Lifting COVID-19 Visitation Restrictions in a Palliative Care Unit: A Two- Year Experience

Lifting COVID-19 Visitation Restrictions in a Palliative Care Unit: A Two- Year Experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Lifting COVID-19 Visitation Restrictions in a Palliative Care Unit: A Two- Year Experience Manabu Tatokoro, Mihoko Takahashi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7639886/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background Visitation restrictions during the COVID-19 pandemic have been linked to psychological distress and compromised quality of palliative care. However, few long-term studies have evaluated the consequences of lifting these restrictions. This study aimed to investigate the outcomes after lifting visitation restrictions in a palliative care unit (PCU). Methods We retrospectively analyzed consecutive advanced cancer patients admitted to a 20-bed PCU and their visitors from July 18, 2023 to March 31, 2025. Visitation policies imposed no restrictions on visitor numbers, relationships, or duration. Visitors undertook mandatory in-person health screening by nursing staff, masking, and hand hygiene in accordance with institutional infection control guidelines. Descriptive statistics and trend analyses by patient–visitor relationship were performed. Results A total of 385 patients (median age, 76 years; 55.8% male) were admitted. No COVID-19 infections occurred within the PCU. Two visitors reported COVID-19 infections after visitation, but no secondary transmission to patients was observed. In total, 14,164 visits were documented, with 13,800 valid registrations identifying 2,959 individual visitors. The median visit duration was 65 minutes (interquartile range, 30–139 minutes). Longer visit duration was significantly associated with closer relationships: spouses (98 minutes), parents and children (72 minutes), siblings, grandparents and grandchildren (54 minutes), other relatives (43 minutes), and friends and associates (31 minutes) ( p < 0.001). Conclusions Lifting visitation restrictions under multilayered infection control measures was successfully sustained for nearly 2 years and did not result in any COVID-19 outbreaks in the PCU. These findings highlight the importance of safeguarding patients’ rights to be with their loved ones at the end of life while ensuring infection prevention. Palliative care Hospital visitation Visitation restriction COVID-19 Infection control Pandemic Figures Figure 1 Introduction Hospital visitation restrictions during the Coronavirus Disease 2019 (COVID-19) pandemic have been linked to considerable psychological distress and a perceived loss of dignity among patients receiving palliative care, as well as their family members and close caregivers [ 1 ]. Although these restrictions were initially implemented in response to the uncertainty surrounding the novel coronavirus, they have often remained in place well beyond the acute phase of the pandemic [ 2 ]. In Japan, nationwide surveys have revealed that visitation was restricted in 98% of palliative care units (PCUs) [ 3 ], and that 70% of PCU administrators perceived a decline in the quality of palliative care during the pandemic, with visitation restrictions identified as a major contributing factor [ 4 ]. Since November 2021, the Japanese government has encouraged medical institutions to consider resuming in-person visitation [ 5 ]. In May 2023, COVID-19 was reclassified in Japan under the Infectious Disease Control Law into the same category as seasonal influenza. As a result, the legal enforceability of prior public health restrictions was lifted, allowing citizens to resume their pre-pandemic patterns of daily life [ 6 ]. However, the development and implementation of specific policies were left to the discretion of individual hospitals and healthcare facilities. In November 2024, a group of doctors comprising an association for post-COVID-19 medical and welfare issues conducted an assessment of university and Red Cross hospitals across Japan, with their findings indicating that the majority of the institutions continued to maintain some form of visitation restriction [ 7 ]. While multicenter surveys conducted in Japan and other countries have documented the continuation of visitation restrictions, long-term practice studies after the lifting of such restrictions remain limited. In our PCU, all restrictions regarding the number of visitors, their relationship to the patient, and the duration of visits were lifted in July 18, 2023. We previously reported our initial 2-month experience following this policy change [ 8 ]. However, the report was limited in scope. Therefore, we conducted the present study to examine the outcomes at approximately 2 years after the lifting of visitation restrictions. Methods Study setting The study was performed at Saiseikai Utsunomiya Hospital in Utsunomiya, Japan, an urban city with a population of approximately 500,000 people. The 644-bed hospital is designated as an emergency care center and a regional cancer center. The PCU has 20 beds. Study population A retrospective analysis was conducted on consecutive advanced cancer patients admitted to the PCU and their visitors from July 18, 2023 to March 31, 2025. Visitation policy Visitation was conducted in accordance with the guidelines developed by the Infection Control Committee at the hospital. Visitors were required to complete a registration form and undergo an in-person health screening by nursing staff. Visitors were only permitted to enter the PCU if they met all of the following criteria: (1) body temperature < 37.0°C, (2) no fever within the past 7 days, (3) absence of cough, sore throat, or throat discomfort, (4) no abnormalities in taste or smell, (5) no general malaise or unusual fatigue, (6) absence of the aforementioned symptoms among cohabiting family members, and (7) no known contact with confirmed or suspected cases of COVID-19. No restrictions were placed on the visitor numbers, relationships, or duration of visits. Mask use and hand hygiene were mandatory, and eating and drinking were prohibited. Visitors were instructed to notify the hospital if they tested positive for COVID-19 within 10 days after the visitation. If patients developed unexplained fever or respiratory symptoms during hospitalization, COVID-19 screening tests were conducted at the discretion of the attending physician. If a positive result was obtained, the patients continued to receive care in a private room within the PCU. Data collection Clinical data were obtained from the electronic medical records and included the dates of admission and discharge, patient age and sex, primary tumor site, results of COVID-19 tests, and infection status. Visit-related data were extracted from the visitor registration forms and included the relationship to the patient and the times of arrival and departure. Reports of COVID-19 infection among visitors were obtained from the infection control records. Statistical analysis Categorical variables were summarized as frequencies and percentages, and continuous variables were presented as medians with interquartile ranges (IQRs). Trends across the closeness of relationships to the patient were assessed using the Jonckheere–Terpstra test. Analyses were performed using EZR (version 1.68) [ 9 ] and R (version 4.5.1; R Foundation for Statistical Computing, Vienna, Austria) software. A two-sided p-value < 0.05 was considered statistically significant. Results During the study period, 385 patients (median age, 76 years; 55.8% male) were admitted to the PCU. The most common primary tumor sites were the hepatobiliary system or pancreas (21.3%) and the upper gastrointestinal tract (14.3%). The median length of hospital stay was 15 days, and 79.5% of the patients died during their stay in the PCU (Table 1 ). Table 1 Characteristics of patients admitted to the palliative care unit ( N = 385). Variable n (%) or median (IQR) Age, years 76 (68–83) Sex, male 215 (55.8) Primary tumor site Lung 44 (11.4) Upper gastrointestinal 55 (14.3) Lower gastrointestinal 43 (11.2) Hepatobiliary/pancreas 82 (21.3) Breast 7 (1.8) Gynecological 52 (13.5) Genitourinary 52 (13.5) Head and neck 32 (8.3) Hematological 4 (1.0) Others 14 (3.6) Length of hospital stay, days 15 (6–27) Outcome during PCU stay Death 307 (79.5) IQR, interquartile range; PCU, palliative care unit. No cases of COVID-19 were identified within the PCU. Two visitors were diagnosed with COVID-19 infections after their visitation, but the patients they had visited did not acquire the infection. A total of 14,164 visits were recorded (mean: 22.8 visits/day). Analysis of 13,800 completed visitor registration forms identified 2,959 individual visitors, 94.7% of whom were relatives. The median visit duration was 65 minutes (IQR, 30–139 minutes), with 90.0% lasting for 15 minutes or longer and 9.0% lasting for 5 hours or more. Visit duration was longest for spouses (median, 98 minutes), followed by parents and children (72 minutes), siblings, grandparents and grandchildren (54 minutes), other relatives (43 minutes), and friends and associates (31 minutes). Closer relationships with the patient were associated with longer visits ( p < 0.001, Fig. 1 ). Discussion In this study, visitation was examined for approximately 2 years following the lifting of restrictions in our PCU, and no COVID-19 outbreaks were noted. Analysis of the visitation records indicated that family members and close friends demonstrated a strong desire to spend meaningful time with patients without limitations on the visit duration. Visitation restrictions during the COVID-19 pandemic have been linked to considerable psychological and physical burdens for patients, their families and caregivers, and healthcare staff. An integrative review that examined the consequences of these restrictions revealed that patients experienced increased pain, reduced nutritional intake, and heightened psychological distress, while family members faced elevated anxiety and disruption of relationships, and healthcare staff encountered ethical dilemmas, pressure to facilitate virtual visits, and distress related to the deterioration of unsupported patients [ 10 ]. To the best of our knowledge, only a limited number of studies have examined the impact of lifting visitation restrictions. One recent study showed that the removal of federal restrictions on nursing home visitations was not associated with a significant increase in COVID-19 infection rates among residents [ 11 ]. Another study conducted within a large hospital system in Singapore evaluated the effects of relaxing visitation restrictions in isolation, without concurrent changes to other policies, and reported no associations between periods of relaxed visitation and increased hospital-associated SARS-CoV-2 transmission [ 12 ]. However, no prior studies have provided specific long-term real-world data from PCUs, thus underscoring the novelty and clinical significance of our findings. We believe that a multilayered approach can effectively reduce the risk of COVID-19 exposure in a PCU. The synergistic effect observed in the present study likely arose through the distinct contributions of the key infection control measures: in-person health screenings conducted by registered nurses, which prevented the entry of visitors who were symptomatic or potentially exposed to infection, and universal masking combined with hand hygiene and prohibition of eating or drinking, which collectively reduced the risk of transmission between patients and visitors. Although the risk of transmission from asymptomatic infected individuals was not negligible, it was mitigated by mask use and adherence to hand hygiene practices. A study that investigated the effects of face mask use on secondary SARS-CoV-2 transmission in Beijing households reported that transmission was reduced by 79% when all household members wore masks prior to symptom onset [ 13 ]. During the COVID-19 pandemic, many hospitals in Japan adopted restrictive visitation policies, including limiting visits to a single 15-minute session and entry for only two relatives [ 14 ]. Notably, a 15-minute visitation period is insufficient for families to provide adequate mental and emotional support to patients and is unlikely to meet patients’ needs and expectations [ 15 ]. At our PCU, there were no restrictions on the visitor relationships, numbers, or duration of visits. On average, 7.7 visitors were recorded per patient, the median visit duration was 65 minutes, and 90% of visits lasted for 15 minutes or longer. These findings underscore the inadequacy of limiting visitation to only two relatives for a 15-minute period. The present study has several limitations that require consideration. First, this was a retrospective analysis conducted in a single ward. Second, COVID-19 testing was performed at the discretion of the attending physician based on the clinical presentation. Therefore, some cases of infection may have gone undetected, particularly in a PCU setting where the primary focus is symptom management. Third, because the study was primarily conducted during the Omicron-dominant period, caution should be exercised when extrapolating the findings to other variants. Finally, the study was conducted at a single institution in an urban setting, and thus the generalizability of the findings to other regions and healthcare contexts may be limited. Despite these limitations, our findings provide valuable real-world evidence obtained from a PCU after the lifting of visitation restrictions, highlighting the feasibility and importance of maintaining family presence under appropriate infection control measures. Beyond infection control, ensuring opportunities for visitation is a fundamental ethical imperative in the palliative setting, where preserving the dignity of patients and their families is central to the quality of care. Our study offers practical insights for institutions worldwide that are seeking to balance infection control with compassionate support for patients and their families and caregivers. Conclusions Our findings indicate that multilayered infection control measures in a PCU safeguard patients’ rights to be with their loved ones at the end of life without imposing visitation restrictions. To facilitate the rational revision of visitation policies across institutions, timely collection of practice reports and establishment of a robust evidence base are essential. Abbreviations PCU Palliative care unit COVID-19 Coronavirus Disease 2019 IQR interquartile range Declarations Ethics approval and consent to participate The study was approved by the Institutional Review Board of Saiseikai Utsunomiya Hospital (reference number 2025-03; May 7, 2025) and was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent to participate was waived by the Institutional Review Board due to the retrospective study design, in accordance with the Ethical Guidelines for Medical and Biological Research Involving Human Subjects, which were implemented in Japan in June 2021. Consent for publication Not applicable Competing interests The authors declare that they have no competing interests. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author Contribution MT contributed to conceptualization, investigation, formal analysis, and writing – original draft. MiT contributed to data curation, supervision, and writing – review & editing. All authors have read and approved the final manuscript. Acknowledgement We are deeply grateful to all of the people who visited our PCU and to our staff, whose careful attention to infection control measures made it possible to sustain the lifting of visitation restrictions. We also thank Alison Sherwin, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. Data Availability The data supporting this study’s findings are available from the corresponding author on reasonable request. References Chochinov HM, Bolton J, Sareen J. Death, dying, and dignity in the time of the COVID-19 pandemic. J Palliat Med. 2020;23:1294–5. Lassi N, Jiang S, Du Y. The legal and ethical dimensions of hospital visitation bans in the COVID-19 era. Healthc (Basel). 2025;13:288. Japanese Society for Palliative Medicine. [Results of a Web-based Survey on the Impact of the COVID-19 Pandemic on Specialist Palliative Care]. 2020. Available from: https://www.jspm.ne.jp/information/COVID_19/individual.html?entry_id=2284 . Accessed 17 Sept 2025. Japanese. Sato H, Miyashita M, Abo H, Tamura K, Abe N, Matsushima T, et al. [Impact of COVID-19 on Japanese Palliative Care Units from Survey in March and November 2021]. Palliat Care Res. 2025;20:171–9. Japanese, with English abstract. Cabinet, Secretariat. Infectious Disease Crisis Management. [Basic response policy for COVID-19]. 2021. Available from: https://www.kantei.go.jp/jp/singi/novel_coronavirus/th_siryou/kihon_r_031119.pdf . Accessed 17 Sept 2025. Japanese. Iwai K, Kubo Y, Yamazaki T, Hayashi T. Impact of Japan’s revised Infectious Disease Control Law on older adults’ social life during the COVID-19 pandemic. Ann Geriatr Med Res. 2024;29:53–7. Kyodo News. FEATURE: Doctors denounce continued COVID restrictions at Japan’s hospitals. 2025. Available from: https://english.kyodonews.net/articles/-/53835 . Accessed 17 Sept 2025. Tatokoro M, Takahashi M. [Can infection control lift visitation restrictions in a palliative care unit during the coronavirus disease 2019 pandemic?]. Palliat Care Res. 2023;18:293–8. Japanese, with English abstract. Kanda Y. Investigation of the freely available easy-to-use software EZR for medical statistics. Bone Marrow Transpl. 2013;48:452–8. Hugelius K, Harada N, Marutani M. Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review. Int J Nurs Stud. 2021;121:104000. Bowblis JR, Li S, Kuo YF, Heston-Mullins J, Goodwin JS, Xu H. Lifting federal visitation restriction and COVID-19 infections in nursing homes. J Am Med Dir Assoc. 2025;26:105682. Wee LE, Conceicao EP, Sim JXY, Aung MK, Venkatachalam I. Impact of visitor restrictions on healthcare-associated respiratory viral infections during the COVID-19 pandemic: Experience of a tertiary hospital in Singapore. Am J Infect Control. 2021;49:134–5. Wang Y, Tian H, Zhang L, Zhang M, Guo D, Wu W, et al. Reduction of secondary transmission of SARS-CoV-2 in households by face mask use, disinfection and social distancing: a cohort study in Beijing, China. BMJ Glob Health. 2020;5:e002794. Tashiro S. [Ethics of Visitation Restrictions: Can Visitation Policies in Japanese Hospitals Be Justified?]. Bunka. 2023;86:74–93. Japanese, with English abstract. Satomichi R, Mitoma R. [Literature Review: Restrictions of Visiting to Intensive Care Patients in Japan]. Jpn J Clin Nurs Manag. 2019;1:48. Japanese. Additional Declarations No competing interests reported. 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Although these restrictions were initially implemented in response to the uncertainty surrounding the novel coronavirus, they have often remained in place well beyond the acute phase of the pandemic [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn Japan, nationwide surveys have revealed that visitation was restricted in 98% of palliative care units (PCUs) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], and that 70% of PCU administrators perceived a decline in the quality of palliative care during the pandemic, with visitation restrictions identified as a major contributing factor [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Since November 2021, the Japanese government has encouraged medical institutions to consider resuming in-person visitation [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In May 2023, COVID-19 was reclassified in Japan under the Infectious Disease Control Law into the same category as seasonal influenza. As a result, the legal enforceability of prior public health restrictions was lifted, allowing citizens to resume their pre-pandemic patterns of daily life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the development and implementation of specific policies were left to the discretion of individual hospitals and healthcare facilities. In November 2024, a group of doctors comprising an association for post-COVID-19 medical and welfare issues conducted an assessment of university and Red Cross hospitals across Japan, with their findings indicating that the majority of the institutions continued to maintain some form of visitation restriction [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile multicenter surveys conducted in Japan and other countries have documented the continuation of visitation restrictions, long-term practice studies after the lifting of such restrictions remain limited. In our PCU, all restrictions regarding the number of visitors, their relationship to the patient, and the duration of visits were lifted in July 18, 2023. We previously reported our initial 2-month experience following this policy change [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the report was limited in scope. Therefore, we conducted the present study to examine the outcomes at approximately 2 years after the lifting of visitation restrictions.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy setting\u003c/h2\u003e\u003cp\u003eThe study was performed at Saiseikai Utsunomiya Hospital in Utsunomiya, Japan, an urban city with a population of approximately 500,000 people. The 644-bed hospital is designated as an emergency care center and a regional cancer center. The PCU has 20 beds.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStudy population\u003c/h3\u003e\n\u003cp\u003eA retrospective analysis was conducted on consecutive advanced cancer patients admitted to the PCU and their visitors from July 18, 2023 to March 31, 2025.\u003c/p\u003e\n\u003ch3\u003eVisitation policy\u003c/h3\u003e\n\u003cp\u003e Visitation was conducted in accordance with the guidelines developed by the Infection Control Committee at the hospital. Visitors were required to complete a registration form and undergo an in-person health screening by nursing staff.\u003c/p\u003e\u003cp\u003eVisitors were only permitted to enter the PCU if they met all of the following criteria: (1) body temperature\u0026thinsp;\u0026lt;\u0026thinsp;37.0\u0026deg;C, (2) no fever within the past 7 days, (3) absence of cough, sore throat, or throat discomfort, (4) no abnormalities in taste or smell, (5) no general malaise or unusual fatigue, (6) absence of the aforementioned symptoms among cohabiting family members, and (7) no known contact with confirmed or suspected cases of COVID-19.\u003c/p\u003e\u003cp\u003eNo restrictions were placed on the visitor numbers, relationships, or duration of visits. Mask use and hand hygiene were mandatory, and eating and drinking were prohibited. Visitors were instructed to notify the hospital if they tested positive for COVID-19 within 10 days after the visitation. If patients developed unexplained fever or respiratory symptoms during hospitalization, COVID-19 screening tests were conducted at the discretion of the attending physician. If a positive result was obtained, the patients continued to receive care in a private room within the PCU.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003eClinical data were obtained from the electronic medical records and included the dates of admission and discharge, patient age and sex, primary tumor site, results of COVID-19 tests, and infection status. Visit-related data were extracted from the visitor registration forms and included the relationship to the patient and the times of arrival and departure. Reports of COVID-19 infection among visitors were obtained from the infection control records.\u003c/p\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analysis\u003c/h2\u003e\u003cp\u003eCategorical variables were summarized as frequencies and percentages, and continuous variables were presented as medians with interquartile ranges (IQRs). Trends across the closeness of relationships to the patient were assessed using the Jonckheere\u0026ndash;Terpstra test. Analyses were performed using EZR (version 1.68) [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] and R (version 4.5.1; R Foundation for Statistical Computing, Vienna, Austria) software. A two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eDuring the study period, 385 patients (median age, 76 years; 55.8% male) were admitted to the PCU. The most common primary tumor sites were the hepatobiliary system or pancreas (21.3%) and the upper gastrointestinal tract (14.3%). The median length of hospital stay was 15 days, and 79.5% of the patients died during their stay in the PCU (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of patients admitted to the palliative care unit (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;385).\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003en\u003c/em\u003e (%) or median (IQR)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge, years\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e76 (68\u0026ndash;83)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex, male\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e215 (55.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePrimary tumor site\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLung\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e44 (11.4)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUpper gastrointestinal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e55 (14.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLower gastrointestinal\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e43 (11.2)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHepatobiliary/pancreas\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e82 (21.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBreast\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7 (1.8)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGynecological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (13.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGenitourinary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e52 (13.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHead and neck\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32 (8.3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHematological\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4 (1.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOthers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e14 (3.6)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLength of hospital stay, days\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15 (6\u0026ndash;27)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOutcome during PCU stay\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDeath\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e307 (79.5)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eIQR, interquartile range; PCU, palliative care unit.\u003c/p\u003e\u003cp\u003eNo cases of COVID-19 were identified within the PCU. Two visitors were diagnosed with COVID-19 infections after their visitation, but the patients they had visited did not acquire the infection.\u003c/p\u003e\u003cp\u003eA total of 14,164 visits were recorded (mean: 22.8 visits/day). Analysis of 13,800 completed visitor registration forms identified 2,959 individual visitors, 94.7% of whom were relatives. The median visit duration was 65 minutes (IQR, 30\u0026ndash;139 minutes), with 90.0% lasting for 15 minutes or longer and 9.0% lasting for 5 hours or more. Visit duration was longest for spouses (median, 98 minutes), followed by parents and children (72 minutes), siblings, grandparents and grandchildren (54 minutes), other relatives (43 minutes), and friends and associates (31 minutes). Closer relationships with the patient were associated with longer visits (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, visitation was examined for approximately 2 years following the lifting of restrictions in our PCU, and no COVID-19 outbreaks were noted. Analysis of the visitation records indicated that family members and close friends demonstrated a strong desire to spend meaningful time with patients without limitations on the visit duration.\u003c/p\u003e\u003cp\u003eVisitation restrictions during the COVID-19 pandemic have been linked to considerable psychological and physical burdens for patients, their families and caregivers, and healthcare staff. An integrative review that examined the consequences of these restrictions revealed that patients experienced increased pain, reduced nutritional intake, and heightened psychological distress, while family members faced elevated anxiety and disruption of relationships, and healthcare staff encountered ethical dilemmas, pressure to facilitate virtual visits, and distress related to the deterioration of unsupported patients [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo the best of our knowledge, only a limited number of studies have examined the impact of lifting visitation restrictions. One recent study showed that the removal of federal restrictions on nursing home visitations was not associated with a significant increase in COVID-19 infection rates among residents [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Another study conducted within a large hospital system in Singapore evaluated the effects of relaxing visitation restrictions in isolation, without concurrent changes to other policies, and reported no associations between periods of relaxed visitation and increased hospital-associated SARS-CoV-2 transmission [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, no prior studies have provided specific long-term real-world data from PCUs, thus underscoring the novelty and clinical significance of our findings.\u003c/p\u003e\u003cp\u003eWe believe that a multilayered approach can effectively reduce the risk of COVID-19 exposure in a PCU. The synergistic effect observed in the present study likely arose through the distinct contributions of the key infection control measures: in-person health screenings conducted by registered nurses, which prevented the entry of visitors who were symptomatic or potentially exposed to infection, and universal masking combined with hand hygiene and prohibition of eating or drinking, which collectively reduced the risk of transmission between patients and visitors. Although the risk of transmission from asymptomatic infected individuals was not negligible, it was mitigated by mask use and adherence to hand hygiene practices. A study that investigated the effects of face mask use on secondary SARS-CoV-2 transmission in Beijing households reported that transmission was reduced by 79% when all household members wore masks prior to symptom onset [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDuring the COVID-19 pandemic, many hospitals in Japan adopted restrictive visitation policies, including limiting visits to a single 15-minute session and entry for only two relatives [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Notably, a 15-minute visitation period is insufficient for families to provide adequate mental and emotional support to patients and is unlikely to meet patients\u0026rsquo; needs and expectations [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. At our PCU, there were no restrictions on the visitor relationships, numbers, or duration of visits. On average, 7.7 visitors were recorded per patient, the median visit duration was 65 minutes, and 90% of visits lasted for 15 minutes or longer. These findings underscore the inadequacy of limiting visitation to only two relatives for a 15-minute period.\u003c/p\u003e\u003cp\u003eThe present study has several limitations that require consideration. First, this was a retrospective analysis conducted in a single ward. Second, COVID-19 testing was performed at the discretion of the attending physician based on the clinical presentation. Therefore, some cases of infection may have gone undetected, particularly in a PCU setting where the primary focus is symptom management. Third, because the study was primarily conducted during the Omicron-dominant period, caution should be exercised when extrapolating the findings to other variants. Finally, the study was conducted at a single institution in an urban setting, and thus the generalizability of the findings to other regions and healthcare contexts may be limited.\u003c/p\u003e\u003cp\u003eDespite these limitations, our findings provide valuable real-world evidence obtained from a PCU after the lifting of visitation restrictions, highlighting the feasibility and importance of maintaining family presence under appropriate infection control measures. Beyond infection control, ensuring opportunities for visitation is a fundamental ethical imperative in the palliative setting, where preserving the dignity of patients and their families is central to the quality of care. Our study offers practical insights for institutions worldwide that are seeking to balance infection control with compassionate support for patients and their families and caregivers.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eOur findings indicate that multilayered infection control measures in a PCU safeguard patients\u0026rsquo; rights to be with their loved ones at the end of life without imposing visitation restrictions. To facilitate the rational revision of visitation policies across institutions, timely collection of practice reports and establishment of a robust evidence base are essential.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003ePCU Palliative care unit\u003c/p\u003e\u003cp\u003eCOVID-19 Coronavirus Disease 2019\u003c/p\u003e\u003cp\u003eIQR interquartile range\u003c/p\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e The study was approved by the Institutional Review Board of Saiseikai Utsunomiya Hospital (reference number 2025-03; May 7, 2025) and was conducted in accordance with the principles of the Declaration of Helsinki. The requirement for informed consent to participate was waived by the Institutional Review Board due to the retrospective study design, in accordance with the Ethical Guidelines for Medical and Biological Research Involving Human Subjects, which were implemented in Japan in June 2021.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eMT contributed to conceptualization, investigation, formal analysis, and writing \u0026ndash; original draft. MiT contributed to data curation, supervision, and writing \u0026ndash; review \u0026amp; editing. All authors have read and approved the final manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003e We are deeply grateful to all of the people who visited our PCU and to our staff, whose careful attention to infection control measures made it possible to sustain the lifting of visitation restrictions. We also thank Alison Sherwin, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data supporting this study\u0026rsquo;s findings are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eChochinov HM, Bolton J, Sareen J. Death, dying, and dignity in the time of the COVID-19 pandemic. J Palliat Med. 2020;23:1294\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLassi N, Jiang S, Du Y. The legal and ethical dimensions of hospital visitation bans in the COVID-19 era. Healthc (Basel). 2025;13:288.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJapanese Society for Palliative Medicine. [Results of a Web-based Survey on the Impact of the COVID-19 Pandemic on Specialist Palliative Care]. 2020. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.jspm.ne.jp/information/COVID_19/individual.html?entry_id=2284\u003c/span\u003e\u003cspan address=\"https://www.jspm.ne.jp/information/COVID_19/individual.html?entry_id=2284\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Sept 2025. Japanese.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSato H, Miyashita M, Abo H, Tamura K, Abe N, Matsushima T, et al. 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Ann Geriatr Med Res. 2024;29:53\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKyodo News. FEATURE: Doctors denounce continued COVID restrictions at Japan\u0026rsquo;s hospitals. 2025. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://english.kyodonews.net/articles/-/53835\u003c/span\u003e\u003cspan address=\"https://english.kyodonews.net/articles/-/53835\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Accessed 17 Sept 2025.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTatokoro M, Takahashi M. [Can infection control lift visitation restrictions in a palliative care unit during the coronavirus disease 2019 pandemic?]. Palliat Care Res. 2023;18:293\u0026ndash;8. Japanese, with English abstract.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKanda Y. Investigation of the freely available easy-to-use software EZR for medical statistics. Bone Marrow Transpl. 2013;48:452\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHugelius K, Harada N, Marutani M. Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review. Int J Nurs Stud. 2021;121:104000.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBowblis JR, Li S, Kuo YF, Heston-Mullins J, Goodwin JS, Xu H. Lifting federal visitation restriction and COVID-19 infections in nursing homes. J Am Med Dir Assoc. 2025;26:105682.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWee LE, Conceicao EP, Sim JXY, Aung MK, Venkatachalam I. Impact of visitor restrictions on healthcare-associated respiratory viral infections during the COVID-19 pandemic: Experience of a tertiary hospital in Singapore. Am J Infect Control. 2021;49:134\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWang Y, Tian H, Zhang L, Zhang M, Guo D, Wu W, et al. Reduction of secondary transmission of SARS-CoV-2 in households by face mask use, disinfection and social distancing: a cohort study in Beijing, China. BMJ Glob Health. 2020;5:e002794.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTashiro S. [Ethics of Visitation Restrictions: Can Visitation Policies in Japanese Hospitals Be Justified?]. Bunka. 2023;86:74\u0026ndash;93. Japanese, with English abstract.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSatomichi R, Mitoma R. [Literature Review: Restrictions of Visiting to Intensive Care Patients in Japan]. Jpn J Clin Nurs Manag. 2019;1:48. Japanese.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Palliative care, Hospital visitation, Visitation restriction, COVID-19, Infection control, Pandemic","lastPublishedDoi":"10.21203/rs.3.rs-7639886/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7639886/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eVisitation restrictions during the COVID-19 pandemic have been linked to psychological distress and compromised quality of palliative care. However, few long-term studies have evaluated the consequences of lifting these restrictions. This study aimed to investigate the outcomes after lifting visitation restrictions in a palliative care unit (PCU).\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe retrospectively analyzed consecutive advanced cancer patients admitted to a 20-bed PCU and their visitors from July 18, 2023 to March 31, 2025. Visitation policies imposed no restrictions on visitor numbers, relationships, or duration. Visitors undertook mandatory in-person health screening by nursing staff, masking, and hand hygiene in accordance with institutional infection control guidelines. Descriptive statistics and trend analyses by patient\u0026ndash;visitor relationship were performed.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eA total of 385 patients (median age, 76 years; 55.8% male) were admitted. No COVID-19 infections occurred within the PCU. Two visitors reported COVID-19 infections after visitation, but no secondary transmission to patients was observed. In total, 14,164 visits were documented, with 13,800 valid registrations identifying 2,959 individual visitors. The median visit duration was 65 minutes (interquartile range, 30\u0026ndash;139 minutes). Longer visit duration was significantly associated with closer relationships: spouses (98 minutes), parents and children (72 minutes), siblings, grandparents and grandchildren (54 minutes), other relatives (43 minutes), and friends and associates (31 minutes) (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eLifting visitation restrictions under multilayered infection control measures was successfully sustained for nearly 2 years and did not result in any COVID-19 outbreaks in the PCU. These findings highlight the importance of safeguarding patients\u0026rsquo; rights to be with their loved ones at the end of life while ensuring infection prevention.\u003c/p\u003e","manuscriptTitle":"Lifting COVID-19 Visitation Restrictions in a Palliative Care Unit: A Two- Year Experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-15 02:18:39","doi":"10.21203/rs.3.rs-7639886/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8ea85095-31aa-4781-a9af-0c6dabd90e20","owner":[],"postedDate":"October 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-10-16T15:38:52+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-15 02:18:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7639886","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7639886","identity":"rs-7639886","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}