|Year : 2021 | Volume
| Issue : 1 | Page : 3-10
Palliation in coronavirus Disease-19: Need of the hour
Shashank Banait1, Preetam Salunkhe2, Supratim Roy3, Jyoti Jain2
1 Department of Ophthalmology, Jawaharlal Nehru Medical College, Sevagram, Wardha, Maharashtra, India
2 Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
3 Department of Orthopaedics, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra, India
|Date of Submission||03-Feb-2021|
|Date of Acceptance||07-Jun-2021|
|Date of Web Publication||29-Jun-2021|
Dr. Jyoti Jain
Department of Medicine, Mahatma Gandhi Institute of Medical Sciences, Sevagram, Wardha, Maharashtra
Source of Support: None, Conflict of Interest: None
The current coronavirus disease-19 (COVID-19) pandemic has triggered intense suffering by causing physical illness, social distancing, stress, anxiety, financial concerns, social variability, and death. The imbalance between the increasing number of cases and the availability of infrastructure, trained personnel, oxygen, and drugs, are further adding to the crisis. The response to the pandemic requires mitigation of suffering in forms. One of the needs of the hour is providing effective and safe palliative care and end-of-life care to mitigate suffering. A vast majority of COVID patients are dying with an unmet need of palliation therapy. Palliative care is an approach that improves the quality of life of patients through the relief of suffering, so this is one of the fundamentals of COVID-19 treatment beyond the use of ventilators. The purpose of this article is to review the recent guidelines of palliative care in COVID-19 patients, to help healthcare workers know how to apply the principles of palliative care in the pandemic scenario, to foster good end-of-life care. India is currently fighting to ebb the second wave of the pandemic, and this article will provide inputs for the government to make triage decisions and policies in view of the paucity of resources. Various aspects of palliation in COVID-19, including recent guidelines, planning, triage, management, communication skills, and necessary decision-making for the health care worker and end-of-life care in the Indian scenario are highlighted in this review.
Keywords: Coronavirus disease 2019, COVID-19, ethics, healthcare facilities, palliative care
|How to cite this article:|
Banait S, Salunkhe P, Roy S, Jain J. Palliation in coronavirus Disease-19: Need of the hour. J Mahatma Gandhi Inst Med Sci 2021;26:3-10
|How to cite this URL:|
Banait S, Salunkhe P, Roy S, Jain J. Palliation in coronavirus Disease-19: Need of the hour. J Mahatma Gandhi Inst Med Sci [serial online] 2021 [cited 2021 Jul 24];26:3-10. Available from: https://www.jmgims.co.in/text.asp?2021/26/1/3/319824
| Introduction|| |
Coronavirus disease-19 (COVID-19) is a challenge to humanity. The dreadful nature of this 120 μ diameter virus lies in the fact that it is highly infectious, and has taken over the entire globe in just 3 months. This severe acute respiratory syndrome coronavirus 2 (SARS-CoV2) has percolated into our life and global human behavior has changed, affecting not only physical but also mental, social, and spiritual health., The World Health Organization (WHO) reported it as a public health emergency of international concern on March 30, 2020. The virus is unique in its overwhelming ability to infect humans and kill them with the overall mortality rate being 3%–6%. Social distancing and lockdown have become a strategy to prevent the disease. In response to the exploding pandemic and absence of definitive treatment and inadequate medical facilities, drugs and life-saving oxygen, palliative care remains an approach that improves the quality of life of patients, especially those who are denied intensive care support. Palliative care has a significant role in the treatment through the relief of suffering and hence it is one of the fundamentals of COVID-19 treatment, beyond the ventilators. Patients who require palliative care are those who are receiving end-of-life care, not improving on ventilators and who are left at home due to unavailability of hospital beds and oxygen. Care is also needed in those who require symptomatic treatment of breathlessness, including post-COVID recovery. Caregivers of patients also require grief and bereavement support. Health-care workers need to understand essential skills of sensitive, effective, empathetic communication, discussion, and review of care plans, providing all help to ensure a comfortable and dignified death. This article makes an effort to guide health-care providers toward the palliative care approach while supporting patients and their families, who are directly or indirectly impacted by COVID-19, in the hospital, hospice, or home setting. In the absence of treatment and high mortality rates, palliative care remains the mainstay of treating, especially those patients who are denied intensive care support. They have a fundamental right to receive palliative care.
| Methods|| |
All relevant English-language articles identified through the MEDLINE database, PUBMED, and UpToDate from 2000 to April 2021 were systematically searched by using the following MESH words: Coronavirus disease 2019, COVID-19, palliative care, pandemic, healthcare facilities, severe acute respiratory syndrome coronavirus 2, ventilators, and ethical principles. Selected references from these articles and appropriate textbooks were also reviewed.
| What is Palliative Care?|| |
Palliative care is a biopsychosocial-spiritual approach of care, which involves holistic and active care of patients of all ages with health-related issues due to serious illness and especially of those near the end-of-life. The World Health Organization definition of palliative care states that: “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering using early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”
| The Burden of COVID-19|| |
The most commonly used term to describe the coronavirus disease 2019 is COVID-19, and the scientific term for the virus is SARS-CoV-2. According to the WHO, as on May 25, 2021, there are 167,252,150 confirmed COVID-19 cases, 3,467,663 deaths from the disease. In addition, data from India shows 26,948,874 confirmed cases and 307,231 fatalities from coronavirus.
| Role of Palliative Care|| |
'In times of crisis people want to know you care more than they care what you know”
The present COVID-19 pandemic has resulted in a humanitarian crisis globally. The average death rate reported by the WHO is between 2% and 4%, and among the elderly COVID-19 patients, it is 15%–22%.
COVID-19 patients with severe or critical illness, or with life-threatening comorbidities such as terminal malignancies, end-stage organ damage, chronic non-communicable illnesses, and advanced age are at increased risk of mortality from COVID-19. As the current pandemic situation continues in India, oxygen beds and ventilators are being occupied by elderly patients with comorbidities and poor outcomes. In such a situation, there may be unavailability of oxygen beds and ventilators for young and otherwise healthy patients. With the increasing number of active cases of COVID-19 in India, these subsets of COVID-19 patients who are not eligible to receive aggressive intensive care management or need critical care beds would be denied curative therapy based on a triage system., These patients with serious illness should receive appropriate palliative care in the form of symptom management measures along with mental, social, emotional, and end-of-life care.
Palliative care plays multiple roles in the management of patients with and at risk for COVID-19. Health-care decision-making and advance directives may need to be re-addressed in light of this pandemic. Advanced care planning by physicians and other health-care providers assists in identifying what matters most and planning care in the event of infection. Palliative care is especially important at the end of life, especially since the process of dying has changed with COVID-19; with ill patients being isolated from family and friends, and thus dying terribly lonely.
| The Palliation Plan for the COVID-19 Pandemic|| |
The single most important first step in the management of patients of COVID-19 is triage. When this triage system is functioning, there will be some critically ill patients who may be denied intensive care unit (ICU) care in view of scarce resources. The numbers of these patients are going to be huge. Such patients have a right to palliative care. One cannot take away this fundamental right and shun them from alleviating end-of-life care. Considering the present healthcare facilities and available resources, India should make triage plans and palliative care teams ready to deal with these situations. A triage team may be constituted with the treating clinician, member of the ethics committee, a palliative care physician, a social worker, and a nurse. In an emergency, even the senior staff nurse can act in a lead role to triage patients.
The triage system should be based on four fundamental ethical principles of beneficence, nonmaleficence, respect for autonomy, and equity. It should be transparent. The criteria for ICU triage must be well-defined in advance. In the presence of scarce resources, resource-intensive interventions should be weighed against the benefits. Extracorporeal membrane oxygenation should not be used for just prolonging life in COVID-19 patients. If possible, resuscitation status and intensive life-supporting measures should be discussed in advance; the patient's wishes should be taken into consideration. Various phases for triage are mentioned in [Table 1] for COVID-19.
The ICU triage criteria for COVID-19 are stricter as the healthcare facility is oversaturated and no more beds are available in ICU or wards. The first measure is to make the short-term prognosis criterion more forceful. When the ICU beds are falling short for seriously ill patients then the short-term prognosis of these patients should be considered. Patients who will benefit most from the intensive care facility should be chosen over patients who have a high chance of mortality even with the intensive care treatment. Age should be taken into account as far as “short term prognosis” criteria is considered and in favor of young patients who have no comorbidities. Furthermore, the mortality rate in elderly patients is higher in COVID-19., The ICU Triage Criteria for COVID-19 are mentioned in [Table 2].
|Table 2: Intensive care unit triage criteria for coronavirus disease-2019|
Click here to view
| Phases for Palliative Care in COVID-19|| |
Prehospital advance care planning
Advance care planning performed by clinicians will achieve the goals of documenting patient values and preferences, ensuring designated healthcare decision-makers, and reducing unwanted hospitalizations. Previously completed advance directives for medical care should be reviewed in the context of this pandemic. Advance care planning should also address decision-making about procedures that can be performed or not and their optimal timing, with the palliative care perspective.
After considering the patient parameters, the long duration of isolation and availability of resources, as well as the services, various options with hospitalization may include: homestay with palliative care, or hospice for symptom management, skilled nursing facility admission for symptom management and care, hospital for symptom management if available without ICU, and or ventilator support and hospital for all appropriate life-prolonging measures. The terminally ill patients who choose for the place of death and prefer their death at home as advanced directives. In such patient's palliative care can lessen the anxiety, stress, and burden of patients and their care, by providing supportive care through telephonic communication by counseling, education, and medical attention.
Care for inpatients
In hospital settings, palliative care specialists may be able to provide virtual support (through teleconferencing or telephone) for patients who are kept in strict isolation and their family members, without family visitors and with decreased visits by staff seeking to conserve personal protective equipment (PPE). They can provide direct consultation to the primary clinician who is managing the patient.
Care of the dying
At the end of life, interdisciplinary care is imperative both for the patient and the family. As these patients will be isolated, communication through telephone and video calls via smartphones should be utilized to allow family and friends to be present with the patient. Simple interventions such as playing music the patient likes can also be means of spiritual and psychosocial support. Monitoring equipment can be discontinued with the main focus on symptomatic management continuously or around the clock as patients approach the end of life. All clinicians should be provided with protocols to withdraw invasive support and manage terminal symptoms.,
| Goals of Palliation in COVID-19|| |
Preserving as many lives as possible
This should be the aim when resources are scarce and the health system is overburdened. Decisions should be made in such a way that the least number of people die.
Protection and care of the professionals involved in COVID-19 care
As we discuss COVID-19, in parallel, we also need to discuss measures to protect healthcare professionals. Health-care professionals who have a higher risk of dying, such as the elderly and pregnant women, are to be protected and not allowed to work in COVID-19 hospital settings, because this will cause more deaths. Fear of acquiring infection and risking their own family members, shortage of healthcare professionals, working with minimum staff, and the process of assisting patients in dying and death at hospitals are a few reasons which lead to physical and mental exhaustion of health-care professionals, apart from the increasing number of COVID-19 patients and limited resources. Adequate PPE should be provided to ensure health-care workers' safety and their psychological stress should be relieved with the help of psychiatrists.
Alleviation of suffering
Palliative care services can lessen suffering and may prolong life for patients with serious comorbidities. Patients and families can be given several choices for the course of care for illness, depending on the availability of services in each healthcare community.,
Management of the pandemic
Awareness regarding the modes of transmission of COVID-19, its spread, isolation precautions, prevention strategies, and management should be emphasized to every individual in the community. There are multiple mantras which are evolved to combat this dreadful global emergency. In their article, Downar and Seccareccia describe a 4S-mantra to manage the pandemic. This includes: stuff, staff, space, systems. Another mnemonic for the palliative care pandemic plan is 'Health-Care System MADNESS' where the acronym stands for, H-health-care systems such as hospitals, nursing homes, S-Systems, i.e. triage system, M-Medicines, A-Analgesia and sedation, DN-Doctors and Nurses, E-Equity, S-Separation, S-Secretions. [Table 3] outlines the pandemic management plan published in the Canadian Medical Association Journal including the 4S by Downar and Seccareccia.
| Palliation Treatment Guide for COVID-19 Patients|| |
As per the position statement of the Indian Association of Palliative Care (IAPC) on providing palliative care for severe/critically ill, hospitalized COVID-19 patients who are not eligible for mechanical ventilation or not responding to ventilation, whose care plan is to stay on site and not to use the hospital, or who have no option to get hospitalization, should be triaged appropriately for palliative care and consideration for the non-escalation of treatment. Non-escalation of treatment can be achieved by advance care planning, ascertaining and communicating medical futility, consenting for withholding/withdrawing life-sustaining support treatment and its documentation. These patients under palliation need to be able to rely upon good symptom management for respiratory distress and anxiety and anguish of dying without treatment. Among these patients, various symptoms like dyspnea, discomfort, distress, delirium, and pain at the end of life should be anticipated, and uniquely adapted anticipatory palliative care should be given to all and good end-of-life care. For severe/critically ill COVID-19 patients dying at home, palliative care and nursing support symptoms should be tested by a home visit (virtual or physical), sensitive discussion and explanation of the risks, benefits, and possible likely outcomes of the treatment options with the family and caregivers. The emergency palliation treatment protocol for COVID-19 patients dying at home needs to be modified as per the patient's requirement. Either oral medication or subcutaneous injection route is preferred by training the family if these patients are not able to swallow, using all universal precautions and protective measures.
For COVID-19-infected adults with cancer and chronic end-stage organ impairment who need palliative care, the IAPC position statement advises that the suffering of patients, psychological burden, and availability of opioids should be recognized by the multi-disciplinary palliative care teams. Reorientation of administrative policies to ensure quality palliative care, supportive clinical care, and management of patient-related, disease-related, and prognostication-related complexities due to COVID-related situations is the need of the hour. The defining triage criteria, triage policies, defining roles for healthcare professionals, work-from-home policies, and capacity building for virtual care need full integration of palliative care principles across all levels. Similarly for children with cancer and chronic or end-stage organ impairment infected with COVID-19, the basic principles of pediatric palliative care should be adapted, such as family-centered care, effective pain management, and quality end-of-life care.
To provide psychological, social, and spiritual support for COVID-19 patients whose treatment is limited due to the pandemic situation, the IAPC position statement recommends the evaluation of distress using validated measures and management by counseling and psychotherapy or specialized interventions for moderate-to-severe distress. Recommendations on the rational use of PPE for palliative care providers are also provided by IAPC. These suggest that palliative care providers should be able to access adequate PPE, be properly trained in its correct use, and adhere to guidelines on their appropriate use.
Good care requires supplemental oxygen and morphine (or another opioid) during palliation therapy. Clinicians should make sure that people dying without ventilator support are reasonably comfortable. Apart from medication, patients under palliation therapy require spiritual and psychosocial support. Effective, efficient, and timely communication with emotional intelligence by healthcare workers with the patients and their relatives is also a very important component of the palliation guide.,, Various medications for pain, breathlessness, sedation, nausea and vomiting, anxiety, fever during end-of-life events, through nonoral, nonparenteral use are listed in [Table 4].,,,,
Health-care workers need to communicate effectively, efficiently with the patients and their relatives to avoid conflict between the two parties. They both can together come to the right decision about the mode of care offered to the patient. Communication about the present status of the patients and their prognosis should be done on a time-to-time basis, and it should be honest. For breaking bad news, the treating physician is supposed to be familiar with some basic aspects of communication. The Society Italiana de Cure Palliative has mentioned a Communication Toolkit for doctors in emergency COVID-19 situations which are very simple and basic tips for effectively managing communication with families and patients who are deteriorating. A detailed communication guide for the conscious patient and relatives of unconscious patients in the COVID-19 pandemic is mentioned in [Table 5].
| Challenges to Palliation in Pandemic|| |
There is a loss of connectivity between patients and their near ones, within the family, between the patient and the healthcare worker, between the patient and society, and between healthcare workers because of the highly infectious COVID-19. The nature of the disease is highly uncertain and its prognosis is inaccurate. This makes it difficult to help patients and their families to prepare for death. In India, the benefit of palliative care services reaches only about 1% of the 1.2 billion people in spite of all the developments. One of the fundamental challenges during this COVID pandemic is that access to palliative care in outpatient services may be imposed by financial limitations and the severity of the coronavirus outbreak.
As the number of COVID-19 infections continues to rise in India, the consequent lack of resources throw up ethical challenges such as: if the number of patients who need high level of support, such as a ventilator, exceeds the actual number of ventilators available in the hospital, which patients should be prioritized? Who will decide which patients will get prioritized? What ethical principles should be used if rationing of resources is needed? Do we have a framework to guide the use of public health infrastructure? Making ethical decisions may not be easy for many healthcare workers in relation to the management of COVID-19 patients in this emergency especially in resource-constrained settings.
Most hospitals will have had little experience with supporting people dying from respiratory failure. There are very few palliative care practitioners in India, with requisite skills and experience, such as knowing how to titrate morphine to relieve air hunger, while keeping the possibility open that the person might survive., However, these clinicians need morphine, oxygen concentrators, PPE, and time at the bedside at large numbers. These clinicians need to be on the list of high-priority providers, and their services need to be acknowledged and valued by leadership.
End-of-life decision-making is one of the biggest challenges as the pandemic evolves, decisions around distributive justice and resource use may become necessary. Decision-making around goals of care should, as always, be patient-centered and addressed early in the patient's illness trajectory. It should be shared decision-making which involves the patient party actively. The process of bereavement is disturbed, as traditional death rituals cannot be performed by the family. Informants perceive themselves to be suffering as they suffer the same anxieties, fears, and grief as the patient.
Inappropriate CPR during the pandemic is going to be stressful and dangerous for health care workers. Hence, “do not resuscitate” orders are also a major challenge as multiple healthcare workers with PPE will be needed for effective advanced care life support. Therefore, the COVID-19 pandemic heightens the importance of implementing do-not-resuscitate orders for appropriate hospitalized patients who have a bad short-term prognosis, end-stage or advanced comorbid illness, or long ICU stay. Family satisfaction with communication during decisions about end-of-life care in the ICU is higher if clinicians make explicit recommendations and provide the families with support for the decisions made about withholding or withdrawing life support.
| Conclusion|| |
Palliation and the pandemic go together. Palliation starts from outpatients, inpatients, intensive care and extends to community-based palliation services. We need to understand the basics of palliative care as the COVID-19 pandemic is increasing day by day, and it is jeopardizing the healthcare infrastructure, healthcare workers, patients, and caregivers in terrible way. Clinicians and treating staff are expected to know about triage systems, communication skills, medications, and ethical principles of essential palliative care. The COVID-19 pandemic has resulted in significant consequences for patients who require complex medical decisions in a resource-scarce health-care environment. Palliative care assists providers to integrate planning and comfort into care.
We would like to acknowledge and thank all frontline workers who have been battling during the coronavirus pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]