Musings on SNFs in Covid-19 Times
-- 20 April, 2020

My beloved professors ask, what are my
feelings regarding my SNF (Skilled
Nursing Facility) patients, an elderly
population with numerous comorbid
chronic conditions?  What are my
feelings about SNFs?  And what about
the risks I take in working in a
Covid-19-ridden SNF?

The first question first.  Most of
these folks know that they are unlikely
to leave this SNF alive.  Some have
lived their lives hard on their bodies 
and now pay for those choices.  Others
are just unlucky.  The coronavirus
(for which most test positive) is 
merely a complicating detail, not the
central feature as its avoidance has
become for so many of us able-bodied
folks.  Some are unconscious or partly
so, due to dementia or other
debilitation.  A few are angry or
depressed.  Most, remarkably, are
cheerful and friendly -- glad to see
me as I round in my scrubs taking
vital signs -- and happy to look up
from the endlessly droning TV to
exchange pleasantries and thanks.

With a few, I have had deeper
exchanges.  As a nurse, I am trained
to actively listen and be emotionally
supportive but my interest is as
personal as it is professional.
When someday my lot in life is
similarly reduced, will I be as
gracious?  I recall how nasty and
cruel my mother grew as her dementia
deepened.  Have I inherited (or, in
my own way acquired) that dysfunction?
I dread being perceived as difficult
or worse and hope I will be able to
sustain emotional integrity as other
things fail.

Regarding SNFs (the second question),
could I countenance relegation to
such a place?  I cannot predict my
trajectory nor the choices my children
will make when the time comes for them
to decide my destiny but I have done
what I can to provide the resources
that may be needed, especially
long-term care insurance.
Institutions for the elderly often
give a sense of squalor and even 
the expensive ones are sterile and
charmless.

Those factors dwindle in
importance when there are no
alternatives.  I have seen patients
who, with extremis approaching, claw
at any hope for continued life.
My Advance Directive demands DNR
(Do Not Resuscitate me if my heart
stops) and eschews heroic measures
(give me pain meds but no ventilator,
tube feeding, etc.)  But in those
moments, will these choices continue
to obtain?  They are easy to make
when we are hale.  However, I have
seen DNR-equipped patients (and
their families and doctors) who,
with death approaching, demand
heroic measures after all.  Will
that be me?  I cannot predict.

And finally, the third question:
how do I feel about the risks I take
in working with this Covid-19-
afflicted population?  If I continue,
contracting the virus is likely.
My girlfriend implores me to quit.
I am motivated by the satisfactions
of nursing work -- there is no other
job like it -- and by simply getting
out of the house during these
locked-down, shelter-in-place, cabin
fever times.  My health is good and
I believe that if I did catch the
virus my bout would be mild.
But of course this is unknowable.
It could indeed kill me.

Is the work worth the risk?
I don't know!  What will I do?
I haven't decided!  I feel like I
should have answers to these
questions and regret that I don't.
We'll see.
                -- Dan Keller RN MS