In Italy, the Corona Virus Disease 2019 (Covid-19) developed with extreme virulence, presenting by 17 April 2021 an official number of deceased individuals well beyond 115,000 cases [1]. As in all other countries, it is probable that the real number of deaths due the infection be remarkably higher than that officially reported. Anyhow, the vast majority of known deaths come from individuals aged 70+ years (86.06%), represented by 91,893 deceased individuals counted in the last available report from the Istituto Superiore di Sanita’ (ISS) published on 30 March 2021, with 81 years being the average age of Italians who have lost their life to the virus [2].

Women constituted 43.9% of all deaths out of a total number of 106,779 cases counted on 30 March [2]. If people aged 60-69 years were included in the count, the percentage of older adult victims jumps to 95.6% of all Covid-19-related deaths. In 66.9% of cases, people who died had at least three or more concomitant pathologies, most commonly hypertension, ischemic heart disease, diabetes and kidney problems [2].

The pandemic is severely testing the entire Italian system, in particular the welfare structures. The northern regions were the hardest hit, with Lombardy, Emilia-Romagna, Veneto and Piedmont leading the ranking in terms of deceased individuals. To cope with the emergency, resuscitation units were built in record time and entire hospitals were reconverted into Covid-19 care.

However, the pandemic found the country largely unprepared, failing to provide on time the necessary protection even to its health workers, with consequent serious shortcomings regarding the supply of eyeglasses, masks, gloves and gowns.

Many health professionals lacked the necessary disaster preparedness. The extremely serious difficulties in assisting critical situations, combined with the scarcity of places suitable for the reception of patients in serious conditions and the lack of a sufficient number of ventilators has given rise to very painful ethical choices for health professionals on which to privilege the care with available equipment.

In cities of Lombardy, such as Bergamo and Brescia, especially during the first wave of the pandemic, deaths followed at an impressive rate, giving rise to the sad televisions images of long lines of military trucks carrying coffins to incinerators, often very far from the place of origin of the deceased.

There was no way to celebrate funeral rites, nor accommodation in the cemeteries of the place of residence. One of the most heartbreaking aspects of the loss of life associated with this pandemic was the inability to accompany loved ones in their last moments of life.

The isolation imposed by the pandemic meant that thousands of subsequently deceased subjects were last seen when an ambulance took them to the hospital.

Nursing homes, neglected for too long by government administrations, have paid a very high tribute to the lack of protective measures and social distancing that COVID-19 has imposed. To date, it has been calculated that almost a fifth of all residents in nursing home in northern Italy have died due to COVID-19, with a mortality of Lombardy nursing homes varying between 10 and 50% of all residents [3]. In some cases, 3–4 guests died in a single day [4].

During the first phases of the pandemic, nursing homes become like castles under siege, where guests could no longer leave and new guests could no longer enter, given the spread of the infection within these institutions [4].

Since residents usually watch television for most of their time, they were fully aware from the very beginning of the pandemic that most deaths were concentrated among older people, especially those suffering from chronic conditions (as virtually all of them are).

If they were to get COVID-19 - they said -, they did not want to be intubated, just hoping to be treated by someone already known by them (possibly the same doctors of the nursing home) and, overall, to have the possibility to stay in touch with family members and loved ones [4]. By this they meant ‘in physical’ contact; in fact, many residents refused the tablet offered by the health personnel for video communications.

Residents seemed to face fear of disease and anguish for its threatening consequences with mixed attitudes. These attitudes ranged from continuous praying (a rosary to pray was a frequent request from residents) to a nihilistic form of fatalism (“There is nothing I can do; I can only hope death will come without too much suffering”).

Episodes of severe anxiety and psychomotor agitation requiring sedation were noticed quite frequently among residents. People crying constantly were also often seen: they lost their roommate or the people they befriended in the nursing home.

Health workers wearing protections, which reminded them that the virus was highly contagious, frightened them; therefore, getting infected would have only been matter of hours. Many residents dictated their last will. They often asked a doctor to certify that they were "compos mentis". In this case, their will would have been valid.

Another concern was the fear of being buried in mass graves. With the pandemic, these old people knew that no one could hold a funeral, but they hoped to be cremated and their ashes placed in an identifiable cinerary urn [4].

Residents’ families have struggled with the breakdown of direct relationships with their loved ones. Some have developed feelings of guilt, as they had decided to place their loved one in a nursing home. All were dominated by fear and anguish because the messages filtered by the staff about the condition of loved ones did not eliminate anxieties for the future.

Family members felt as if they were left outside the walls of a castle, knowing nothing of what was happening inside.

Swab tests were initially performed only in hospitals, when residents became symptomatic. Seeing doctors and other operators rapidly progressing ill (and even dying) - despite protections and precautions - residents felt progressively more frightened and left to fend for themselves. The death of a roommate or other residents fueled distressing experiences of imminent danger as well as the painful feeling of being trapped.

Disorientation and uncertainty were also perceived in the faces of doctors and staff. There was a kind of shared feeling that clinical predictions were quite difficult: some subjects looked seriously ill but then recovered, while others seemed to be well enough and then suddenly died. This created a 'fatal lottery' atmosphere, in which every resident could feel like being the next to go.

When health conditions actually deteriorated, many residents did not want to be transferred to hospital (and never to intensive care units). This was because they did not believe in a favorable outcome of treatments, and because they would have only encountered unnecessary pain in complete detachment and isolation from the surrounding world. They did not believe that effective treatments were really available, and therefore none of the therapeutic protocols in place would have had a positive outcome.

Doctors working in nursing homes often felt responsible (even if the blame most often lied with government administrations) for not having isolated residents in a timely manner, meaning that many residents transmitted the virus to their relatives. Doctors felt powerless and completely disoriented. In small communities the warmth stirring around the residences compensated for the solitude of guests and operators, but this was not the case in large centers, where the bigger turnover of personnel made the atmosphere more impersonal.

The access of new guests was soon blocked, but many residences were increasingly pressed to admit old people discharged from hospitals. No attention was paid to those who managed the residences, no support was offered in terms of economic support in the face of damage caused by the release of beds caused by the death of guests. Nursing homes were seemingly operating at the limit of economic survival, with no provision for an emergency. At the first crisis, the system thus met with serious difficulties.

In December 2020- during the second wave- the situation changed completely. If during the first wave of the COVID-19 pandemic, nursing homes were like isolated citadels, with very little contact with the external environment, Italian nursing homes seemed then as abandoned castles, where the virus entered and settled, causing serious damages [5].

They were abandoned by the government, which repeatedly declared that nursing homes do not belong to the public service network [6]. The big losses due to missed revenues and increased costs called for governmental support (“ristori”), but this was not provided: different types of private enterprises received money from the state but none was dedicated to helping the survival of residences for older people.

Furthermore, nursing homes were abandoned by staff, particularly nurses, with some of them moving to public hospitals, where the salary is usually much higher than in nursing homes [7]. Replacements were almost impossible to find (at least in the short run) because in Italy there is a chronic shortage of qualified health-care workers. The remaining staff felt abandoned, betrayed and disappointed. Distressed and overworked, they were often forced to cover extra hours and extra roles [8].

The drama of so many deaths in nursing homes not only made survivors and relatives angry and revengeful towards governments (both national and regional), but also nourished in the public opinion feelings of hostility towards nursing homes: instead of defending these facilities in their regions, people accused them of poor management, insufficient defensive measures, and inadequate treatment of residents [8].

In essence, nursing homes showed a number of critical aspects: a) they have remained alone in the management of the infected residents and in the prevention of further infections; b) their interactions with the hospital network and other health units were non-existent, apparently in an effort to protect hospitals from an excess of hospitalizations; c) with regards to the distribution of personal protective equipment and other essential devices for the management of cases, priority was certainly given to hospitals and not to nursing homes; d) screening activities using nasal-pharynx swabs were not planned in a systematic and homogeneous way; e) work was done with staff absences up to 50%, with exhausting workloads for those who had remained on duty.

At this point, the besieged castle image with strong internal resilience was better than this vision of castles on the verge of being completely abandoned.

After the besiege and the surrender in the face of the irresistible onslaught of the Covid-19, the vaccination campaign has achieved encouraging results, in line with what happened, for example, in the USA. This has given new life to nursing homes, despite the still ongoing serious problems, in particular the economic ones, aggravated by the lack of targeted measures by the national and regional governments. The vaccination of guests and operators has restored a respectable role of nursing homes in Italian society; these institutions no longer appeared as besieged or abandoned castles, but places that returned to their historical function of assisting the frail older adults.

It could be said that today nursing homes have become ‘proud castles’ of their function, both socially and with respect to the individual. Now it is important to transform the regained respectability into concrete acts, to avoid that every crisis would again negatively impact on nursing homes functioning and reputation.

What has happened should represent a big opportunity for a better management and coordination among health-related institutions operating in the territory. Self-confident castles, nursing homes appear now ready to lower their drawbridges, allowing performing the caring activities needed by their residents. This should be the lesson learned over the last 14 months. This could also have a strong influence on the quality of life of the staff, induced to improve the general level of care, assistance and organization.

As many other countries, Italy was insufficiently prepared to cope with COVID-19. The pandemic has confined million citizens at home or in nursing homes. The latter were especially vulnerable to the dramatic impact of the virus. Many healthcare professionals operated on the edge of their forces and energies and fatigue and were overworked. Nursing homes residents were confronted by an emergency situation, perceived as even more alarming given the precarious availability of protective equipment and the generally poor disaster preparedness. This created a climate of extreme inadequacy, raising levels of anxiety and anguish. The availability of vaccines has fortunately provided an occasion of reestablishing the protected ad protective environment that frail older adults need. Nursing homes could thus regain their role of ‘proud castles’.