We owe better to our most vulnerable elderly citizens

There is an urgent need to get a better grip on COVID-19 in the aged-care sector. A Monash University expert, Joseph Ibrahim, has told the royal commission into the sector that he believes not enough was done to prepare for this foreseeable risk, with the result that hundreds of residents may die prematurely. Deputy Chief Medical Officer Nick Coatsworth rejects the suggestion that a lack of urgency led to inaction, but data and anecdotal reports from aged care combine to present an alarming picture. In this newspaper Sharri Markson reported a series of concerns, raising the possibility of unethical treatment of the vulnerable and avoidable deaths. Australia’s COVID mortality began to increase rapidly around 50 days after the first 100 deaths, and aged care and the Victorian outbreaks have been at the heart of this trend. We are now the third- or fourth-worst country in the world for the concentration of COVID deaths in aged care, and this turnaround has been quick. The royal commission has heard that more than 1000 staff in aged care have been infected by the virus, and for many their working lives are full of worry and grief.

The issue is inescapably emotive and its partisan political edge can only be sharpened by the institutional blame-shifting that comes with a royal commission. But the priority must be to keep cool heads, and quickly learn to make better decisions and put them into practice under crisis conditions. Constitutional demarcations of responsibility are artificial in the sense that nothing will improve without more effective co-operation between all levels of government, the sector itself and families with a stake in it. There seems to be credible evidence of the commonwealth falling short in its preparations, but this can’t be separated from the failures on the ground in Victoria by the state government. All those in positions of authority need to shift their focus from brand protection for the moment, and find common cause in a fundamental human truth. The elderly, frail and vulnerable possess inherent dignity and worth as individuals and as cherished members of family and community. We as a society knew months ago that those in aged and residential care would be especially at risk of this virus, and we had a duty to do everything possible to prevent avoidable suffering, death and bereavement. That goal, after all, was a key rationale for the imposition of an unprecedented lockdown with high costs. Did we make the most of this breathing space? Evidence before the royal commission — and out there in the aged-care sector — suggests we did not, although federal Health Department secretary Brendan Murphy insists planning was adequate. It’s true the pandemic hit a sector with multiple problems and therefore not well set up to deal with a crisis. In our culture, many families have decided they cannot — or do not want to — care for aged relatives in their own homes, yet they also have shown discontent with the fees charged by the sector or the taxation levels necessary for more subsidy. And the sector has its own inefficiencies and reform needs.

The result has been an underperforming sector and facilities chronically short of stable workforces and adequately qualified staff. There has long been a push to set minimum staff-to-resident ratios and this may look superficially attractive. The deeper question is where enough suitably trained staff would come from. And it would still be possible to have a poorly run facility with exactly the right number of staff. There will be no quick fix, short of reforming incentives, training and regulation to maximise the likelihood that each facility will have an effective staff profile and a workplace culture of genuine care and seriousness about fixing problems.

The more immediate problems highlighted by Markson’s reporting have to be addressed in far from ideal circumstances with acute staffing problems and terrible dilemmas. The proper and limited use of sedatives and anti-psychotics is a longstanding debate but becomes more fraught when institutions are in crisis mode and families are unable to visit. If a delirious or agitated resident with the virus is an infection risk to others, some medication may be justified. But at what point does it become a convenient chemical restraint for management of an institution, albeit one in crisis?

The same goes for so-called advanced care or end-of-life plans. The risk is that these become a rationale for neglect of infected residents who with the right care might well survive the illness. Worse still is the prospect of residents who are infected but not seriously ill ending up on de facto palliative treatment such as morphine. Each case involves ethically challenging decisions about risks and benefits, both for the individual and others in the facility. Likewise consideration of whether to move infected patients out of aged care and into a hospital, something the Victorian government reportedly resists. We don’t seem to have thought these issues through with enough rigour or urgency. It’s a sound principle that a society ought to be judged by how it treats its most vulnerable people.