During the height of the COVID-19 pandemic, a patient was admitted to John Hopkins Hospital in Baltimore, MD, after suffering a traumatic gunshot wound to his right parietal lobe. The patient needed surgery to relieve the swelling on his brain. Dr. Tej Azad, the neurosurgery resident on call, knew exactly what to do medically: intracranial pressure monitoring and possible hemicraniectomy.

Yet in those days, there was an unprecedented challenge in caring for neurocritical care patients. In accordance with CDC recommendations during the COVID-19 pandemic, institutions like Johns Hopkins allowed trauma patients just one initial two-hour visit with family. After that, communication was limited to phone or teleconference.

Dr. Azad struggled with telling the gunshot victim’s and other patients’ family members that they would not be allowed by their loved ones’ bedside in the days and weeks to come. “I remember talking to this patient’s daughter, and she was just distraught,” Dr. Azad recalls. “It was her wedding the next day, and she just kept pleading, saying, ‘Why can’t we be there? Why can’t we BE there? And I had to explain the visitor policy restriction. You don’t forget those conversations.”

In the end, the patient who underwent the hemicraniectomy survived. But as expected, families were very distressed to be physically separated from their loved ones in their greatest time of need. “They’d say ‘My sister, my father, my brother, is this sick and I can’t see them? How can you do this?’,” Dr. Azad says.

Dr. Azad says he was typically in control in such situations but during COVID-19, he had to yield to the pandemic restrictions of the facility at large. “As surgeons, the buck’s supposed to stop with us,” he says, “but I was powerless.”

In addition to the added distress of keeping loved ones apart, COVID-19 visitor restrictions also impacted care decisions, according to Dr. Azad, who led a study that found that such restrictions lengthened the average amount of time each patient spent in the Neuro ICU.

Neuro ICU: Remote vs. Beside Care Decisions

Unlike some ICU patients, neurologically impaired patients can rarely make their own medical decisions so in the Neuro ICU, neurosurgeons rely on family members for key care decisions. During the early days of the COVID-19 pandemic, when families weren’t allowed to come into the Neuro ICU, those care decisions became even more challenging and complex.

“Yes, we can make medical recommendations, but we don’t know these patients’ personal beliefs and they can’t speak for themselves,” Dr. Azad says. “We don’t know their value system and what they would want after a very severe injury, so we have to rely on family members to make life-changing decisions about their care.”

Traumatic brain injuries often entail grave calculations that balance quality of life prognosis and risk considerations. When family members are able to sit beside and see their loved ones surrounded by beeping machines, breathe through a tube and with an external ventricular drain in their brain, they are able to fully absorb the gravity of the situation, Dr. Azad says. And it is almost impossible to relay that kind of magnitude about their injuries remotely via phone or via Zoom.

Dr. Azad gives credits to the nurses and social workers who worked closely with family members during the pandemic. And yet it was also his job to call the family after surgery and discuss the next steps of care. Typically, family members and surgeons meet regularly in the Neuro ICU and develop a trusting relationship as they determine next steps of care. With that impossible during COVID restrictions, Dr. Azad believes it inhibited effective decision making.

Lengths of Stay in Neuro ICU Increased

Dr. Azad authored a study that determined that the 940 adults with non-COVID-related illnesses admitted to Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center ICUs for at least one day during the restrictive visitor policy in effect on March 21, 2020 through August 31, 2020 spent an average of 2.9 days longer in the ICU (including the Neuro ICU) than before the policy was enacted. There was also a significantly longer time to the first do not resuscitate/do not intubate/comfort care order.

“Our findings suggest that a policy restricting family presence may have led to longer ICU stays and delayed decisions to limit treatment prior to death,” the study by Azad et al. concluded. “This unintended consequence is particularly concerning when ICU beds become a scarce medical resource. The phenomenon appeared to decrease as locoregional COVID-19 positivity rates dropped and exceptions to the policy were granted with greater regularity.”

The Impact on End-of-Life Care Decisions

There was one standard exception to the COVID-19 visitor restrictions: If the family decided to move a patient to comfort/end-of-life care, they were allowed one visitor by the patients’ bedside. “That was one of the things I felt most conflicted about,” Dr. Azad says.

“There was no bad intent on anyone’s part, but you’d be having these conversations with the family at 2 a.m. and they’d start to put two and two together— the only way I can get in there to be with my family member is to change their status to comfort care,’” he says. “Of course, we would try to correct that conclusion, but it was terrible that people may have felt swayed to change their care decisions because it was the only way they could see the patient.”

Should Traumatic Cases Be an Exception?

In the months that followed, visitor restrictions during COVID-19 evolved and gradually loosened. Yet even in the peak, early days of COVID-19 cases, certain patient populations had more visitation opportunities. For instance, many hospitals allowed a parent or guardian to accompany pediatric patients and a support person for women giving birth.

Dr. Azad believes visitor policy exceptions should also be made for traumatic brain injury patients as well. If it’s a question of infection control, maybe it’s about building an effective testing paradigm.

The question remains: What happens if there’s another lockdown in the future? Dr. Azad wants to find a solution that doesn’t have negative consequences for brain-injured patients and their families. “That’s the moral and ethical side of things,” Dr. Azad says. “I think this is something people are certainly talking about, but I don’t think there’s a good solution yet.”

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