Editorial: Diagnostic Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations of a Delphi Panel of Long-Term Care Clinicians.

With the COVID-19 pandemic progressing, guidance on strategies to mitigate its devastating effects in nursing facilities (NFs) is critical to preventing additional tragic outcomes. Asymptomatic spread of COVID-19 from nursing facility staff and residents is a major accelerator of infection. Facility-wide point-prevalence testing is an emerging strategy in disease mitigation. Because time is not available to await the results of randomized controlled trials before implementing strategies in this high-risk setting, an expert Delphi panel composed of experienced long-term care medicine professionals has now met to provide testing guidance for SARS-Coronavirus-2 to NFs. After many email and telephone discussions, the panel responded to a questionnaire that included six different scenarios, based on varying availability of Polymerase Chain Reaction (RT-PCR) testing and personal protective equipment (PPE). The panel endorsed facility-wide testing of staff and residents without dissent when diagnostic RT-PCR was available. While the panel recognized the limitations of RT-PCR testing, it strongly recommended this testing for both staff and residents in NFs that were either COVID-19 naive or had limited outbreaks. There was also consensus on testing residents with atypical symptoms in a scenario of limited testing capability. The panel favored testing every 1 to 2 weeks if testing was readily available, reducing the frequency to every month as community prevalence declined or as the collection of additional data further informed clinical critical thinking and decision-making. The panel recognized that frequent testing would have consequences in terms of potential staff shortages due to quarantine after positive tests and increased PPE use. However, the panel felt that not testing would allow new clusters of infection to form. The resulting high mortality rate would outweigh the potential negative consequences of testing. The panel also recognized the pandemic as a rapidly evolving crisis, and that new science and increasing experience might require an updating of its recommendations. The panel hopes that its recommendations will be of value to the long-term care industry and to policy makers as we work together to manage through this challenging and stressful time.

Physicians' attitudes toward tube feeding chronically ill nursing home patients.

OBJECTIVE: To determine attitudes of physicians toward the limitation of tube feeding in chronically ill nursing home patients and the influences of patient preferences and other patient and physician variables on these decisions. DESIGN: Questionnaire-based, mailed survey. Hypothetical case scenarios derived by fractional factorial design to determine the influences of patient and family preferences, age, life expectancy, physical and cognitive functioning; direct scaling to determine the influences of legal and cost considerations. PARTICIPANTS: Randomly selected national samples of American Geriatrics Society and American Medical Association members (n = 141, participation rate 41%). MAIN RESULTS: Nearly all physicians indicated they would withhold (95%) or withdraw (92%) tube feeding in at least one of the 16 scenarios studied. Physician decisions were most highly associated with patient preferences, followed by family preferences, life expectancy, and cognitive status (p less than 0.02 to less than 0.001). When patients and families agreed, physicians concurred in 87% to 95% of the decisions. However, when patients and families disagreed, physicians concurred with patients in only 48% to 55% of the decisions. Increasing physician concern regarding legal and cost considerations was significantly associated with significantly higher and lower likelihoods of tube feeding, respectively (p less than 0.05). CONCLUSIONS: These results suggest that the majority of study physicians are willing to limit tube feeding in nursing home patients under some circumstances. Patient preferences appear to be the most important factor in these decisions, but may not be honored, especially if the wishes of patients and their families are not in concurrence.