By Judith Graham DECEMBER 17,
2020
This story also ran
on CNN.
It can be republished for free.
Imagine this: Your
elderly mother, who has dementia, is in a nursing home and COVID-19 vaccines
are due to arrive in a week or two.
You think she should be
vaccinated, having heard the vaccine is effective in generating an immune
response in older adults. Your brother disagrees. He worries that development
of the vaccine was rushed and doesn’t want your mother to be among the first people
to get it.
These kinds of conflicts
are likely to arise as COVID vaccines are rolled out to long-term care
facilities across the country.
“This is a highly
politicized environment, not only with respect to vaccines but also over the
existence of the virus itself,” said Michael Dark, a staff attorney with
California Advocates for Nursing Home Reform. “It’s not hard to imagine
disputes arising within families.”
About 3 million people —
most of them elderly — live in nursing homes, assisted living centers and group
homes, where more than 105,000 residents have died of COVID-19. They should be
among the first Americans to receive vaccines, along with health care workers,
according to recommendations from the Centers for Disease Control and
Prevention and various state plans.
But long-term care
residents’ participation in the fastest and most extensive vaccination effort
in U.S. history is clouded by a significant complication: More than half have
cognitive impairment or dementia.
This raises a number of
questions. Will all older adults in long-term care understand the details of
the vaccines and be able to consent to getting them? If individual consent
isn’t possible, how will families and surrogate decision-makers get the
information they need on a timely basis?
And what if surrogates
don’t agree with the decision an elderly person has made and try to intervene?
“Imagine that the
patient, who has some degree of cognitive impairment, says ‘yes’ to the vaccine
but the surrogate says ‘no’ and tells the nursing home, ‘How dare you try to do
this?” said Alta Charo, a professor of law and bioethics at the University of
Wisconsin-Madison Law School.
Addressing these issues
will occur against a backdrop of urgency. Deaths in long-term care facilities
are rising dramatically, with new estimates suggesting that 19 residents die of
COVID-19 every hour. With viral outbreaks increasing, already-overwhelmed
staffers may not have much time to sit down with residents to answer questions
or have conversations with families over the phone.
Meanwhile, CVS and
Walgreens, the companies operating vaccine programs at most long-term care
facilities, have aggressive timetables. Both companies have said the
large-scale rollout of the Pfizer-BioNTech vaccine — the first one that the
Food and Drug Administration has authorized — will begin on Dec. 21.But
facilities in some states may get supplies earlier. Altogether, there are more
than 15,000 nursing homes and nearly 29,000 assisted living residences in the
U.S.
At a meeting of the
federal Advisory Committee on Immunization Practices early this month, Dr.
Nancy Messonnier, director of the CDC’s National Center for Immunization and
Respiratory Diseases, acknowledged the agency was “very concerned” that
information about vaccines be adequately explained to long-term care residents.
“It’s very important for the frail elderly not only to ensure that they are
understanding the vaccine that they’re getting but also that their family
members do,” she said.
Each vaccine manufacturer
will be required to prepare a fact sheet describing what’s known about benefits
and risks associated with a vaccine, what’s not known, and making it clear that
a vaccine has received “emergency use authorization” from the FDA — a
conditional endorsement that falls short of full approval. A second vaccine,
from Moderna, is poised to receive this kind of authorization after an FDA
meeting on Thursday.
Something that will need
to be made clear to residents: while vaccines have been tested on people age 65
and older, those tests did not include individuals living in long-term care,
according to Dr. Sara Oliver, a CDC expert.
Some operators have
crafted communication plans around the vaccines and already begun intensive
outreach. Others may not be well prepared.
Juniper Communities
operates 22 senior housing communities (a standalone nursing home, multiple
memory care and assisted living facilities, and two continuing care retirement
communities) in Colorado, New Jersey and Pennsylvania. This week, it is
planning an hour-long town hall videoconferencing session for residents and
families about coronavirus vaccines. Last week, it held a similar event for
staffers.
Juniper has contracted
with CVS, which is requiring that every resident and staff member fill out
consent forms in triplicate before being inoculated. When written consent can’t
be obtained directly, verbal consent, confirmed independently, may substitute.
Walgreens has similar requirements.
For residents with memory
impairment, two Juniper nurses will reach out by phone to whomever has
decision-making authority. “One will ask questions and obtain verbal consent;
the other will serve as a witness,” said Lynne Katzmann, Juniper’s founder and
chief executive officer. Separately, emails, blog posts and prerecorded voice
messages about the vaccines have gone out to Juniper residents and staffers,
starting at the end of November.
A key message is “we’ve
done this before, not at this scale, mind you, and not at this level of import,
but we do flu vaccinations annually,” said Katzmann, who plans to be the first
Juniper employee to get the Pfizer vaccine when it comes to New Jersey.
At Genesis Healthcare,
crucial messages are “these vaccines have been studied thoroughly, tens of
thousands of people have received them already, they’re very, very effective,
and no steps have been skipped in the scientific process,” said Dr. Richard
Feifer, executive vice president and chief medical officer. Genesis, the
nation’s largest long-term care company, operates more than 380 nursing homes
and assisted living residences in 26 states, with about 45,000 employees and
more than 30,000 residents.
Medical directors at each
Genesis facility have been scheduling video conferences with families,
residents and staffers during the past few weeks to address concerns. They’ve
also distributed a letter and a question-and-answer document prepared
by the Society for Post-Acute and Long-Term Care Medicine, in addition to
getting information out through closed-circuit TV channels and social media.
In partnership with Brown
University researchers, the company will monitor daily the side effects that
its long-term care residents experience after getting coronavirus vaccines.
Most reactions are expected to be mild or moderate and resolve within a few
days. They include fatigue, pain at the injection site, headaches, body aches,
fever and, rarely, allergic responses.
Administering the vaccine
will occur over three visits for all long-term care facilities. At the first,
all Genesis residents and staffers will get inoculations. At the second, three
to four weeks later, those same people will get a second dose, and new staffers
and residents will get a first dose. At the third, those who still qualify for
a second vaccine dose will get one.
What will happen if lots
of people experience uncomfortable side effects and employees don’t come in for
a couple of days while recovering? “It’s a very difficult problem and we’re
making contingency plans to address it,” Feifer said.
And what about continuing
care retirement communities — also known as “life plan communities” — where
residents in skilled nursing, assisted living and independent living can reside
in close proximity?
That’s the case at
Bayview in Seattle, which houses 210 residents in a 10-story building. For the
moment, independent living residents aren’t on the priority list but “I know
there will be a contingent of residents and staff who won’t want to be
vaccinated and we’ll see if we can use those vaccines for our independent
living people instead,” said Joel Smith, Bayview’s health services
administrator.
Logistical challenges are
sure to arise, but many operators have an acute sense of mission. “It is
critical that we lead the way out of this crisis,” Feifer of Genesis said.
“Nursing homes need to go first and be the first ones to address vaccine
hesitancy head-on and be successful at generating a high level of acceptance.
There is no alternative, no Plan B right now. We have to be successful.”
Judith Graham: khn.navigatingaging@gmail.com, @judith_graham
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