Lisa Hicks is a malignant hematologist at St. Michael’s Hospital in Toronto


In late March, as the COVID pandemic settled around us, the Ontario Ministry of Health and Long Term Care introduced a no visitors policy for hospitals and other congregate care settings. The rationale for restricting visitors during the COVID-19 pandemic is straightforward. It is R-values, droplet spread, and unknown incubation times that have brought us to this place.

Initially we worried that visitors would bring the novel coronavirus to the hospital and the vulnerable people housed within our walls. Now as the pandemic evolves, and hospitals become a source, not just a potential recipient of the virus, we also worry about visitors spreading the virus from us to their community. Either way, I can follow the simple math. Less people in the hospitals means less opportunity for viral spread.  If reducing contagion is the only concern, a strict no visitors policy maximizes benefit.

Of course, reducing viral spread is not the only medical outcome that matters. One weekend of ward call was more than enough to drive home this lesson for me.  In the first room, an elderly man with delirium, greatly prolonged in the absence of familiar faces to anchor him to reality. In another, a woman who spoke no English trying to communicate through an elaborate pantomime. “Your IV? There’s a problem with your IV?” More gestures. A phone is found and a family member translates. “Oh, your IV is itchy? Yes, I see, it’s the tape. I think, some people are allergic.” A problem I can solve.

The next room is more difficult, “I’m sorry, I know your vision is getting worse – it’s the cancer, it’s spreading.”  It’s picking off cranial nerves in a pattern that’s difficult to predict. One day it may take the nerve that enables clear speech. I imagine a future conversation, “I cannot understand my wife, why can’t I understand my wife?” How will I explain that our no visitors policy does not make exceptions for dysarthria?

The last room is the hardest, “I wish I could see my family too,” says the man in the bed by the window, nodding at the woman quietly visiting with his roommate.

“I’m sorry, the rules are very strict,” I say.

“I know,” he says softly, patting my hand, “I’m glad things aren’t that bad for me.”

Even in lock-down, word travels quickly. Friends and family members, once part of the fabric of our floor, now signify an anticipated death.

I do not care for children or labouring women. In the corner of the medical world I inhabit, the only patients allowed visitors are people whose death is considered imminent – except for those unlucky enough to be sick with COVID, when even dying doesn’t allow an exemption. One of the many problems with this rule is that doctors have never been terribly good at predicting death. Sometimes the transition to end of life is clear, but sometimes, especially in acute illness, even the near future can be difficult to pin down.

I am used to being asked to estimate the probability that a person will survive their illness – it’s an inexact exercise involving generalizing from imperfect data to the person in front of you – a person different in innumerable ways from those in the trials we quote.  An individual – not aggregate data.  What I’m not used to is my estimates being used to determine whether a person can see their family. What is the right number to allow visitation? A 10% risk of death this week? 25%? 50%? This is not a decision we can take back. If, despite our best efforts, we deny a family the opportunity to say goodbye to a loved one, to hold their hand, to stroke their hair, we can’t undo the damage. This is what haunts me this evening, when I should be sleeping.

I follow the policy, as I must, but neither my heart nor my mind believe that the harm we aim to prevent with current no visitors edicts outweighs the harm we are causing. COVID-19 will be with us for months or years to come; I believe it’s time to cautiously invite families and friends back to the bedside because we can’t deliver truly compassionate care without them.

 

I would like to acknowledge Martina Trinkaus and Devin Singh for their editorial input and encouragement