Introduction
This guidance has been developed for Disability Services responding to issues arising in relation to the testing for COVID-19. It is has been developed in accordance with national guidelines and legislation, and on the basis that those who provide health and social care services must work on the presumption that every person who uses our services has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. A person who lacks decision making capacity continues to enjoy individual rights such as the exercise of freewill, self-determination, freedom of choice, dignity and autonomy.
This guidance recognises that most health and social care decisions regarding people who lack decision making capacity arise in the community, and, except in emergencies, it may often be impractical or undesirable to try to impose care, treatment or investigation on someone who refuses it. The presumption of capacity should not be challenged unless an adequate trigger exists. The fact that a person with disability may not have sufficient understanding or an appreciation regarding a decision, should signal a requirement for the provision of supports in order to ensure that the decision-making capacity of the individual is enhanced to the greatest degree possible. Therefore, utilising such supports, may enable the individual to signal whether they consent or refuse consent to a medical test and/or examination.
These core principles will apply to this guidance for the test for COVID-19. This guidance is intended to support services and can be adapted depending on the needs of the individual service. It can also be adapted into an easy-read format.
The test for COVID-19
In order to determine whether a person has COVID 19 they must undergo a test. As well as providing evidence that the person has COVID 19, the test provides important information for clinical purposes and it supports population surveillance. Thus, testing is very important in the current public health response to tackling the COVID 19 pandemic and it is important that people whose capacity may be in question are afforded every opportunity to have the test.
The test requires the following steps:
- A swab to be taken from deep inside the person’s mouth and nose.
- A healthcare worker will approach the person to be tested.
- The person to be tested will be given a mask to put on, the tester will explain the procedure/what will happen to the person to be tested, ask some questions and take the person into the testing area.
- The person to be tested will be asked to wash their hands properly.
- Healthcare staff will take some personal details from the person to be tested – this is so the person who is being tested can be contacted with their results.
- The person to be tested will be asked to blow their nose into a tissue and bin it in a secure bin.
- A healthcare worker will take a sample from inside the persons mouth and nose using a swab. This will be sent to a lab for testing.
This test is invasive and may be very uncomfortable for some people. For others, it may be intolerable without appropriate supports.
Symptoms of COVID 19
- Fever (88%) Feeling hot /feverish or chills (A high temperature is anything above 38⁰ C or 100.4⁰ F)
- Dry Cough (68%)
- Breathing Difficulty (19%) Shortness of breath
Other commonly reported symptoms
- fatigue (38%),
- sputum production (33%),
Other less commonly reported symptoms
- sore throat (14%), headache (14%)
- achy muscles / bones (15%).
- Less common symptoms are diarrhoea (4%) vomiting (5%).
Criteria for Testing
The criteria for testing are constantly evolving. Thus, it is important to check the HSE (https://www2.hse.ie/coronavirus/) and HSPC (https://www.hpsc.ie/a-z/respiratory/coronavirus/novelcoronavirus/) website for the most up to date symptom criteria for testing.
Supporting a person to have a test for COVID-19
In order to prepare people with disabilities for a test for COVID 19, a programme of supports has been prepared by the Muiriosa Foundation for staff and carers who are supporting people with disabilities. This programme of supports is intended to guide staff and carers to prepare, encourage and support people with disabilities to undertake the test. It is divided into 5 sections:
- Emotional wellbeing and routine
- Social Stories (in your control, changes to normal routines, about COVID-19 and testing if you feel sick)
- Activities
- Desensitisation Programme (steps to prepare for COVID-19 testing)
- Supports and Managing Anxieties
The programme is in Easy-to-Read format and includes photographs and a stepped out process for desensitisation which include 9 steps and suggests practicing 2 steps per day until (and if) the person will a disability tolerates all 9 steps. The programme also encourages staff and carers to “increase the individual’s tolerance and exposure to protective equipment … by wearing the equipment intermittently throughout the day while doing everyday tasks”.
In addition, discussions with the person’s General Practitioner regarding the use of a short acting anti-anxiety medication could be useful in supporting the person who is fearful of medical procedures to undertake the test. This must always occur with the person’s consent.
Factors impacting on the decision to test
If, having exhausted all measures to inform and prepare the person for the test for COVID-19, and that person does not want the test, there are legal, ethical and human rights obligations which must be considered. In this context, the person cannot be forced to take the test against their will. Any refusal or indication of an objection must be respected. Testing must only be carried out with the consent or agreement of the individual. The expression of the person’s will and preference is paramount in this decision. Efforts to take the test another time should be explored where possible.
A decision has been made not to test for COVID-19
Having followed all appropriate measures to inform and desensitise the person and a decision in consultation with a GP or a medical practitioner has been made not to test the person, and there is a high clinical suspicion of COVID-19, the following must apply as per national guidelines:
- The person will be placed in isolation
- All group activities should be suspended for that home/residential setting
- The resident should avoid communal areas until 48 hours after resolution of symptoms, but may go outside alone, if appropriate, or accompanied by a staff member maintaining a distance of 2 metres
- Staff members who can avoid physical contact and maintain a distance of 2 metres do not require apron, mask or gloves but should take basic precautions (Standard Precautions) to include careful attention to hand hygiene, respiratory hygiene/cough etiquette and environmental hygiene.
- Staff members who must provide intimate care, toileting and any other interventions that do not allow the staff member to maintain the distance of 2 metres should use full Personal Protective Equipment (PPE) when undertaking those interventions comprising of a gown or apron, gloves, a fluid resistant surgical facemask (and if risk assessed to be necessary, eye protection).
- Residents should be encouraged to perform hand and respiratory hygiene and cough etiquette.
- Healthcare workers should increase their attention to hand, respiratory hygiene and cough etiquette.
Documentation
The process for supporting the person to have the test must be clearly documented including unsuccessful efforts to undertake the test. The decision not to undertake the test and the subsequent process put in place must also is clearly documented. For contact tracing, it will be imperative to adhere to the Health Act 2007 Regulations regarding the keeping of a roster of all staff who provide support to residents. This roster will provide the means of knowing who has been in contact with a person suspected of being COVID positive.