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The geriatrician Markus Gosch from the Nuremberg Clinic is currently drafting recommendations with colleagues on how old people with Covid-19 can be well cared for in the home.
It's also about how they can die there with dignity.
Because contrary to what is often assumed, very old infected people are not even brought to the hospital.
WORLD:
Covid-19 is a serious disease, especially dangerous for people over 80.
Why are therapy recommendations needed for care in the home at all?
Don't these people belong in the hospital?
Gosch:
We'll have to talk more precisely about when they definitely belong in the hospital.
We wrote this down because we simply de facto see an urgent need for it.
Most home residents are not even brought to the clinic if they contract Covid-19.
There is this sad number: two thirds of all deaths related to the new coronavirus affect home residents, but only a fifth of those affected die in a clinic, the others stay in the home until they die.
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WORLD:
And what about the assumption that the many very old infected people would, so to speak, clog the capacities of the intensive care units, block them in the long term?
Gosch: In
my opinion, that is completely wrong.
Most of the patients in intensive care units belong to different groups.
People who live in long-term care are often very frail.
That is why family doctors so often decide against being referred to the clinic, especially with them.
WORLD:
But is that correct?
Then you leave them to their fate?
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Gosch:
It is right if you are very careful when making a decision and apply the right standards.
Many home residents have already decreed what happens in such a case.
If a person no longer wants maximum therapy, no longer wants to see a hospital from the inside, then one should not take him there either.
Another aspect is: if it is foreseeable that therapy will no longer help, then a conscientious doctor should spare the patient the burden of driving in an ambulance or ventilating with a trachea tube.
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WORLD:
But that's triage: the doctor decides who gets the treatment and who doesn't.
Gosch:
It is, albeit a form of triage that is constantly being used in medicine.
When people get pneumonia at the end of their lives from flu, many GPs do the same.
Very cautious about major interventions.
Many of the treatments that you would then try are painful and uncomfortable.
And often risky for very weak bodies.
And even if someone like that came to the clinic - there too the doctors would think about what else to expect them to do.
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WORLD:
So there is the old man in his care bed, bedridden for months, very demented, dusky.
Now he's also got the corona virus and is breathing hard.
The fever rises, the pulse is racing.
How can the nurses help him?
You don't have the resources like a hospital.
Gosch:
That's right, and we see that as a big problem.
Don't get me wrong: You don't need much for good supportive therapy, but that is exactly what is often lacking in the facilities.
But that must not be the case, especially not in this situation with many thousands of sick people, hundreds of dying people a day.
The people who stay in the home have often decided for themselves that they no longer want invasive ventilation.
But they never said they weren't expecting any therapy.
If they could still express themselves, they would certainly ask that everything be done for them that makes it easier for them.
The institutions should at least be equipped for these simple measures.
WORLD:
What do you think is necessary?
Gosch:
Oxygen therapy is very important.
It would be important now to equip all nursing homes with simple ventilation technology, for example with oxygen enrichment devices and so-called nasal tubes, the tubes that hang under the nose.
If the course is severe, the infection attacks the lungs and the sick cannot get enough air.
With Covid-19, oxygen is the best therapy, because if you supply it to the lungs, it slows down the overreaction in the body, the damage is not as severe - oxygen helps to survive, the earlier you use it, the better.
And even if the dying process has already started, I believe that oxygen is indispensable.
Otherwise the patient will have the feeling of suffocating, that is one of the worst feelings, one should absolutely spare him that.
I think it's really urgent that we support the homes and equip them accordingly.
WORLD:
And what else has to be done?
Gosch:
If the inflammatory reaction takes on a life of its own, a high dose of cortisone is given in the hospital.
This can recapture the chains of inflammation.
This therapy would also work on site in the home, at least for the patients who can swallow the corresponding tablets.
Anticoagulants should also be given, which is standard anyway when old people get serious infections.
However, I also have to consider: If a person can no longer swallow and the signs of the cytokine storm are there, then one should think a second time whether the referral to the clinic might not be appropriate, depending on the condition in which the patient is Patient before the disease.
WORLD:
But how do the nurses notice the cytokine storm without laboratory values?
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Gosch:
The oxygen saturation that suddenly drops is very noticeable.
Amazingly, patients do not notice this themselves at first with Covid, but a pulse oximeter shows it.
These are those little devices that you clip onto your finger.
If there is a value in the low 80s range, it is clear that something is going wrong with the patient.
He needs oxygen very quickly - and anti-inflammatory drugs like dexamethasone.
WORLD:
Are there pulse oximeters in the care facilities?
Gosch:
In our experience, unfortunately, often not either.
They are very useful for all possible respiratory infections, or for patients with COPD - and only cost about 30 euros.
WORLD:
You said: suddenly.
And: very quickly.
It sounds like there is a moment when the infection turns into a life-threatening course.
How can you make sure you don't miss this moment?
Gosch:
We thought about this for a long time.
Of course, permanent monitoring of vital functions, as we do in hospitals, would be ideal.
But the nursing staff in the homes are already so overloaded.
That is why our compromise is: to take the vital parameters three times a day, i.e. to measure the oxygen saturation, blood pressure, pulse, fever.
It's not perfect, but we think it's justifiable.
Because if someone decides not to want to go to the hospital anymore, then he probably takes the risks of this decision into account.
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WORLD:
It is now also known that Covid sufferers get better the earlier they are treated.
What can nursing homes pay attention to in order to detect infected people at an early stage?
Because in most federal states testing is only done weekly.
Gosch:
That is a very important point, and unfortunately there are still completely wrong assumptions.
Younger people often experience symptoms like those of a cold.
Not the elderly: The disease typically starts atypically with them, they become confused or even more confused, apathetic, somehow powerless.
That really has to become clear to everyone who works in geriatric care: It doesn't help anything for your clientele to watch out for signs of a cold.
Patients who seem weaker than the day before are the suspect cases.
WORLD:
Couldn't you just secure the homes better so that not so many of the people there become infected?
Then the carers could take better care of those who get sick?
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Gosch:
Of course, there are many things that could be done better, for example explaining to visitors that you have to adjust FFP2 masks so tightly that they inflate with every breath.
Deny you entry without such a mask, if necessary with security guards.
You can also test more broadly.
In our ward, we are currently combining PCR and rapid tests: All of them are regularly tested with the PCR, but if someone gets a scratchy throat while on duty, they check again with the rapid test.
However, I fear that even if all of this is organized more strictly and closely, we will still not get the care facilities virus-proof.
We cannot professionally isolate the residents, separate them from one another and from their relatives.
That would destroy her inside.
They are communal facilities and they are extremely susceptible to this airborne pathogen.
Markus Gosch
Source: Jasmin Szabo
To person:
Dr.
Markus Gosch works in the medical management of the Nuremberg Clinic (Clinic for Internal Medicine 2, focus on geriatrics) and as a university professor at the Paracelsus Medical Private University Salzburg (PMU).