Provider and system consequences of restrictive visitor policies
| Subtheme | Participant quotes |
|---|---|
| Provider consequences | |
| Increased time and effort on communication and need to establish limits | “I think that the main thing with families was that we would essentially have daily conversations with families, going over clinical status and changing it in accordance with just daily conversations of 15 to 30 minutes, multiplied by the number of patients that we have. So it was really just a huge increase in the work volume. And I think for family members there was just such a need to have that dialogue because they couldn’t see or participate in the care in any other way.” — GIM3 Male “I did notice at the beginning, families were just very happy to get any communication at all. But as months went on that changed from gratitude to just anger and not being able to come in and not getting daily updates and I would perpetually explain to the families that my practice is to update them multiple times a day at the bedside and to talk to anybody who’s there, but because … if I’m on the phone all day and this takes me away from the patient’s bedside, I’m not able to always promise to call every single day even though I want to because I can’t be in 7 places at once and if their loved one needs me or needs resuscitation or anything like that … I can’t be on the phone to someone else’s family. And I think once I framed it like that — I want to call you and I want to be on the phone with you, but it’s taking me away from them if they need me. Then that helped change their mind frame, but I did my best to try and set expectations with that family member.” — ICU5 Male |
| Increased efforts to establish trust and connection to family | “I mean, there’s no substitute for being in person with someone. When you’re with someone and they’re not there, you’re basically doing it blind when you’re on the phone, you’re robbing yourself of one of the most important senses, which is your visual, your body language. And body language gives off an energy where you can connect with someone you. It’s easier to empathize with someone when you can see what they look like and over the phone you just can’t, it’s a voice. It’s impersonal. You can say any … it’s almost like a conversation on the internet, your username. But when you’re in someone’s face, when you’re sharing a space that are 4 walls around you’re together, you’re present. So it makes a huge difference.” — GIM3 Male “Very difficult to establish a relationship because they were not in the unit. I usually, in normal times … I advocate for patient presence during patient rounds because I think it’s saving me time. It is creating trust. It is transparency. They realize that we don’t hide information or whatever. There is a lot of information communicated during the rounds so they are aware of changes, minimizing the time and spending on phone calls and updates and when we have a more rearranged family meeting, they already [have] a lot of information already incorporated. So it’s think there’s only benefit to have the family presence during rounds and the pandemic cancelled all of it. Horrible. Honestly it’s horrible.” — ICU2 Male |
| Decreased input from family on patient status and response to treatments | “I think that this has been so used to having family as people who help with identifying symptoms, quantifying, improvement with treatment; being able to have them nearby and easily accessed so that the ongoing psychoemotional spiritual support can be provided them and their families. And in their absence, that that became a little bit more difficult from the point of view of assessing the severity of symptoms, the effectiveness of treatment and certainly being able to provide the emotional support is necessary”. — PC5 Male |
| Supporting patient–caregiver communication and being a surrogate for family | “Sometimes we … I would go, and I and our nurses would go into the rooms because these people are alone and it was … didn’t … it was not the best that they were alone for their last hours and days all the time because, again, the nurses were going less frequently and the MRP wasn’t going in at all at that point.” — PC9 Female |
| “I called his family and to say, you know, he’s awake, he’s interacting and he’s articulated that he wants to stop. This is too much for him. And so we’re purely just going to focus on symptoms and comfort and pain, and they said they weren’t going to come in, but then they gave me all these messages to tell him and so that aspect … most of the patients we’re palliating with families that come to the bedside; they are comatose, likely can’t have awareness of what’s going on. But in this situation, there was kind of the anguish associated with me having to portray the final thoughts of their loved ones and then me not knowing what he’s thinking … like maybe he understood why they weren’t coming in, but I didn’t know that and it’s enough for him to realize that he’s dying and I just didn’t want to ask the questions of … So that was awful … that was probably the worst experience of anything.” — ICU3 Female | |
| The emotional toll of being in the role of advocate, gatekeeper or enforcer of visitor policies, which was exacerbated by lack of evidence and inconsistent enforcement | “It’s like there is this inhumanity to the whole interaction where you are speaking to someone who you’ve never met over the phone. And telling them and you’re acting as the gatekeeper, you no, no you can’t come in. No. No, yes. Only one son can come in but the other no.” — PC4 Female “There was one patient on one unit and they had 6 visitors at one time, and then they would go to another unit and be told no visitors allowed. This would be 12 hours apart. It was incredibly difficult. Some units would say no visitors whatsoever, some would say one at a time, some would say one per day, some would say no one under 18. So it’s incredibly inconsistent and when patients who moved from unit to unit, that was so challenging to try to tell families why there’s no visitors.” — PC12 Male |
| System consequences | |
| Changes in occupancy, length of stay and place of death | “Everyone wanted to be discharged yesterday. Patients wanted to stay home to die there.” — PC12 Male “I think that was one of the biggest, not COVID but COVID-related, shifts was people dying at home. I know this happened everywhere. I think we had an extra 100 people die in Q1, or Q2 I should say. In [region], when compare[d] to the year before, Our PCU had been 15 beds, we are now 10. We gave up 5 because we couldn’t fill them. Oncology needed isolation and private rooms. And even the 10 that we had there was a reasonable balance. There was a while it was hard to fill even 10 … So that shift of people choosing to go die at home. Really. I mean, it was driven by people’s strong desire to be with the family. To be able to have visitors.” — PC8 Female “I guess it also changed how, you know, about disposition planning, especially at the peak of COVID because we were mindful of what other services would have been impacted by COVID. So, you know, some families were concerned about going to hospice because they wouldn’t … the visitor restrictions would still be in place versus they may be more motivated to get home for end-of-life care.” — PC6 Female |
Note: ICU = intensivist, GIM = internist, MRP = most responsible provider, PC = palliative care physician, PCU = palliative care unit.