Think that you should be vaccinated, as you have felt that the vaccine is effective in generating an immune response in older adults. Your brother disagrees. He worries that the vaccine will develop quickly and does not want your mother to be one of the first people to get it.
“This is a highly politicized environment, not only in terms of vaccines, but also because of the existence of the virus,” said Michael Dark, a staff advocate for California Advocates for Nursing Home Reform. “It’s not hard to imagine disputes that arise within families.”
About 3 million people – most of them elderly – live in residences, assisted living centers and collective residences, where more than 105,000 residents have died from Covid-19. They should be among the first Americans to receive vaccines, along with health care workers, according to the recommendations of the U.S. Centers for Disease Control and Prevention and various state plans.
But the involvement of long-term care residents 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 several questions. Will all adults with long-term care understand the details of the vaccines and be able to consent to them? If individual consent is not possible, how will families and surrogates get the information they need in a timely manner?
What if the substitutes don’t agree with the decision an older person has made and tries to intervene?
Imagine that the patient, who has some degree of cognitive impairment, says ‘yes’ to the vaccine, but the substitute says ‘no’ and says to the residence, ‘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 in a context of urgency. Deaths in long-term care centers increase dramatically, with new estimates suggesting 19 residents die of Covid-19 every hour. With the increase in viral outbreaks, already overwhelmed employees may not have much time to sit down with residents to answer questions or talk to families over the phone.
Meanwhile, CVS and Walgreens, the companies that operate vaccine programs at most long-term care facilities, have aggressive schedules. Both companies have said that the large-scale deployment of the Pfizer-BioNTech vaccine – the first that the Food and Drug Administration has authorized – will begin on December 21st. But facilities in some states can be supplied sooner. In total, there are more than 15,000 nursing homes and about 29,000 assisted living homes in the U.S.
At a meeting of the Federal Advisory Committee on Immunization Practices earlier this month, Dr. Nancy Messonnier, director of the National Center for Vaccination and Respiratory Diseases at the CDC, acknowledged that the agency was “very concerned.” so that information about vaccines is properly explained to term care residents.
“It’s very important for frail seniors not only to make sure they understand the vaccine they’re getting, but also what their relatives are doing,” he said.
Each vaccine manufacturer will be required to prepare a fact sheet describing what is known about the benefits and risks associated with a vaccine, what is not known and whether it is clear that a vaccine has received an “emergency use authorization”. “from the FDA, a less conditional endorsement of full approval. A second vaccine, from Moderna, is about to receive such approval after an FDA meeting on Thursday.
One thing to make clear to residents: Although vaccines have been tested in people 65 and older, these tests did not include people living in long-term care, according to Dr. Sara Oliver, a CDC expert.
Some operators have developed communication plans around vaccines and have already begun to publicize them intensively. Others may not be well prepared.
Juniper Communities operates 22 housing communities for seniors (a self-contained nursing home, multiple memory centers and assisted living facilities, and two continuing care retirement communities) in Colorado, New Jersey, and Pennsylvania. This week, he plans an hour-long city council video conference session for residents and families on coronavirus vaccines. Last week he held a similar event for employees.
Juniper has contracted with CVS, which requires each resident and staff member to fill out consent forms in triplicate before being inoculated. When written consent cannot be obtained directly, verbal consent, independently confirmed, may be substituted. Walgreens has similar requirements.
For residents with memory impairment, two Juniper nurses will contact by phone whoever has authority to make decisions. “One will ask questions and get verbal consent; the other will serve as a witness,” said Lynne Katzmann, founder and CEO of Juniper. Separately, pre-recorded emails, blog posts and voicemails about the vaccines have been sent to Juniper residents and employees since late November.
A key message is that “we’ve done it before, not at this scale, mind you, and not at this level of import, but we do get flu shots every year,” said Katzmann, who plans to be the first employee of Juniper to get the Pfizer Vaccine when it comes to New Jersey.
At Genesis Healthcare, the crucial messages are: “These vaccines have been thoroughly studied, tens of thousands of people have already received them, they are very, very effective and no steps have been taken in the scientific process,” he said. Dr. Richard Feifer, executive vice president and chief physician. Genesis, the country’s largest long-term care company, operates more than 380 nursing homes and care homes 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 staff over the past few weeks to resolve the issues. They have also distributed a letter and a question and answer document prepared by the Society for Post-Agute and Long-Term Care Medicine, in addition to obtaining information through closed-circuit television channels and social media.
In collaboration with researchers at Brown University, the company will monitor the long-term side effects its long-term care residents experience after receiving 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.
Vaccine administration will be performed during three visits to all long-term care centers. At first, all Genesis residents and employees receive inoculations. In the second, three to four weeks later, the same people will receive a second dose and new employees and residents will receive a first dose. In the third, those who still meet the requirements to get a second dose of vaccine will receive one.
What if a lot of people experience uncomfortable side effects and employees don’t come in for a couple of days while they recover? “It’s a very difficult issue and we’re making contingency plans to fix 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 very close together?
This is the case of Bayview in Seattle, which houses 210 residents in a ten-story building. At the moment, independent living residents are not on the priority list, but “I know there will be a contingent of residents and staff who do not want to be vaccinated and we will see if we can use these vaccines for our independent living people in change, “said Joel Smith, Bayview’s health services administrator.
Sure, logistical challenges will arise, but many operators have a keen sense of mission. “It’s critical that we lead the way out of this crisis,” Feifer of Genesis said. “Nursing homes must be the first and be the first to face vaccination of the vaccine directly and succeed in generating a high level of acceptance. There is no alternative, there is no plan B. right now. We have to be successful. “
KHN (Kaiser Health News) is a non-profit news service that covers health issues. It is an editorially independent program of KFF (Kaiser Family Foundation) which is not affiliated with Kaiser Permanente.