The last research roundup provided an overview of recent research around prescribing medication and symptom management in end-of-life care. In this month's review of recent publications we will continue to build upon the theme of end-of-life care by looking at end-of-life care in a global pandemic. Many of you will have experience of caring for people at the end of their life whether that be in their home setting, hospice setting or in hospital. Many of the rapid publications in this area are commentary or editorial pieces and much new research is to be expected in these areas.
End-of-life decisions and care in the midst of a global coronavirus (COVID-19) pandemic
This editorial considers how end-of-life decision making has been impacted by the SARS-COVID-19 pandemic (Pattison, 2020). They state that the ‘unprecedented and unfolding global has forced healthcare providers globally to consider end-of-life issues in a very rapidly changing scenario. They discuss the need to have end-of-life conversations earlier in chronic illness and the issue of healthcare provider facing shortages of beds to care for people at the end of life. The issue of pandemic planning incorporating end-of-life care is also discussed. NICE guidance is also an area they recommend healthcare professionals use to help with decision making. The COVID 19: Rapid Guidance for Critical Care (National Institute of Clinical Health and Excellence (NICE), 2020) published in response to the pandemic, places the focus on how and when to use frailty on admission to help inform rapid and timely admission decisions. The Association of Palliative Medicine have issued guidance to support palliative care clinicians providing palliative care in secondary care. Like many other things during the pandemic, these are rapidly produced publications and will no doubt change and evolve as COVID-19 does. Another area addressed is the area of bereavement support and the issue of providing this in larger numbers in unexpected situations. There is an expectation that future research and publications will try to address the many aspects of care identified.
End-of-life care in the emergency department for the patient imminently dying of a highly transmissible acute respiratory infection (such as COVID-19)
This commentary piece looks at end-of-life care in the ED about care of the imminently dying who have COVID-19 and state that interventions should be as early as possible in the patients care but still being patient-centred (Hendin et al, 2020). The recommendations provided were based on best evidence where available and by consensus from ‘Canadian physicians who practice both Emergency and Palliative Medicine’.
The recommendations include:
- Document the discussion around goals of care
- Consider involving spiritual care, social work, and/or palliative care if appropriate
- Place the patient in a private room if possible
- Visiting as per local protocols
- Symptom management.
The article also discusses approaches to when and how to withdraw life-saving interventions. They conclude that as the situation of COVID-19 continues to grow that many end-of-life discussions may now be happening in ED situations rather than in inpatient care settings.
Providing quality end-of-life care to older people in the era of COVID-19: perspectives from five countries
This commentary piece looks at frailty and end-of-life care in the frail elderly in light of the COVID-19 pandemic. They state that ‘Providing quality end-of-life care for older people is one of our biggest challenges in this new COVID-19 era’ (Lapid et al, 2020). The authors provide statistics from a range of current sources regarding morbidity and mortality in the elderly population due to COVID-19 compared with the under 45 age group and the figures are quite revealing. They do state that frailty alone is only one aspect to consider and that use of an accepted frailty index to assess risk should be used. The article also discusses issues around human rights and advanced care planning in this patient population. Symptom management is well discussed and as this article draws from five different countries the issues of assisted dying and euthanasia are touched upon. Long term care, including that in hospice, hospital and at home is well attended to. The article concludes with some suggestions for clinicians including
- How to use guidelines to fatten the curve
- Embracing change for example telemedicine and remote consultations as a change to working practices.
- The role of staff and organisational support
- Proper consideration of advanced care planning.
‘Prescribers need to be aware of guidelines supporting prescribing decision making but also the need to tailor the clinical interventions to meet patient's needs’
Characteristics, symptom management, and outcomes of 101 patients with COVID-19 referred for hospital palliative care
This article sought to identify symptom burden, management, response to treatment, and outcomes for a case series of 101 inpatients with confirmed COVID-19 referred to hospital palliative care at two large London hospitals (Lovell et al, 2020). Data were collected from medical and nursing case notes. The most prevalent symptoms (n) were breathlessness (67), agitation (43), drowsiness (36), pain (23), and delirium (24). The commonest medicines prescribed in the period of study were opioids and midazolam. At the end of the study period, 75 patients had died; 13 been discharged back to team, home, or hospice; and 13 continued to receive inpatient palliative care. This is discussed as being the first report of characteristics, symptom management, and outcomes of patients withCOVID-19 referred for hospital palliative care. In addition, they reveal that patients near the end of life commonly experience agitation, while cough is infrequent. Time spent under the palliative care team was brief (median time two days), and symptom control with subcutaneous infusion was achieved in most cases using relatively small doses of opioid and benzodiazepine. They conclude that patients severely affected by COVID-19 frequently experience symptoms and distress, and palliative care is an essential part of the response to this pandemic and that teams must rapidly adapt with new ways of working.
Conclusion
The area of end-of-life care in a global pandemic presents the prescriber with a wide range of challenges, especially considering the recent changes seen due to COVID-19. Prescribers need to be aware of guidelines supporting prescribing decision making but also the need to tailor the clinical interventions to meet patients' needs.