As the volume of coronavirus disease 2019 (COVID-19) cases began to escalate, end-of-life care quickly emerged as a prominent aspect of the pandemic. Among other issues, the high death count and rapid deterioration of the condition in many patients with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus have highlighted the essential role of palliative care in supporting healthcare providers, patients, and their loved ones in the context of the current crisis.
In an article published in the Journal of Pain and Symptom Management, James Fausto, MD, MHA, and colleagues at the University of Washington (UW) in Seattle shared their strategy for developing a plan to meet palliative care needs related to COVID-19 in the emergency department, intensive care units, and acute care settings.
Together with healthcare system leadership, the authors created a system-wide response plan for the delivery of high-quality palliative care across a continuum of conventional, contingency, and crisis capacity scenarios, based on the framework used in many previously published disaster preparedness and response approaches. “These proposals highlight that the primary objective in a disaster is to remain in conventional and contingency care to avoid crisis care, which will compromise patient outcomes,” wrote Fausto et al. The goal of contingency care is to adapt usual practices to provide functionally equivalent care.
For example, according to the UW strategy, clinicians in the ED, ICU, and acute care settings can access onsite palliative care consultations by request 7 days per week from 9 am to 6 pm in the conventional care situations, with palliative care coaching available by phone at all times. In contingency and crisis care situations, the strategy shifts to daily huddles with ED and ICU teams to assess palliative care needs, as well as a palliative care specialist embedded in these settings to meet demands for increased support. For acute care settings, palliative care teams would check in with teams on a regular basis to assess and address needs for coaching, support, and assistance.
The authors also identified the following topics that warranted consideration in developing their response plan:
Limited Palliative Care Specialty Staffing
The UW plan calls for the reallocation of palliative care staff from nonpalliative care tasks as needed to adequately serve the most patients, as well as redeployment of the palliative care workforce across UW sites to “level-load” resources.
Personal Protective Equipment (PPE) Preservation
Palliative care personnel should aim to provide consults remotely when possible and should use PPE only when necessary in the provision of care.
Palliative care support would be available after routine working hours in an on-call capacity but with limited hours for in-person visits to preserve the palliative care workforce.
Urgent consultations will be prioritized, while routine, non-urgent consultations will be deferred to either an outpatient program or later consultation when possible.
Early Goals-of-Care Discussions and Addressing Code Status
Palliative care specialists will provide guidance regarding these topics and assistance with complex communication.
In addition, the UW strategy “specifies that in a crisis capacity setting, we would consider the creation of an end-of-life care unit specifically for patients dying with COVID-19, which would be staffed by palliative care physicians and advanced practice provider specialists trained in use of PPE,” and telephonic palliative care support would be available to primary teams at all hours, as explained in the article.
We further discussed palliative care response planning with one of the authors of the paper, J. Randall Curtis, MD, MPH, the A. Bruce Montgomery–American Lung Association Endowed Chair in Pulmonary and Critical Care Medicine, professor of medicine, and director of the Cambia Palliative Care Center of Excellence at UW Medicine in Seattle.
What are some of the main COVID-related palliative care needs that you have been seeing, and what are some ways in which these are being addressed at UW?
I would say the three greatest needs are: having goals-of-care discussions with patients early in their course of COVID-19 while they can still communicate about their values and goals; supporting and communicating with family members of patients who are hospitalized with COVID-19 in the context of limited family presence in the hospital, especially if patients are too ill to communicate; and supporting patients and family members when it becomes clear that patients will not survive this illness.
Our palliative care team has staffed up to be able to support the ICU and acute care teams in all 3 of these important areas. The palliative care team is doing this through coaching the ICU and acute care teams through these conversations, brief targeted consults to provide support, as well as traditional full palliative care consults.
In publishing your palliative care inpatient response plan, you and your colleagues shared an excellent resource that we are sure others will find helpful in developing or refining their own plan. Can you offer any suggestions about how they might adapt this strategy to their own setting?
It is very important to understand the local culture of each hospital unit and their propensity toward and capacity for delivering primary palliative care themselves. When that propensity and capacity are both high, then the palliative care team can check in regularly just to make sure they are doing okay and identify the difficult issues they can help with. When the propensity and/or capacity are not as high, the palliative care team will need to be more involved.
What are other implications for clinicians regarding palliative care in the context of COVID-19?
Palliative care and discussions about goals of care and advance care planning are not really different in the context of the COVID pandemic — these are the same conversations we should be having all the time — but the COVID pandemic has heightened the importance of these conversations because of the large numbers of older patients, often with significant comorbidities, who are becoming extremely ill.
Fausto J, Hirano L, Lam D, et al. Creating a palliative care inpatient response plan for COVID-19-The UW medicine experience [published online March 31, 2020]. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2020.03.025
1. Fusi-Schmidhauser T, Preston NJ, Keller N, Gamondi C. Conservative management of COVID-19 patients-emergency palliative care in action. [published online April 8, 2020]. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2020.03.030
2. Costantini M, Sleeman KE, Peruselli C, Higginson IJ. Response and role of palliative care during the COVID-19 pandemic: A national telephone survey of hospices in Italy [published online April 29, 2020]. Palliat Med. doi:10.1177/0269216320920780