By Jordan Davidson

Palliative care specialists are particularly adept at handling a patient’s swift deterioration and heightened anxiety, even if the patient is isolated from family. During the COVID-19 crisis, palliative care clinicians and nurses are sharing their expertise with hospital-based specialists. However, World Health Organizations guidelines for treating COVID-19 omitted the crucial role that palliative care plays.

“This was an oversight,” wrote the Lancet in an April editorial ([Epub Apr 11, 2020]. https://doi.org/10.1016/S0140-6736(20)30822-9). “Indeed, palliative care ought to be an explicit part of national and international response plans for COVID-19. Practical steps can be taken: Ensure access to drugs, such as opioids, and protective equipment; consider a greater use of telemedicine and video; discuss advance care plans; provide better training and preparation across the health workforce; and embrace the role of lay caretakers and the wider community.”

Palliative care clinicians have specific training that makes them uniquely adept at providing symptom management, support to families and spiritual care. Therefore, in this extraordinary crisis, new research-based guidelines for best practices are emerging.

“This virus is bringing a lot of death and difficult symptoms to manage, which puts tremendous value on experts in end-of-life care,” said Nancy Preston, PhD, a professor and co-director in the International Observatory on End of Life Care at Lancaster University, in Lancaster, England. “You need professionals used to death and dying who have coping strategies and know how to talk to patients and families.”

A recent study that Dr. Preston co-authored and published in the Journal of Pain and Symptom Management (2020 Apr 7. [Epub ahead of print]. doi: 10.1016/j.jpainsymman.2020.03.030) analyzed how emergency palliative care in Ticino, Switzerland, adjacent to Northern Italy, tailored treatment plans for patients with COVID-19.

The study recommended writing clear and simple palliative treatment plans for reallocated generalist staff to follow. It also noted the need to adapt swiftly to an emergency style of medicine and to prepare for potential shortages in staff and pharmaceuticals.

Dr. Preston and her co-authors suggest palliative care centers prepare to use alternatives to drugs like midazolam and fentanyl, which may be needed in ICUs, for stable patients. They also prioritize rectal and oral administration of drugs to save IV and subcutaneous equipment.

“This virus can cause rapid deterioration, so a lot of decisions need to be made quickly,” Dr. Preston said. “It’s important to be prepared and have simple protocols in place for new staff.”

The reallocation of staff has spurred palliative care specialists from around the United States to lend help to cities in need. Clinicians across the country, for example, are volunteering their time to help New York City–based Mount Sinai Hospital’s 24-hour palliative care hotline, which is stretched thin and overburdened.

Relevant Expertise
Professional organizations like the Center to Advance Palliative Care (CAPC) are producing comprehensive, yet easily understandable tool kits to help staff and clinicians with palliative care strategies and protocols.

“We’ve created a one-stop resource for front-line clinicians,” said Andy Esch, MD, a medical education consultant at CAPC. “Palliative care clinicians are specialists in many of the most severe COVID-19 symptoms. We’re experts on how to deal with high symptom burdens like dyspnea, respiratory congestion, pain, nausea, anxiety and delirium.”

The CAPC tool kit provides communication scripts for ED and ICU physicians when a patient’s family is anxious and separated by strict visitor restrictions. The resources also help clinicians with the paperwork involved in telemedicine, including billing, notarization and state waivers. Dr. Esch said the Centers for Medicare & Medicaid Services’ 1135 waiver, which has eased the red tape of telemedicine, is one of the most important changes in how palliative care is delivered during the pandemic.

Research backs up the importance of technology in communication. A recent analysis in the Canadian Medical Association Journal (2020;192[15]:E400-E404. doi: 10.1503/cmaj.200465) stressed that palliative care clinicians must “maximize the use of telemedicine, both for efficiency and reducing infection,” during COVID-19. Overall, they advocate a multipronged approach of care that focuses on supplies, staff, optimized space, functional and fluid systems, sedation, separation, communication and equity.

The paper says staff should provide emotional support to patients and bereaved family members, as well as education for front-line providers on symptom management and the safety of targeted opioids. The authors stressed the need for clearly articulated advanced care and treatment plans, a stockpile of comfort medications (morphine, haloperidol, midazolam and scopolamine), and equipment.

The crucial role of telemedicine was also pinpointed in a comprehensive review in the Journal of Pain and Symptom Management (2020 Apr 7. [Epub ahead of print]. doi: 10.1016/j.jpainsymman.2020.03.030), which looked at effective palliative care responses to various epidemics dating back to 2004.

In their review, the researchers observed that flexible and rapid redeployment of resources, protocols for symptom control, and training nonspecialists were the keys to success.

Palliative care guidelines around the world have adopted the published findings. In New Zealand, the pandemic care guidelines stress stockpiling medications and equipment, ensuring nursing staff is up-to-date on best practices and updating end-of-life goals (J Pain Symptom Manage 2020 Apr 1. [Epub ahead of print]. doi: 10.1016/j.jpainsymman.2020.03.026).

“Planning for end-of-life care is particularly important at this time because of how the virus affects older patients with underlying conditions,” said J. Randall Curtis, MD, MPH, the director of the Cambia Palliative Care Center of Excellence at the University of Washington, in Seattle, and a co-author of an opinion piece (JAMA 2020 Mar 27. [Epub ahead of print]. doi: 10.1001/jama.2020.4894) that underscored the paramount importance of an advance care plan prior to COVID-19 infection.

“These conversations are best if they can start before COVID-19 infection and include family and loved ones,” he added. “Unfortunately, waiting may mean that family members are having these conversations in times of extreme stress, on a teleconference instead of face-to-face, often without the patient’s input and knowing you may never be in the same room as your loved one again.”

The article indicated that a plan helps clinicians avoid unwanted intensive life-sustaining treatments, which also reduces the burden on a stressed health care system and helps lower the risk for transmission of the coronavirus to family and health care workers.

Dr. Curtis noted that palliative care clinicians are helping in the ICU to facilitate these conversations with families. He said clinicians should reach out now to patients in nursing homes, community settings and assisted-living facilities to assess goals for care and to document a plan. For hospitalized patients, clinicians should discuss goals for care prior to talking about code status, CPR or advanced cardiac life support.

“Unwanted CPR or life support, for example, is an enormous stress on patients and families,” Dr. Curtis said “It also puts physicians and nurses at risk and uses up valuable resources like PPEs [personal protective equipment].”