Public Health Watch: Analysis Highlights Role of COVID-19 Palliative Care

Findings reveal that most unhealthy seniors and/or their families opt for comfort-directed care rather than life-sustaining treatment.

Generally, helping patients survive coronavirus 2019 (COVID-19) is the duty of frontline clinicians.

However, it may not always align with patient goals. An analysis published by JAMA Internal Medicine highlights the complexities of these issues within the context of the ongoing global pandemic.

As of this writing, nearly 2.2 million Americans have died from COVID-19, according to figures from Johns Hopkins University, which has been tracking the pandemic. At least in the US, the bulk of these deaths have occurred in adults 65 years of age and older, with those 85 years of age and older accounting for the highest percentage, based on data reported to the US Centers for Disease Control and Prevention (CDC).

And so, issues related to the appropriate treatment of the disease caused by the new coronavirus, SARS-CoV-2, and end-of-life care intersect.

Indeed, their findings serve to highlight the potential role for palliative care in the treatment of COVID-19.

The authors of the JAMA Internal Medicine analysis—specialists in palliative care at Columbia University Irving Medical Center—reported on the outcomes of 110 with confirmed or suspected COVID-19 patients at the hospital (median: 81.5 years of age) with whom they were called into consult. In all, 106 of the patients had at least 1 comorbidity—with hypertension, cardiovascular disease, and diabetes being the most common—and 36 were residents of long-term care facilities at the time of hospital admission due to COVID-19.

Notably, 95 of the patients had no decision-making capacity and all but a few lacked an advanced directive (7) or DNR (6), the researchers said. In most cases, a family member served as a healthcare proxy or surrogate.

After the initial palliative care intervention, the number of those requesting life-sustaining treatment (ie, CPR, ventilator support, intubation) decreased from 91 patients to 20 patients, according to the researchers. In all, 71 declined CPR and 61 refused mechanical ventilation. Of this latter group, 29 patients received comfort-directed care, they noted.

By the end of the analysis period, the number of patients on comfort-directed care increased to 54. Ultimately, 71 of the patients died in the hospital. Among the 33 patients who were discharged alive, 6 were discharged with hospice care.

“Patients without advance care planning conversations are known to be at risk of receiving unwanted, high-intensity, lower-quality care, even though many seriously ill patients do not prefer life-sustaining treatments at the end of life,” wrote the investigators, who declined to comment at the time of publication. “After palliative care intervention in the ED, most patients and their surrogates opted to forgo mechanical ventilation and/or CPR, and that tendency further increased on discharge."

They emphasized that timely conversations on goals of care from the palliative care team helped patients with poor prognoses avoid unwanted, life-sustaining therapies.

These are difficult conversations to have—and the findings of this study only serves to further highlight the devastating toll of the pandemic.