As Hospitals Relax No-Visitor Policies, Let’s Work to Do Better Next Time

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Original story posted on: July 22, 2020

Dear hospital administrator/provider who believes you comprehend how terrible the no-visitor policy is:

You don’t.

Having practiced as a pediatric hospitalist for a decade, I’ve participated in thousands of conversations with patients and family members wherein my goal was to be as straightforward as possible. I try to stick to the simplest course of action: this is the situation, here is what we think is happening, this is how we will address it. The same continues to apply, having moved into an administrative role. Many times, the obstacle or issue to be sorted out is complex, but can be broken down into manageable, clear steps. The situation is this; what’s happening is this; this is how we will address it.

We’re all fully cognizant of the difficulties COVID-19 has created within hospital and skilled health facility settings. One of the most harrowing challenges has been the “no visitors” policy virtually all institutions have been forced to implement. You’ve read the stories – family members saying goodbye over FaceTime as their loved one dies in an intensive care unit; women giving birth without their partner present; only one parent allowed at a time in their child’s hospital room. Still, fraught feelings have been accompanied by the understanding that this is what’s needed. In order to protect our patients, our staff, and our communities, we just have to put these visitor limitations into place until the tide turns.

Not too long ago, I woke to my alarm clock as usual. What followed was not usual. Lying stiffly on his back, my husband declared, “I think I need to go to the emergency room.” He’d mentioned vague discomfort the day before, which was easily chalked up to a week of installing new floors in his latest home renovation project. That, and perhaps he shouldn’t have eaten that leftover sushi for lunch. But now, he’d battled frank abdominal pain all night, and even he – a never-really-sick-a-day-in-his-life, hospital-hating, ultramarathoner, just past 40 – knew something was not right.

Thirty minutes later, walking up to the entrance of our local hospital’s emergency department, we were prepared: masks on, hand sanitizer in my coat pocket, a bottle of water and a phone charger in my purse. My husband was nervous, and I did my best to be cool and describe how things would go down. I explained what he could expect. After all, I’d spent my entire adult life inside hospitals. Going to the ED might seem complex, but it could be broken down into manageable, clear steps, I reasoned: here’s the situation; here’s what’s happening; here’s how we will address it. I’d make sure he was well-cared for every step of the way.

Immediately upon entering the building we were stopped and asked, “which one of you is the patient?” My husband hobbled forward, and I was told, “only he can come in. You’ll have to wait in your car.” I feel utterly ridiculous about how we reacted, when I think back to this moment. While we’d intermittently discussed and debated the merits and necessities of things like no-visitor policies over the last month, in our own reality of the moment, the limitation had completely slipped our minds. Were we stunned? Shocked? Embarrassed? I’m not quite sure how to qualify it, but the result horrified me for the next six hours. 

It wasn’t until I got back to my vehicle that it sunk in, what I had done. We had simply shrugged, said, “well…see you in a bit,” and parted ways. My partner in life, the man who devoted himself to my well-being and that of our children at every turn, walked off into a potential medical crisis without so much as a peck on the cheek from me: no hug or squeeze of the shoulder, not even a last-minute exclamation of “I love you!” before the sliding glass doors shut behind him. Back in the parking lot, closing the car door, I cried in fear, disbelief, and rage at my callousness.

While he was in the ED, I didn’t trust myself to talk to my husband over the phone. I worried that my lack of composure might lead to outright panic for this man who could barely, under normal circumstances, walk the hallway to my office for a brief lunch date, without experiencing a sense of existential dread from the hospital surroundings. Also, he was in pain, unsettled, with so many strangers in his personal space, and he seemed to be more comfortable communicating updates via text. It wasn’t long before he was caught in a flurry of IV starts, medication administration, physical examinations, and CT scans. The more I played back his signs and symptoms in my head, the more I expected the diagnosis, which ultimately came: acute appendicitis.

“Doc says it’s pretty clear-cut,” the text read. And I had no reason to disagree or question. No one asked my husband if there was anyone with whom he wanted to listen in over the phone when the diagnosis was revealed and plan discussed. Still uncomfortable, both physically and emotionally, he didn’t ask. Surgery was scheduled for later in the afternoon, and we agreed to FaceTime when he was transferred out of the ED to his room, where it would be less hectic. Understandably, he was tired. He hadn’t slept most of the night before, and now the Dilaudid was kicking in. “Get some sleep,” I texted back before starting the engine to make the short drive home.

About an hour later, I found myself in a state of disbelief, again. In my mind, I can imagine how things played out. Thinking he was delivering welcome and relieving news, the nurse strode into my husband’s room announcing that the surgery was being pushed up, and he was going to get him ready to head off to the operating room. Perhaps with a compassionate but somewhat rushed demeanor, the anesthesiologist entered next. She deftly reviewed the standard protocol and expectations with my husband while trying to keep out of the way of the OR techs, who were actively corralling IV poles and unlatching the bed brakes to start rolling him down the hall. In the midst of this, barely awake and out of sorts from the narcotics, my husband had time to send me two texts. 

“They’re about to take me to surgery.”

“I’ll catch you on the other side.”

I had already failed miserably to convey even the slightest expression of physical affection before I left him at the hospital entrance. Now, as my husband was headed to the OR, I’d lost my chance to even speak with him, possibly permanently. All of my positive thoughts about how young, strong, and healthy he was – every positive check box for “uncomplicated procedure” and “full recovery” – evaporated. My eldest (a senior in high school, the only one awake that morning, getting ready for her shift at work) looked ashen as she witnessed my unraveling.  Her no-nonsense, straightforward mother couldn’t escape one hopeless thought:  now, I might never touch or speak to my best friend again.

Over the hours, as I waited for the next communication, I thought of all the others who were caught in the same, previously unimaginable circumstance. Being hospitalized, or having a loved one hospitalized, is an extremely unsettling and often traumatic event. Even so, a similar comforting experience for most is the fact that they are able to be there for each other. Patients have visitors to keep them company and provide another set of ears when nurses and doctors provide information. Family and friends are able to hold on to some sense of purpose, simply being there for the patient during such a vulnerable time. The anguish over the dissolution of this symbiotic relationship should not be lost on anyone, whether they have ever faced the situation or not. 

Following these events, I was commended by friends and acquaintances for not erupting into rage at the messengers – or, indeed, the entire system. In reality, I truly understood the reasoning for what was happening. I knew our situation was not the result of some cold-hearted administrator who wanted to take the easy route out of a dilemma. It was one of many difficult decisions made to combat COVID-19. And there was nothing to be done about it. 

While my husband’s microscopically rupturing appendix met the surgeon’s laparoscopic tools, cuddling up close beside its hepatic buddy until his abdomen was opened with a six-inch incision, I created a list of ways my regrets over the course of the day could have been lessened:

  1. For those greeting folks at emergency department entrances, direction about only the patient being allowed to enter should immediately be followed by a statement like, “now’s the time for a fist-bump, hug, kiss, or wave goodbye, until things are sorted out.” Could this occasionally or even commonly be an awkward suggestion? Absolutely. Nonetheless, I am here to tell you that this one reminder to snap us out of our shock would have prevented a world of anguish for my husband and me. This is the most unexpected of lessons I learned, and also the most urgent I would encourage you to support in your own facilities.
  2. Initial check-in should include discussion with the patient about if there is anyone they want to keep updated via phone, and how often they want to include this individual in discussions. “Shall we make sure to call him/her every time we have updates or new information to share?” should be the first suggestion, to avoid any scenario in which patients feel like they are a burden to staff. This question should be repeated any time the patient moves to a new location, like an inpatient hospital room or a different unit. While such transfers may be routine for medical professionals, a new physical environment, accompanied by new faces on the care team, can feel to a patient like they have entered a whole new world, with different rules. They need to be reassured that communication with their support person can continue as before.
  3. Regardless of the initial answer to the question above, every physician or advanced practitioner who enters the room to interview, examine, or discuss results or plans with the patient should ask again if they have someone they’d like to be included via phone call to listen in and participate in the conversation. Patients MUST be made to feel that this is not an unreasonable action. No one should assume that patients will actively ask for this to happen, because odds are, they won’t. I encourage all providers to anticipate at baseline that their patient has a family member or friend out in the world who would be there in the room as a support, if allowed. You can be confident that same person is sitting at home, waiting for the phone to ring with an update.
  4. Moments in which a patient is suddenly whisked off to surgery or an invasive procedure should be limited to when the patient’s life is in danger or their condition is dangerously deteriorating. Outside of these emergency situations, all patients should be offered the chance and time to contact someone before heading to an operating room or procedural suite. The medical team needs to consistently remain cognizant of the fact that this moment is likely one of the most fearsome and anxiety-provoking in a person’s life – both for the patient and their loved ones. I cannot stress enough how strongly my panicked psyche believed that since I was unable to say “I love you” one more time, my husband would die under the OR floodlights.

Luckily, three days later, he came home. I know many others are not as fortunate. Much more can be said of the routine use of electronic medical records to communicate updates and care plans to designated patient supports, of how nurse matrixes and provider coverage schedules should be adjusted to allow for this necessary increase in communication, given the circumstances, and how it must be understood that many patients won’t advocate for their own needs because they are racked with assumed guilt that they are contributing to burnout of overworked healthcare providers during this global pandemic. If nothing else, please put protocols in place to remind patients and their supports that it’s OK to demonstrate affection at the moment one of them is turned away. We need to make sure a step is added into the process: here’s the situation; here’s an expression of concern and caring; here’s what’s happening; this is how we will address it.

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV

Juliet B. Ugarte Hopkins, MD, CHCQM-PHYADV, practiced as a pediatric hospitalist and now serves as Physician Advisor for Case Management, Hospital Utilization, and Clinical Documentation for ProHealth Care, Inc. in Wisconsin. She is Vice President of the American College of Physician Advisors.

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