Palliative Care in COVID-19
April 23, 2020
Posted by Andy Jagoda, MD in: Feature Update , trackback
Palliative Care Principles in the Age of COVID-19
By Ashley Shreves, MD
Most emergency clinicians are familiar with the guiding principles of palliative care, which focus on improving the quality of life for patients who are facing life-threatening illnesses. Palliative care uses a variety of mechanisms to ensure that patient values and goals are aligned with the medical treatment being given, while careful attention is paid to the patient’s pain and to the physical, psychosocial, and spiritual symptoms of the illness. I have been working in New Orleans as an emergency medicine and palliative care physician throughout the COVID-19 pandemic (except for the week that I had COVID-19 myself) and can share my observations about how palliative care principles apply to this patient population.
Nothing and everything have changed. Though most patients with COVID-19 – even those who are hospitalized – are recovering, some are not. Patients who require mechanical ventilation have a higher mortality rate than those who do not; older patients, and particularly those with serious comorbidities, are faring worse.
We are struggling with prognostication in this disease. The critical care team and I have been surprised by patients in the ICU who seemed certain to die, but instead went on to make full recoveries, and I have been equally surprised by patients who were expected to do well, but took sudden turns to decline and death. While the absolute numbers may vary, in terms of patterns, the trajectories of these patients are not very different from those of patients with serious illness in the pre-COVID era, for whom our prognostication abilities were often mediocre.
These are important factors to consider when structuring conversations about goals of care, particularly in the first minutes to hours of a patient’s ED care. These conversations should not be radically different from those conducted before this pandemic. This equation would change if crisis standards of care are established, but rationing has not yet been needed here in New Orleans, even at peak healthcare resource utilization.
Basic Principles Apply
When caring for a patient with COVID-induced respiratory failure, the basic principles of palliative care apply. For patients who are unable to communicate, I seek advance directives and contact surrogate decision-makers (even though they are not physically present in the ED, nearly all are anxiously awaiting our phone calls) for guidance about the use of life-sustaining treatments (LST). For patients who are able to communicate but do not have clearly established wishes about the use of LST, I have found that a “hope for the best, plan for the worst” discussion works best. For example: “I hope that you will recover. At the same time, this disease can get very serious. I want us to make a plan for how we can best take care of you should you get sicker…”
For patients who have serious comorbidities or are at a very advanced age, I share with them my worry that they are unlikely to recover should they become critically ill and require mechanical ventilation. I outline 3 care strategies and let them opt in to the one they prefer:
- Care that aggressively focuses on prolonging life regardless of burdens and potential outcome,
- Care that prioritizes getting the patient through this illness but places limits on invasive interventions should the condition worsen, or
- Care that strictly prioritizes patient comfort.
Many patients have chosen time-limited trials of critical care or aggressive noninvasive care (eg, use of high-flow nasal cannula) and have done surprisingly well. For example, I treated a 93-year-old woman who had DNR/DNI orders but was also in relatively good health and was highly motivated to recover; she required first a nonrebreather mask and then high-flow nasal cannula for a week, but she has since been discharged from the hospital.
The “everything” that has changed includes the sheer volume of patients we are seeing with life-threatening illness, the uncertainty about how to manage this disease, the legitimate fear that clinicians have about becoming ill themselves, and the isolation our patients face at a time when family and loved ones would usually be gathered by their sides.
Not all of these challenges have perfect solutions, but technology has been the unexpected hero in this saga, with smartphones and iPads playing invaluable roles in facilitating communication amongst loved ones at all stages of illness. I have found that the most effective way to communicate with all parties is to call the family from the hospital room, using the patient’s cell phone placed on speaker. I have done this to discuss goals of care early in a patient’s disease trajectory as well as at the end of life when patients were too sick to dial the phone, to enable family members to say goodbye.
Finally, sometimes the most valuable gift we can give to our patients in these moments is our ability to bear witness to their lives, recognize their intrinsic dignity, and empathize with their suffering. In COVID-19 hotspots like New Orleans and New York City, it can be easy to lose sight of the humanity of the individual patient when faced with an overwhelming surge of patients hidden behind masks. Resisting this urge, getting back to the basic principles of palliative care, and slowing down to take a much-needed deep breath may be our best tools to find our way through this pandemic.
Ashley Shreves, MD, is an attending physician at Ochsner Medical Center in New Orleans, LA, and is board certified by the American Board of Emergency Medicine and the American Academy of Hospice and Palliative Medicine. She is the author of the July 2018 Emergency Medicine Practice article on emergency department management of dyspnea in the dying patient.