TMA-Backed Principles Call for Flexibility in End-of-Life Visits for COVID-19 Patients
By Sean Price


The Texas Medical Association, joined by six other state health care organizations, has produced a list of principles to help hospitals and other health care facilities provide more flexible visitation policies for patients facing serious illness or end-of-life situations during the COVID-19 crisis.

Whether due to emergency state rules or their own infection control procedures, many facilities have enforced strict policies against visiting COVID-19 patients to prevent the spread of the disease. That has forced thousands of Texas patients to die or endure prolonged stays without any contact from loved ones, says Robert Fine, MD, a member of TMA’s COVID-19 Task Force and clinical director of the Office of Clinical Ethics and Palliative Care at Baylor Scott & White in Dallas.

“We wanted to open up the possibility of more visitation for patients who are isolated in these facilities currently,” said Dr. Fine, who helped write the principles. Under current restrictions, “visitors can’t go in, and patients can’t go out. And we were looking for some flexibility and to give some guidance.”

The organizations asked Texas Gov. Greg Abbott and Cecile Young, executive commissioner of the Texas Health and Human Services Commission (HHSC), to strongly consider the principles when developing emergency rules related to visitation policies during the pandemic. The group includes: TMA, the Texas Hospital Association, Texas Assisted Living Association, Texas Nurses Association, Texas Health Care Association, Leading Age Texas, and Texas & New Mexico Hospice Organization. 

“Our organizations wish to recognize the mental, emotional, spiritual, and other health needs of the patient that may be unmet with strict, limited, or ‘no visitation’ policies. We would expect the emergency rules will evolve with time as the rate of virus growth ebbs,” TMA President Diana L. Fite, MD, wrote Governor Abbott and Commissioner Young.

The principles do not cover routine visitation – only visits at the end of a patient’s life or during serious illness, Dr. Fine explained.

The principles define an “end-of-life in-person visitation” as a meeting between the patient and family to discuss medical treatment goals or when death is expected soon. It also defines “serious illness” as when a physician “would not be surprised if a patient died within the next year,” and “chronic critical illness” as when the patient is expected to remain in intensive care for more than one week.

The definitions are important because many health care facilities have defined these terms inconsistently or inflexibly, Dr. Fine says. Physicians and other medical staff have witnessed that this can cause unnecessary pain for patients and families.

“In the acute care setting, we said at the beginning [of the pandemic] that there’s no visitation unless the patient is actively dying,” he said. “So when do we know when the patient’s actively dying? They may die quicker than you can get the family here to visit.”

Facilities can make visits from children possible as well, but all flexibility for visitation must be weighed against the availability of personal protective equipment (PPE) and rapid testing for anyone entering a facility, the document says. Some facilities may not be able to accommodate visitation because they do not have enough of either. The facility’s infection control leadership also must approve any protocol changes.

Other considerations include:

  • Making sure visitors comply with PPE policies;
  • The limitations on staff time when planning visits;
  • Potentially registering all visitors to COVID-19 patients to share that information with health authorities in the event of disease spread;
  • Potentially requiring a signed waiver of liability by a visitor;
  • Requiring visitors who will be with the patient for more than an hour to agree in advance to self-quarantine for 14 days after the date of the visit.

Facilities will need to be more nimble in how they approach any future changes, the document states.

“We also recognize that the ‘new normal’ we are currently living through may last years, meaning any set of rules may change as the disease and its treatment change,” it says.

As always, find the latest news, resources, and government guidance on the coronavirus outbreak by visiting TMA’s COVID-19 Resource Center regularly.

Last Updated On

August 14, 2020

Originally Published On

August 13, 2020

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Sean Price


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Sean Price is a reporter for Texas Medicine and Texas Medicine Today. He grew up in Fort Worth and graduated from the University of Texas at Austin. He's worked as an award-winning writer and editor for a variety of national magazine, book, and website publishers in New York and Washington. He's also helped produce Texas-based marketing campaigns designed to promote public health. Sean lives in Austin and enjoys hiking, photography, and spending time with his wife and two sons.

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