Palliating COVID-19

March Madness lived up to its name but without the basketball. The novel coronavirus (COVID-19) quickly graduated from regional phenomenon to worldwide pandemic in the space of a few weeks.

#PalliCovid

Every day local and national news organizations tally up a growing number of confirmed cases and deaths. Physical spaces like schools and offices have been replaced with virtual ones. Open restaurants serve cars instead of tables.

Many American workers are furloughed for an undetermined period. Clinical recommendations and virus spread forecasts evolve daily. The hospice and palliative community started the #pallicovid Twitter hashtag to facilitate discussion and share information about COVID-19. Cooperation between hospices will be key to survival. There is no room for competition in a pandemic. 

Long-term care and hospice facilities first responded by limiting visitors and interaction with staff when possible. Some hospices consolidated nursing care by assigning RNs CNA and LPN duties to reduce PPE and patient exposure to multiple providers. Visits that could be made over-the-phone or through the internet were encouraged instead of in-person communication. Hospice agencies should compose a list of visit types and specify criteria for in-person vs. virtual visits for staff to consult as they make care decisions.

Telehealth is unknown territory and many healthcare organizations are wondering how best to incorporate it into their practice now that it is the preferred method for patient interaction. The Centers for Medicare and Medicaid (CMS) have loosened telehealth requirements to support healthcare professionals serve beneficiaries remotely during this emergency period but remember that state telehealth laws and regulations still apply. Virtual visits should be documented thoroughly in the medical record and include consent to be treated

Concern was expressed that visit restrictions may hurt a patient population vulnerable to loneliness but is essential for the patient and public safety during this critical period of “flattening the curve,” or reducing spread so as not to overwhelm the healthcare system. Skype or Facetime family visits may help patients feel connected to their loved ones during separation. Some facilities have been able to accommodate “window visits” for patients and family members when possible. The end-of-life is already a fraught time and emotions may be heightened by the additional stress of living through a pandemic. Even if in-person visits are reduced, do not reduce contact. Patients, caregivers, and family members need the support more than ever.

While following recommended guidelines is the best solution, consider each case individually to provide quality patient care. There are no easy answers to rely upon as we struggle to adjust to extreme circumstances. We must use our best ethical judgment as we wade forward in unprecedented waters. Be prepared for flexibility—including adjusting protocols weekly if not daily—and creativity. With schools temporarily closed and not enough PPE nationwide some hospices obtained extra protective eye gear from high school science departments for caregivers

Some question the role of palliative care in this crisis. Recent news stories highlight experimental medications, treatments, and a worldwide race to vaccinate against COVID-19. Palliative care is not a curative branch of medicine, but healing is multidimensional. Its foundational philosophy of providing comfort during a complex--and often fatal--health crisis will be an important care solution as the situation unfolds. In the most severe stage of a pandemic, not all critically ill patients will receive life-sustaining treatment because of limited resources.. When aggressive treatment measures fail or are no longer available, palliative care offers a humane alternative to keep the “care” in healthcare so that patients aren’t abandoned. 

Researchers, James Downer and Dori Seccareccia provide a palliative care pandemic framework based on four essentials: Stuff, staff, space, and systems. On Twitter, palliative care professionals have already discussed what essential medications and equipment should be prepared in kits to be delivered to LTC facilities and home care services. Items discussed include opioids, scopolamine, subcutaneous butterflies, insuflons and PCA pumps. To avoid a last-minute scramble to access these supplies, store them in a single location with access to necessary personnel. There are not enough palliative care specialists to treat all patients in a pandemic and so other frontline providers (physicians, nurses) will need to be trained to meet demand. Training could be held remotely through video conferencing. Downer and Seccareccia advise creating standardized protocols and order sheets for symptom management of common end-of-life symptoms of influenza sufferers to assist makeshift palliative care providers. A thorough triaging system will determine where and who patients should receive palliative care from. Only the most complex patients will be reserved for palliative care specialists. Dedicated palliative care wards separated from active treatment areas will provide a peaceful environment necessary for a dignified death.

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Works Cited  

Downar, James, and Dori Seccareccia. "Palliating a Pandemic: ' All Patients Must Be Cared Fore.'" Jounral of Pain and Symptom Management, vol. 30, no.2, 2010, pp. 291-295., doi: 10.1016/j.jpainsymman.2009.11.241.