University of Toronto Family Medicine Report
CARING THROUGH COVID-19
Caring for homebound patients during the COVID-19 pandemic
house calls for
patients in 2020 UTOPIAN data, 2020
In June 2020, Buzz – a 90-year-old homebound patient of ours – had been tired for several days and was too weak to bear weight. His son, Don Neal – a family doctor living out of town – worried that Buzz might have contracted COVID-19, but his father was too weak to visit a COVID-19 assessment centre. After hearing about Buzz's situation, our home visit team stepped into action.
At the heart of our team’s philosophy of care is the importance of patient-centred care: What are the patient’s goals and wishes? Some of our homebound patients continue with active medical treatment, seeing specialists and going to hospital when such care would improve their function or quality of life. Others want only comfort-based care at home.
Our team is a group of three family doctors, a nurse practitioner, a clinical pharmacist and a LHIN (local health integration network) co-ordinator. We serve a high number of seniors living alone in some of the lowest income postal codes in the city.
Uncertainty is part of our culture in family medicine, even more so in caring for older patients.
This uncertainty is particularly challenging when making shared decisions in the absence of clear guidelines for the care of homebound patients with COVID-19. We had to Don was relieved that "someone was willing to ‘PPE- consider: If a patient deteriorated, should we provide the up’, go in to do a swab and get an early diagnosis." His medications that were being used in long-term care? Do instincts were correct: Buzz had COVID-19. We put in we order oxygen to keep on hand at home or should they supports to manage him at home with minimal contact call 911 immediately? These are questions we grappled and provided an oxygen saturation monitor with instruc- with in caring for patients with COVID-19. tions on when to call. Buzz initially seemed to recover well from COVID-19. Early in the pandemic, we saw that virtual care wasn’t However, on day 14, a personal support worker reported going to work for our patients. Most don’t have computers, Buzz's pupils were strangely dilated. He had suffered a and some don’t even have a phone. Many have dementia haemorrhagic stroke, a known complication of COVID-19, or severe hearing loss. To meet our patients’ needs in this and was transferred to hospital. new environment, we quickly developed protocols for using personal protective equipment (PPE), testing and The family strongly wished to bring him home to die. It monitoring patients with COVID-19. We also accessed would take days to arrange a palliative team, but the COVID-19-focused goals of care discussion guides and family wanted him home as soon as possible. Our team created an end-of-life symptom management kit with delivered a symptom management kit and cared for him at home until the formal palliative care team arrived. He special consideration for patients who live alone. died peacefully at home.