about it. 1/
There is essentially no way to prevent COVID19 from doing a slow burn through every nursing home* in the US.
The only way to prevent this would have been aggressive lockdown and widespread testing in the whole country starting in mid Feb.
* (Assisted Living is different) 2/
The only way to prevent this would have been aggressive lockdown and widespread testing in the whole country starting in mid Feb.
* (Assisted Living is different) 2/
Patients in skilled nursing facilities tend to be elderly, usually requiring complex care for things like diabetes, dementia, heart disease, hypertension, COPD.
Each one of conditions is a risk factor for COVID19 mortality.
Long term infection control is nearly impossible. 3/
Each one of conditions is a risk factor for COVID19 mortality.
Long term infection control is nearly impossible. 3/
As long as the area has community transmission of coronavirus, it WILL make its way into skilled nursing facilities.
The precautions being taken by SNFs today— no patient visits, limiting outside practitioners, wearing masks— are only buying time.
I’m really sorry.
4/
The precautions being taken by SNFs today— no patient visits, limiting outside practitioners, wearing masks— are only buying time.
I’m really sorry.
4/
If your elderly parent resides in a skilled nursing facility, it’s probably because you can’t realistically take care of them at home. I know our family can’t.
If you can realistically *truly* get your parent out and carefully isolate amd care for them at home, consider it. 5/
If you can realistically *truly* get your parent out and carefully isolate amd care for them at home, consider it. 5/
Most of us can’t realistically care for elderly, chronically ill parents at home. I remember trying that route for years, and the toll it took on us.
So I’m resigned to the fact that my dad is a sitting duck. I give him a 60-75% of exposure to coronavirus. Hard damn truth. 6/
So I’m resigned to the fact that my dad is a sitting duck. I give him a 60-75% of exposure to coronavirus. Hard damn truth.
6/
I’m telling you things right now that the geriatric care team and nursing home staff would tell you, if they were allowed to.
Nursing home admins don’t want to admit this because it makes them look bad. The truth is that it’s not really the nursing home’s fault at this point. 7/
Nursing home admins don’t want to admit this because it makes them look bad. The truth is that it’s not really the nursing home’s fault at this point. 7/
If you don’t believe me, that’s OK. I don’t have energy to debate people. Check my prediction record this year if you want, or not.
If you’ve come to these conclusions already, I can’t give you advice but I can tell you how I’m thinking my way through this with my family. 8/
If you’ve come to these conclusions already, I can’t give you advice but I can tell you how I’m thinking my way through this with my family. 8/
I’ve accepted that there’s a high likelihood that my dad will be exposed to coronavirus as a nursing home patient.
None of us siblings can care for him at home.
It’s really a question of what happens if (when) he does get sick with suspected COVID19. 9/
None of us siblings can care for him at home.
It’s really a question of what happens if (when) he does get sick with suspected COVID19. 9/
When an old, chronically ill patient gets COVID19, their chances are poor.
It’s not an automatic death sentence. Some of these sick patients survive, but we don’t really know why.
We DO know that heroic lifesaving measures like intubation don’t seem to help these patients. 10/
It’s not an automatic death sentence. Some of these sick patients survive, but we don’t really know why.
We DO know that heroic lifesaving measures like intubation don’t seem to help these patients. 10/
COVID19 in nursing home patients can be sneaky, without dramatic initial symptoms With weak immune systems, they might not even spike a fever.
Often times they’ll just feel “down” or they’ll stop eating. Docs know at this point to keep a close eye on their oxygen saturation. 11/
Often times they’ll just feel “down” or they’ll stop eating. Docs know at this point to keep a close eye on their oxygen saturation. 11/
With COVID19, there’s not much the nursing home docs can do beyond keeping the patient comfortable and providing basic support to give them a better chance to fight it off.
Supplemental O2, fluids, tylenol, azithromycin (it’s a macrolide so it’s also an anti-inflammatory). 12/
Supplemental O2, fluids, tylenol, azithromycin (it’s a macrolide so it’s also an anti-inflammatory). 12/
The thing to note about all these supportive therapies is that ALL of them can be provided in the nursing home.
Here’s my personal opinion: an elderly nursing home resident with COVID19 isn’t coming back from the hospital. 80% of these patients who go on a ventilator die. 13/
Here’s my personal opinion: an elderly nursing home resident with COVID19 isn’t coming back from the hospital.
80% of these patients who go on a ventilator die. 13/
Hospitals are extraordinarily dangerous places in the best of times. This is not a critique — it’s just the nature of acute care.
Pulling a nursing home resident away from their familiar room, away from staff who know them and their med history, is frightening and stressful. 14/
Pulling a nursing home resident away from their familiar room, away from staff who know them and their med history, is frightening and stressful. 14/
If you’re the healthcare proxy, can you have a realistic talk with your loved one about what kind of care they want if they get suspected COVID19?
Talk to the care team. Talk to the Medical Director about treatment approach.
Make sure the advance directive is up to date. 15/
Talk to the care team. Talk to the Medical Director about treatment approach.
Make sure the advance directive is up to date. 15/
Talk to other family members if you need to. Do some what-if scenario planning.
Don’t assume you’ll be able to get a quick COVID19 test result. You’ll have to make decisions with uncertainty.
Doesn’t hurt to check on basic stuff like pneumovax. Get lots of FaceTime calls in.
Don’t assume you’ll be able to get a quick COVID19 test result. You’ll have to make decisions with uncertainty.
Doesn’t hurt to check on basic stuff like pneumovax. Get lots of FaceTime calls in.
