Geriatric patient-centered care during the COVID-19: Provision of interactions vs. the imposition of isolation.

Introduction

Age is one of the dominant risk factors for morbidity and mortality from the emerging COVID-19 [1]. Older persons diagnosed with cancer, their families, and the medical staff face a meticulous trade-off between aggressive physical/social distancing and maintaining as close an interaction with family and community life as possible. This conflict, between the need for close contact that gives a sense of meaning and imposed isolation, while relevant for healthy older person, is aggravated following infection and has a tremendous impact at the time of near death.

Patients as well as family members and health care teams have to confront dilemmas and make difficult decisions such as whether to interrupt ongoing treatment due to possible infection or whether to allow family members to accompany older patients who cannot travel alone to treatment and feel too fragile and vulnerable to be alone. The regulations dictated by the pandemic crisis although for the benefit of the patients may be perceived as external imposition without being integrated part as active participation. This seems to contradict older patients' preference for autonomy and decision-making about their life and health [2].

The Tapestry of Loneliness

It can be hypothesized that the COVID-19 virus and the chronic condition of cancer are the “natural offspring of this cultural century,” in which loneliness is a disturbing problem for people the world over [3]. Some authors (e.g., Buchholz [4]) have suggested that there are benefits in voluntary use of “alone time” for the consolidation of the self. Cacioppo and Cacioppo noted that while loneliness can hurt, aloneness can heal and solitude can be the springboard for health and positive coping [5]. Nonetheless, loneliness is typically characterized in older people by feelings of depression, anxiety, emptiness, helplessness, vulnerability, stress, and emotional instability [6].

Loneliness can be defined as a subjective experience: a conscious, cognitive feeling of estrangement or social separation from meaningful others and an emotional lack that concerns a person's place in the world [7]. Older people diagnosed with cancer can feel the negative emotional state of loneliness even without being alone. They may perceive themselves as different and isolated because of their diagnosis and are particularly susceptible to feeling lonely, somewhat independently of their actual social and family environment and any available psychological support.

It should be taken into account that older people are heterogeneous in various aspects; likewise, the impact of loneliness. The problem of loneliness among older patients may be more acute in countries, where the older population are rapidly losing their traditional place of respect and honor and may feel abandoned and betrayed. They therefore often feel alone, socially isolated, and threatened by loss, shattered emotional bonds, and uncertainty, in other words, by a slackening of the pivotal forces that have sustained them and given meaning to their lives.

The Dynamic of Hope and Mutuality

The need for mutuality, which appears to be the expression of our fundamentally social nature [8], is important for maintaining hope. Hope is considered to be a human strength that allows people to optimize resources in their environments and place themselves on positive pathways of development [9]. Older people facing serious disease may maintain hope through the establishment of goals that go beyond just surviving in the isolation caused by the interruption of the daily expectation of a familiar face, touch, and smile [10]. The dominant role of family in the goals of the older patients population increases with age [10]. As they get older, people turn their attention inward and tend to invest in close and meaningful relationships.

In most families, the current isolation policy and total uncertainty alongside the fears of older patients with cancer becoming infected contradict the basic physical needs of security, namely, the need to touch, embrace, hear the sound of a familiar voice, and not be abandoned [11]. Active family interaction throughout the bleak trajectory of COVID-19 should help older people to mitigate the impact of social isolation. Similarly, understanding by the health care staff of the family's needs and the focused attention of physicians and nurses on the hopes of both the older people and their family may, similarly, moderate the various negative effects of the current situation. Health care professionals should consider the pivotal role of the family's priorities and beliefs and the older person's needs as a way of consolidating their strength and trust in the system of care.

The current social and family isolation may be alleviated via technological devices and by allowing meetings under the health care guidelines using maximum personal protective equipment and dedicated safe open spaces for periodic meetings. The positive and negative consequences of such strategies should be discussed with the older person, their family, and the medical team as well as a regular reassessment of all parties' updated hopes. Fig. 1 presents the various interactions and conflicts that surround the older patient with cancer. The basic conflict is between family and social engagement (left hand side) and maximum longevity (isolation – right hand side). The values of the family and friends have to be reconciled with those of the health professional. It can be done by finding new options for interaction (for example: e-meetings, open space for meeting, adaptation of regulations) and by utilization of the logistic strategies (for example: use of specific protective equipment). Any creative should take into account the changing hopes and goals of the patients.

Fig. 1

Factors influencing patient's values reconciliation and optional healthcare system adaptations.

Conclusion

Any decision-making concerning older patients should take into account their perceived goals, which may be very different from those of younger patients. It is essential to make rational decisions on such issues as intubation while being aware of the patient's level of understanding and agreement. Oncologists should actively initiate a “trust” dialogue with the patient and their family and give them several options to think about. This approach will provide patients with a wider understanding while helping them to maintain their resilience, optimism, and emotional embrace of the outside world.

The negotiation of cultural issues in geriatric health helps to manage possible conflicts and controversies between patients, families, and medical policies over differing health care values, beliefs, and practices [12]. The aging process is a synergistic product of biological, behavioral, and social issues within a cultural context. Knowledge about how older people understand, perceive, and experience their illness trajectory – be it cancer or corona – together with autonomous family choices are central to the planning and delivery of effective and comprehensive care [13].

Author Contribution

study concept – YR, manuscript preparation, editing and review – YR, GG and LB.

Declaration of Competing Interest

None.