Adjusting Palliative Care Practices for a Pandemic

Palliative care plans are an essential tool for managing health resources during the coronavirus disease 2019 (COVID-19) pandemic, according to an analysis published in the Canadian Medical Association Journal.

Investigators from Canada outlined the challenges of providing palliative care during a pandemic and offered suggestions from previous experiences in order to help guide health care workers treating COVID-19 patients. The study authors wrote that the current pandemic “will likely strain Canada’s health care system” and understood that there are challenges to providing palliative care during this time. They cited Italy as an example, where older patients with comorbidities were denied access to critical care resources.

The 3 pillars of palliative care include management of patient symptoms; discussion of patient wishes, expectations, and values from advance care planning with an explanation of the goals of care; and supporting the families of those with the illness. In a viral pandemic, the need for palliative care is expected to increase substantially, the authors wrote, meaning palliative care services will likely be needed in intensive care units, hospital wards, emergency departments, and long-term care facilities.

Normally, palliative care includes shared decision making between patients and clinicians; however, in a pandemic scenario much of the patient autonomy may be limited due to available resources and health directives, the authors wrote. The emotional, psychological, social, and spiritual needs of both the patient and their families may also be restricted due to visitor and travel restrictions.

So, what has happened to palliative care during past pandemics? The authors used examples of previous mass casualty events such as terrorism, natural disasters or other epidemics, finding that there are 2 types of categories. The first is a “big bang” event, such as a plane or train crash, while the second is a “rising tide,” such as an epidemic. The authors said little has been written about how to manage palliative care in these events, though much has been written about triage during these events.

“Patients should always have access to high-quality palliative care as a basic human right, but, in a triage situation, our obligation to provide palliative care for those denied life-sustaining measures is increased,” the authors said. “Past experiences with viral epidemics, such as Ebola virus, severe acute respiratory syndrome (SARS) and HIV, have emphasized the integration of palliative care as an essential part of any health care intervention.”

To provide palliative care during an epidemic, the authors suggested thinking about 8 critical elements: stuff, staff, space, systems, sedation, separation, communication, and equity. The framework for the policy was developed using the US Task Force on Mass Casualty Critical Care, the authors wrote.

• Stuff: A medication stockpile should be created for long-term use by facilities, paramedics, and other health care professionals. The authors suggested terming this stockpile “palliative symptom management kits.”
• Staff: Response plans should include all health care professionals with palliative care training as well as those who can educate others in palliative care.
• Space: Utilizing nearby locations or specialized wards may be necessary to “ensure a quiet, peaceful environment for dying patients,” the authors wrote.
• Systems: The authors suggested using new triage systems and virtual care models in order to protect physicians from risk of infection while also increasing their efficiency.
• Sedation: Sedation can offer comfort to patients whose symptoms are not responding to standard comfort medications, the authors wrote.
• Separation: Patients can use video calling and other technologies to connect with family members to lessen the sense of separation they may feel due to isolation measures.
• Communication: Many patients may not want to undergo life-saving measures, so an understanding of a patient’s wishes is critical. The authors suggested maintaining open communication with patients.
• Equity: All patients should have access to palliative care, regardless of status as a marginalized group such as those with disabilities, trauma, or poverty, the authors said.

“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,” they wrote, adding that those who are denied access to critical care, such as a ventilator, should reasonably expect high-quality palliative care in its place.