By Gary L. Stein, JD, MSW, Professor, Wurzweiler School of Social Work

Gary Stein, Wurzweiler School of Social Work

A New York Times podcast on April 15, 2020, presents a heart-breaking portrayal of a son and elderly father who became seriously ill by COVID-19. The son, his father’s primary caregiver, expresses his guilt that he might have infected his father, who died of the illness.

Older adults, those over 65 years of age, have been especially hard hit by the COVID-19 pandemic. According to the Kaiser Family Foundation (April 1, 2020), “just over half of those at higher risk of developing a serious illness are ages 65 and older (55.2% or 51.1 million adults).” In New York, New Jersey and Connecticut, the percentages of impacted older adults are even higher (55%-60%). And older adults in nursing homes are at even higher degrees of risk: the New York Times reports that “more than 21,000 residents and staff members at those facilities have contracted the virus, and more than 3,800 have died.” As a susceptible community, elderly individuals who have both serious disability and chronic illness clustered in congregate living, nursing home residents are most vulnerable to serious illness and death as a result of COVID infection.

The elderly face serious challenges. They risk being isolated, usually through the good intention of protecting them from infection, serious illness, and death. However, protecting the most vulnerable comes with its costs. On April 9, New York Times columnist David Brooks asked for reader input on the psychological impact of the pandemic. Older adults were “especially hard hit, particularly the widows and widowers. For many, it’s the painful sense of missing their grandkids, the precarity of living with a disease that could kill them at any time. For others, it’s the wrenching loneliness.” A 65-year-old single woman describes the experience of isolation and stress: “I cry a lot, which is my new norm. … So to sum it up, I’m feeling totally alone in this crisis and hopeless.”

For those who become seriously ill as a result of COVID infection, the possibility of scarce resources looms large, especially for ventilator support. A shortage of ventilators is anticipated, especially in the hardest hit areas. Thoughtful articles on rationing and allocation of resources have appeared in the New England Journal of Medicine (March 23, 2020) and The Hasting Center Report (April 9, 2020). Old age is the elephant in the room. When older adults have poorer medical outcomes and have enjoyed the benefits of longer lives, should younger patients be prioritized if resources become scarce?

Franklin Miller, a 71-year old bioethicist, makes this case in Hasting, from a perspective both personal and political. With older adults “having a relatively poor prognosis, the number of years of life that they have had the opportunity to experience supports an age criterion for rationing ventilators. Other things being equal, the young have much more to lose from death than the elderly. I would suggest that an initial age criterion for rationing ventilators when the demand outstrips the supply is a cut-off of 80.”

The takeaway message is for all adults, and particularly those over 65 years of age, to complete their advance directives. These legal documents include naming a close family member or friend as their health care proxy; their surrogate becomes legally empowered to make decisions in times of physical or mental incapacity. Living wills, which allow adults to express their desires about life supports, including the use of ventilators, are also critical in the COVID era. Unfortunately, studies show that only about one-third of Americans have advance directives, although older adults complete them at higher rates (Institute of Medicine, 2015). No time is better than now for adults to think about and complete their advance directives and communicate their wishes with their families.

The impact of COVID on older adults has been a personal issue for me. I struggle with the isolation of my elderly mom in a retirement community. Staying alone in her apartment has protected her from possible infection from close friends and others in her community as well as from extended family. However, my mom is very social, and isolation is known to take a serious physical and emotional toll on the elderly (Span, April 13, 2020).

How long is physical separation and isolation desirable? Public health experts and social workers have long advocated harm reduction strategies to mitigate the serious outcomes of health and social problems. As social workers, we need to move in that direction to prevent the growing public health crisis of loneliness among the elderly. As we now rely on digital strategies to conduct our business and better connect during the pandemic, we must adapt “age-friendly” ways to encourage their use by the elderly as well as the service providers and residential facilities that care for them.

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