Recently, I had a disagreement with the public health medical director in Santa Fe about the application of a public health policy related to gastroenteritis in an assisted living facility. The interaction occurred because my mother’s facility had placed the residents on isolation for meals and group activities. This meant that the main social event for the residents, dining together was being stopped for ten days.
When I voiced my concern, I was told by the Director of Nursing that it was state regulations and the residents were not confined to there rooms all day, just at meals and activities. She added that the residents could walk around the halls with no restrictions. My thought was, this is the frail elderly who don’t generally wonder the halls for social purposes. My mother didn’t take her walker and go visit her neighbor. She waited for meals or activities.
The isolation edict was insituted on a Friday evening as I was heading to the airport. I thought it was over the top but was focused on getting home. During the next week, every call that I received from my mother was about how alone she felt and missed her friends. She just didn’t see anyone. She didn’t like eating alone.
During this time, I looked up the CDC’s policy on gastroenteritis and Norovirus. To my surprise, the CDC policy stated that the isolation should be three days after the last case presented with symptoms. At my mother’s facility, the last presenting case had been five days before the isolation was even started. There were no new cases.
And then on the night of the tenth day, one of the residents who went out to eat with her family and got diarrhea. The facility designated it a new case and decided to extend the isolation for another week. I happened to call my mother’s care person and she told me the news. Due to the isolation, my mother had begun to show signs of decline. She told me she was ready to die because she couldn’t stand being in this situation. She needed her socialization and felt it would never end.
I knew I had to do something. The policy was causing harm. I called the Director of Nursing who told me it was the state. So I called three people at the Department of Public Health, the medical director, the director of environmental services and the director of epidemiology. I spoke with the medical director. This is how the call went.
Hari: I am calling about the policy instituted at my mother’s facility. I am concerned because it does not follow CDC guidelines. I feel it is causing more harm than good. There will be a total of 17 days of isolation for the frail elderly.
Doctor: I am happy to try and explain it to you but I don’t think it is going to do any good.
Hari: I am a nurse practitioner, try me.
Doctor: … proceeds to explain the need to contain the infection.
Hari: But why the extended time when CDC is very clear if a new case appears after an extended time then the individual is isolated till symptoms resolve.
Doctor: The facility requested the extended time and we said if you want to it is OK. Better to support a facility that reports an outbreak.
Hari: Again, my concern is the harm that the unnecessary policy is causing.
We bantered for a while longer and then he agreed to speak with his team and the facility. The restriction was lifted that night and there has been no new cases. My mother never recovered from the isolation and is now on hospice. It seems this was the straw that broke the camel’s back.
After the conversation, I started thinking where were the ethics related to this policy. Ethics is basically the examination of what is right or wrong. In medicine, it is the system of moral principals that apply value and judgements to the practice of medicine. I would put forth, that this decision was lacking in ethical thought as the actions of the facility and public health department’s actions caused as much harm as possible good. There seemed to be no thought or caring as to the impact on the lives of the residents. Perhaps my mother did not suffer from gastroenteritis but her mental status suffered. I would say, the actions were ethically incorrect.
Public health policy makers need to balance the good vs harm in all the policies. In this case, the CDC policy if followed would have minimized any potential harm. It was not followed and harm occurred. It should not occur again.