Communicating during Covid – the junior doctor’s perspective
Alice Hogg, Alice Hosking and Elson Musenga, Royal Infirmary of Edinburgh.
The impact of Covid-19 has been huge, both on those who became unwell and even died, and their loved ones, but also on the staff caring for patients whilst the health system changed beyond recognition. As the pandemic waxes and wanes, we have had a chance to reflect on our experiences working as junior doctors on the Medicine of the Elderly wards of a large teaching hospital. Over recent months, we have felt an increased emotional burden, working with vulnerable older people across both coronavirus and non-coronavirus wards. In this blog, we highlight some of the difficulties we have encountered due to the various restrictions required to protect our patients.
Behind the mask
Mask-wearing is now the norm in hospitals, but wearing a mask poses new challenges, and can act as a barrier to communication. When communicating, particularly with older people, forming relationships with patients can become more difficult. Voices are muffled, deaf patients cannot lip-read, and a welcoming smile is hidden from view. Patients with dementia or delirium have found staff wearing masks distressing, though on the other hand some have found comfort in wearing masks themselves. Unable to see any faces, one lady with dementia thought that the nurses tending her in the middle of the night were ‘mask-wearing ninjas’. Another patient, unaware he was in hospital, found his way into other patient’s rooms, and became distressed when masked staff - who he could not hear properly - tried to redirect him.
The empty chair beside the bed
We shall never again underestimate the family contribution to patient care in hospitals. Before the pandemic, initiatives such as “John’s campaign” actively encouraged relatives to support patients through their hospital journey. We now realise we did not fully appreciate the extent of support relatives provide. Although staff joked about enjoying the peace and quiet on the wards, we rapidly realised the huge impact this had on individual patients. During this pandemic the full multidisciplinary team have had to fill in some of these gaps: practical, emotional and social support. As a consequence, we have felt an increase in our emotional burden in the absence of visiting family and friends. Relatives were apart from their family member, sometimes for weeks at a time. Without routine visiting, relatives were not able to see progress, or at times deterioration, in their family member. This affected many areas of patient care, including discharge planning, anticipatory care planning and clarifying a patient’s baseline function.
At our hospital we were very fortunate to have video calling devices donated for patients to use to contact friends and relatives. This can be a real comfort for patients and families at a stressful time. However, our patients with dementia were often unfamiliar with modern technology, and we found they struggled with video calls. Sometimes these attempts provoked confusion rather than comfort. One patient spent the call looking at the ceiling, unable to work out where the sound was coming from. Another patient had a video call with his wife by a window on the ward. Following the call he spent the rest of the day trying to see if he could see his wife through the window, as he thought he had seen her there before. In addition to these difficulties, older relatives were often excluded because they did not have the means to take part in video calls.
We routinely kept relatives up to date through regular telephone calls, even when patients were well. We hope this gave relatives some sort of reassurance when they were unable to see their family members. We soon became familiar with the barriers, however, imposed by telephone conversations. We concentrated on the fundamentals of excellent communication: speaking slowly and clearly and limiting any medical jargon. Over the phone, checking understanding needs to be done explicitly and sensitively. As family meetings on the ward were not possible, multiple relatives might have to be contacted for each patient, to ensure that important discussions were properly communicated. We found relatives to be understanding that difficult or complex discussions around anticipatory care planning, discharge planning and breaking bad news had to happen remotely, and we appreciated their patience.
An early start
One of us (EM) graduated early and worked as an interim F1 during the pandemic. Starting work as a newly qualified doctor in the middle of a global pandemic was a big unknown. It was difficult to envision exactly what new doctors were stepping into and how things would evolve over the coming months. The interim F1s were in a unique position of still being relatively inexperienced, and without established patterns of communication on the ward. Our first discussions with family members as a doctor were through a telephone or wearing a mask, although this is now the norm for us. Nonetheless, we keenly felt we lacked the natural expression of empathy and compassion that is often best achieved in person.
Death and dying: the particular challenges in Covid-19
Dealing with death and dying is an important part of our work as doctors in geriatric medicine. Before the pandemic, we would aim to build a relationship with a patient and their family, and support them through a final illness. Often patients have a gradual deterioration and we are able to anticipate decline. However, during the Covid-19 pandemic this process was challenged in several ways.
Families were allowed to visit only when patients were at the end of their life. Some patients, particularly those with Covid-19, deteriorated very quickly, with little time to allow us to warn relatives.
At other times we were being asked to predict the exact time of death. Patients’ relatives have their own vulnerabilities; some were older themselves or shielding and were only willing to visit if we felt the patient was truly dying. In the worst situations, relatives were weighing up their own risk of catching Covid-19 with the opportunity to say their final goodbyes to their loved one. Relatives would ask us as medical professionals for advice, and it is impossible to not take the weight of this decision onto yourself, particularly when posed with such a difficult dilemma with no solution. We dealt with these situations as a full multidisciplinary team, and we reflected together and supported each other.
Occasionally our predictions of a patient’s decline were wrong. We tried to ask families to visit before it was too late, and sometimes patients survived after families were called in to say their goodbyes. This then put us in the difficult position of once more parting patients and their families, as visiting was only allowed at the end of life.
Thoughts for the future
These experiences will stay with us. Looking after very unwell patients with Covid-19 was traumatic; but the impact is much wider than the specifics of clinical care. We have had to adapt not just to a new disease, but to telephones, visiting restrictions, masks and the fear of Covid-19 transmission. The whole team has come together to support patients and their families, and we are grateful for our nursing, consultant, therapy, administration and domestic colleagues. The last few months have shaped us as doctors, and we will take these skills forward for the rest of our careers.
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