COVID-19-related deaths in long-term care: The moral failure to care and prepare

Coronavirus disease 2019 (COVID-19) has taken a particularly heavy toll on long-term care (LTC) home residents in Western countries. Almost 80% of Canada’s ¹ and 50% of Switzerland’s ² coronavirus-related deaths are linked to LTC facilities even under hermetically closed lockdown conditions. Half of the COVID-19-related deaths in Europe ^3,4 and 35% of the US death toll ⁵ are happening in LTC facilities. Although demographical and epidemiological factors like old age and comorbidities have been proposed to explain the excess mortality of this especially vulnerable population, ⁶ it has become more and more evident that it is not only the vulnerability of individuals but also the place of care that is the major contributing factor capable of explaining this dramatic phenomenon. The failure to plan adequately in this sector, while acute and critical settings received most of the pandemic planning attention, is a reflection of the long-standing low visibility of these care environments. As the unsettling stories of neglect and undignified deaths in LTC facilities continue to unfold, the problem of how we treat older adults, people with disabilities, and those who care for them has been laid bare by the pandemic.

The inability of LTC to cope with the devastating impact of COVID-19 within its institutions comes as no surprise. It is a result of the deep-rooted devaluation of care work that happens at the intersection of ageism, ableism, sexism, and racism and is further aggravated by a rude marketization of this healthcare sector. When human value is mainly tied to economic contribution, old and disabled bodies are perceived to have outlived their usefulness and, thus, are undervalued. Contributions that older and disabled adults have made throughout their lives and continue to make to their families, communities, and society and their past work are often unrecognized. Fragility and dependency are negatively perceived as a burden. Thus, provision of care for this group of individuals is not considered a priority, and they are often left in insecure and vulnerable positions.

The perception of care work as trivial or of less importance has also contributed to the current crisis in LTC during the pandemic. Care work is not considered a fundamental component of growth and development under neoliberal capitalist ideologies ruling healthcare markets. The existing attitude toward care work is that this work is “low-skilled” by nature and, therefore, a type of work that anyone can do. Women, particularly women of color, have been disproportionately overrepresented in this sector. ⁷ Care workers, the ones who bathe, feed, and dress residents, are often among the lowest in the healthcare labor hierarchy, are poorly paid, and are precariously employed. These workers face extra barriers in drawing attention to their unsafe and exploitative working conditions. The job has little recognition and respect, a high turnover, and low career opportunities. ^8,9

The systemic deficiencies and underfunding of LTC have made it impossible for this sector to manage the complexities of care effectively and to build and sustain a reliable workforce to meet the care needs of residents. This deficit has become mercilessly visible during the pandemic. These days, many care homes are under conditions of lockdown. More than ever, they need skilled frontline caregivers to provide hands-on care to the residents, meet their healthcare needs, comfort them, and compensate for the lack of social interaction with spouses, children, and significant others.

LTC settings already struggling with chronic understaffing lost some of their staff to illness, burnout, or mandatory self-isolation during the pandemic. Some workers left their jobs due to unsafe working conditions. Many LTC facilities struggled to find and train workers for the urgent needs of the residents. ¹⁰ In Canada and Spain, the military had to be called in for assistance in some facilities. They reported that the conditions that residents and their care workers were forced to live and work in compromised the basic human rights of the residents. Some of the residents were left in unhealthy and unsanitary conditions, not being provided with basic care for days and often dying alone, whether due to COVID-19, neglect, or both. ¹¹ In many cases, residents were denied hospital care when they contracted the virus. ^12,13 In Switzerland, some cantonal health authorities issued provisions to residential care facilities imposing stricter requirements for the hospital admission of residents compared to non-residents with similar COVID-19-related health needs. ¹⁴

Healthcare workers reported many of the residents die in an undignified and isolated manner, a situation that has been referred to as a “humanitarian crisis,” affecting the society as a whole. ¹⁵ Shouldering the burden of a collapsing system puts LTC frontline care givers in physically dangerous and morally distressing working conditions. These workers, who are mostly marginalized and in a highly feminized and racialized job, may struggle with this experience long after the pandemic. They may experience varying degrees of emotions and reactions such as guilt, fear, burnout, or post-traumatic stress disorder (PTSD).

Under the menacing sword of Damocles of a pandemic with many unknowns, COVID-19 has been represented as the problem of older adults. As a result, the death of older people has been considered bearable, expectable, and somehow less important. The metaphors such as “ground zero,” “death trap,” and “wildfire,” that have been broadly circulating in the media, could convey that the public perceives COVID-19-related deaths in LTC as inevitable, or, taking a narrow and caricaturized utilitarian perspective, a sacrifice worth taking for the sake of society, if the economy can be opened for the apparent good of the majority. These attitudes and beliefs explain why LTC facilities were not a major concern in pandemic planning, but hospitals, ventilators, and intensive care unit (ICU) beds were. These developments severely undermined the continuity of care for residents in LTC facilities, which received little attention and planning. From access to personal protective equipment to infection control measures, staff training, and environmental control, LTC workers and residents received both scant attention and second-class treatment, which is an indication of how we make choices about who to care about at the time of crisis as a society.

In Canada, Switzerland, and elsewhere, the first response to the outbreaks in nursing homes was a radical ban on “visitors.” The residents, who had often already struggled with loneliness, have been restricted to their rooms without being able to visit their families for months who had previously provided companionship and various forms of assistance. ¹⁶ Active family involvement has been shown to reduce staff workload and the mortality, infection, and hospitalization rates of residents. ¹⁷ Imposing a blanket restriction of family visitors has, in many instances, not been able to protect the residents; rather, it has left them in confinement, without a trusted advocate, only intensifying their vulnerability.

A sustainable and stable caregiver workforce is required to provide dignified and quality care to LTC residents during and post-pandemic. By acknowledging our shared interdependence and vulnerability, this commentary is a call to draw attention to the current care crisis in LTC facilities. By putting care at the center of our value system, the existing fragile and resource-limited care economy can be revisited in a way that makes visible its importance to our collective well-being.