What are the challenges facing palliative care during COVID-19?

By Dr. Ananya Mandal, MDApr 1 2020

The current COVID-19 outbreak affecting 180 countries and territories across six continents is taking its toll on healthcare systems globally. In particular, there is growing pressure on and concern for triage and palliative care departments. Now, researchers from the University of Toronto, Université Laval, Québec, and the University of Ottawa have published a new study titled, “Pandemic palliative care: beyond ventilators and saving lives,” in the latest issue of the journal Canadian Medical Association Journal that looks to address the challenges in providing palliative care during a viral pandemic.

With COVID-19 disease, over forty-six thousand individuals have lost their lives. Most of the severe disease and its complications are seen among the elderly who often require intensive care and assisted ventilation. Palliative care physicians have readied plans to offer care to the severely and critically ill patients and help to manage the scarce supplies during the pandemic in the most effective and judicious way.

Image Credit: Numstocker / Shutterstock

What was this study about?

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is likely to stretch healthcare systems to the seams, especially as intensive care units and ventilator systems are in short supply.

End-of-life decision making and planning can be a shared process between clinicians and patients, say the researchers. In a pandemic situation where many patients are critically ill, there are choices to be made, such as “life-prolonging measures” and others such as triage. Triage involves the utilization of the available resources to save an optimum number of lives and often involves making tough decisions.

The authors of the study write, “Failing to deliver palliative care in this context would compound the tragedy of the pandemic and would arguably be a more substantial failure of the health care system.”

The team wrote that palliative care during a pandemic focusses on three major areas;

1. Management of the symptoms in the patient.
2. Discussion with the patient regarding their wishes, expectations, and values. Using these advance care planning, as well as ultimately, the aims of patient care is to be determined.
3. Supporting the bereaved families and families of those who are suffering from critical illness or “life-limiting illness.”

Critical elements

The focus was on eight critical elements such as – “stuff, staff, space, systems, sedation, separation, communication and equity.”

Dr. James Downar, the head of the Division of Palliative Care at the University of Ottawa and a palliative care physician at The Ottawa Hospital and Bruyère Continuing Care, explained, “The current COVID-19 pandemic will likely strain our palliative services beyond capacity. We advise acting now to stockpile medications and supplies used in palliative care, train staff to meet palliative care needs, optimize our space, refine our systems, alleviate the effects of separation, have critical conversations, and focus on marginalized populations to ensure that all patients who require palliative care receive it.”

The authors of the study wrote, “Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill. Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. One-third group of patients may be denied ventilation because of resource scarcity.”

Their plan and recommendations

The US Task Force on Mass Casualty Critical Care has a plan in place for the casualties that are in large numbers with approaches such as sedation, communication, and equity.

This team expanded the approach using other additions such as “stuff, staff, space, systems, sedation, separation, communication and equity.”

• Stock – they advise on stocking medicines such as “morphine, haloperidol, midazolam, and scopolamine.” These would provide comfort to critically ill patients. They also advise stocking personal protective equipment for the palliative health care providers for long term care. They call for a suspension of the regulations that bind the availability of the injectable opioids etc.
• Adequate staffing with clinicians who have experience in palliative care. All front line care providers also need a brief training in palliative care, management of acute respiratory symptoms and also ensure their safety. Allied healthcare staff could be trained to provide support to patients and bereaved family members.
• Optimum utilization of the hospital space and resources. Separate wards need to be earmarked for COVID-19 patients. Palliative care units for dying COVID-19 patients are needed.
• A triage system needs to be adopted to “determine which patients require specialist palliative care consultation and which patients can be seen virtually.” Telemedicine can be used effectively and would also reduce infection risk. Palliative care provider groups can be formed for support and coverage.
• Palliative sedation plans need to be in place for those who are “refractory to common comfort medications.”
• Video calling could be initiated to connect dying and critically ill patients with their family members, especially if they are separated because of infection risks.
• Communication is the key to palliative care; the authors write. The team says that communication and the need to uphold the patient’s wishes are paramount.
• Equity in care is vital. All patients irrespective of their groups, disabilities, trauma, socioeconomic status, and access to palliative care need to be cared for.

Conclusion

The authors write in conclusion, “Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right.”