Mourning and restoration

During the endless days of March and April 2020, New York City experienced more than 20,000 COVID-19 deaths and was considered the "epicenter" of a new global pandemic. Nursing homes witnessed the virus's contagion at staggering rates, with elderly and debilitated patients coming in by the dozens, gasping for breath, scared they would die and never see their loved ones again. Our hospital and our lives were quickly transformed. The author spent most of his clinical effort during those months running a new eight-bed hospice unit in our hospital. The author then presents the story of a hospice patient, a fifty-nine-year-old Black male-to-female transgender homeless woman. She had been diagnosed with an aggressive squamous cell carcinoma. She underwent chemotherapy, radiation therapy, and surgery, including a diverting colectomy, leaving her with a permanent ostomy. She had several other medical problems-chronic kidney disease, heart disease, diabetes, major depression, and chronic lymphedema. Taking care in her last days of life was agonizing. The possibility to have spent more time getting to know her. To explore her world and navigate the challenges of her health and condition together. This is the privilege of the doctor-patient relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Mourning and restoration

During the endless days of March and April 2020, New York City experienced more than 20,000 COVID-19 deaths and was considered the "epicenter" of a new global pandemic. Nursing homes witnessed the virus's contagion at staggering rates, with elderly and debilitated patients coming in by the dozens, gasping for breath, scared they would die and never see their loved ones again. Our hospital and our lives were quickly transformed. The author spent most of his clinical effort during those months running a new eight-bed hospice unit in our hospital. The author then presents the story of a hospice patient, a fifty-nine-year-old Black male-to-female transgender homeless woman. She had been diagnosed with an aggressive squamous cell carcinoma. She underwent chemotherapy, radiation therapy, and surgery, including a diverting colectomy, leaving her with a permanent ostomy. She had several other medical problems-chronic kidney disease, heart disease, diabetes, major depression, and chronic lymphedema. Taking care in her last days of life was agonizing. The possibility to have spent more time getting to know her. To explore her world and navigate the challenges of her health and condition together. This is the privilege of the doctor-patient relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved)

Perspectives of Remote Volunteer Palliative Care Consultants During COVID: A Qualitative Study.

CONTEXT: A novel remote volunteer program was implemented in response to the initial COVID-19 surge in New York City, allowing out-of-state palliative care specialists to serve patients and families in need. No study has detailed the perceptions of these consultants. OBJECTIVES: To understand the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge. METHODS: This qualitative study utilized a thematic analysis approach. During January and February 2021, we conducted one-on-one semi-structured interviews with 15 board-certified palliative care physicians who participated in the program. Codes and emerging themes were identified through iterative discussion and comparison. RESULTS: Five overarching themes (with sub-themes in parentheses) were identified: 1) motivations for participating in the program, 2) logistical evaluation of the program (integration, telehealth model, dyad structure and debriefing sessions), 3) barriers to delivery (language and cultural differences, culture of high-intensity care, legal and administrative differences), 4) emotional burden (moral distress, burnout), and 5) ideas for improvements. Notably, participants observed institutional and cultural differences that posed challenges to delivery of care. Many expressed feelings of distress related to the uncertainty and scarcity caused by the pandemic, although volunteering may have been protective against burnout. CONCLUSION: This study provides an in-depth look at the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge from the unique perspectives of the consultants themselves. Participants expressed overall positive and meaningful experiences and felt that the model was appropriate given the circumstances. Additionally, participants provided recommendations that could guide future implementations of similar programs.

Virtual Interinstitutional Palliative Care Consultation during the COVID-19 Pandemic in New York City.

Context: Amid the COVID-19 surge in New York City, the need for palliative care was highlighted. Virtual consultation was introduced to expand specialist-level care to meet demand. Objectives: To examine the outcomes of COVID-19 patients who received virtual palliative care consultation from outside institutions. Design: This is a retrospective case series. Setting/Subjects: Subjects were 34 patients who received virtual palliative care consultation between April 13, 2020, and June 14, 2020. Measurements: Follow-up frequency and duration, code status change, withdrawal of life-sustaining treatment (LST), and multidisciplinary involvement. Results: Twenty-eight patients (82.3%) were in the intensive care unit and 29 patients (85.3%) were on at least two LSTs. Fifteen patients (44.1%) died in the hospital, 9 patients (26.4%) were discharged alive, and 10 patients (29.4%) were signed off. The median frequency of visits was 4.5 (IQR 6) over 11 days follow-up (IQR 17). Code status change was more frequent in deceased patients. LSTs were withdrawn in eight patients (23.5%). Conclusions: Virtual palliative care consultation was feasible during the height of the COVID-19 pandemic.

The Prevalence of Palliative Care Consultation in Deceased COVID-19 Patients and Its Association with End-of-Life Care.

Background: During the height of the coronavirus disease 2019 (COVID-19) pandemic in New York City, COVID-19 hospitalization was associated with high mortality. It is unknown how palliative care was utilized in this context. Objectives: To describe the frequency of palliative care consultation and its association with end-of-life care for deceased patients with COVID-19. Methods: Adults who were admitted to our institution between February 23, 2020, and April 21, 2020, and died from COVID-19 were included. The primary outcome was the frequency of palliative care consultation. Secondary analyses included the association of palliative care consultation with code status at the time of death, life-sustaining treatments, mechanical ventilation, invasive procedures, intensive care unit (ICU) admissions, and length of hospital stay. Results: The 203 patients were 61% male with median age 76 (interquartile range [IQR] 67-84) years. Palliative care was consulted for 113 patients (56%). At baseline, they were less independent in instrumental activities of daily living (28 patients, 26.1%, vs. 47 patients, 49.0%, p < 0.01) and had more do-not-resuscitate orders (35 patients, 32.7%, vs. 11 patients, 11.5%, p < 0.01). Palliative care consultation was associated with fewer invasive procedures (0, IQR 0-2, vs. 2, IQR 0-3, p < 0.01), less mechanical ventilation (32 patients, 29.9% vs. 65 patients, 67.7%, p < 0.01), and fewer ICU admissions (33 patients, 30.8% vs. 69 patients, 71.9%, p < 0.01). Palliative care was associated with shorter ICU stays (0 days, IQR 0-4, vs. 4 days, IQR 0-12, p < 0.01), whereas hospital stays did not differ significantly (8 days, IQR 5-12.5, vs. 10 days, IQR 5-16.3, p = 0.15). Conclusion: Palliative care was consulted for roughly half of deceased patients with COVID-19 and those patients were less likely to undergo invasive procedures or life-sustaining treatments and spent less time in the ICU at the end of life.

A Comprehensive Approach to Palliative Care during the Coronavirus Pandemic.

Context: The COVID-19 pandemic resulted in a surge of critically ill patients that strained health care systems throughout New York City in March and April of 2020. At the peak of the crisis, consults for palliative care increased four- to sevenfold at NewYork-Presbyterian (NYP), an academic health care system with 10 campuses throughout New York City. We share our challenges, solutions, and lessons learned to help peer institutions meet increased palliative care demands during future crises and address pre-existing palliative care subspecialist shortages during nonpandemic times. Methods: In response to the increased demand, palliative care physician and administrative leadership at NYP piloted multiple creative care models to expand access to palliative care outpatient and inpatient services. The care models included virtual outpatient management of existing patients, embedded palliative care staff, education for providers, multidisciplinary family support, hospice units (which allowed for family visitation), and team expansion through training other disciplines (primarily psychiatry) and deploying an ePalliative Care service (staffed by out-of-state volunteers). Conclusion: Our comprehensive response successfully expanded the palliative care team's reach, and, at the height of the pandemic, allowed our teams to meet the increased demand for palliative care consults. We learned that flexibility and adaptability were critical to responding to a rapidly evolving crisis. Physician and family feedback and preliminary data suggest that virtual outpatient visits, embedded staff, hospice units, and team expansion through training other disciplines and deploying ePalliative Care services were impactful interventions.

Prolonged Critical Illness and Demoralization: Curative Factors in Hospice Care in the Age of COVID-19.

In this case report, an elderly patient with COVID-19 pneumonia and a protracted intensive care course, who was unable to wean from mechanical ventilation, was transferred to the hospice unit for ventilator withdrawal and end of life care. Although symptom management was anticipated to focus on treating acute dyspnea, conditions mandated a shift to addressing the psychological challenges associated with prolonged critical illness. The interventions typical to hospice care-patient centered, family focused, and culturally sensitive-served to alleviate psychological symptoms of demoralization and despair, contributing to an outcome that pointed beyond pulmonary pathophysiology. Thought to be facing imminent death once the ventilator was removed, this patient defied the science behind weaning protocols, which can only be explained by a "will to live," through loving engagement with his family, his favorite music, and a dedicated multidisciplinary hospice team.

The Creation of a Psychiatry-Palliative Care Liaison Team: Using Psychiatrists to Extend Palliative Care Delivery and Access During the COVID-19 Crisis.

CONTEXT: During the course of March and April 2020, New York City experienced a surge of a 170,000 coronavirus disease 2019 (COVID-19) cases, overwhelming hospital systems and leading to an unprecedented need for palliative care services. OBJECTIVES: To present a model for rapid palliative care workforce expansion under crisis conditions, using supervised advanced psychiatry trainees to provide primary palliative services in the acute care and emergency setting. METHODS: In response to the New York City COVID-19 surge, advanced psychiatry trainees at New York-Presbyterian Columbia University Irving Medical Center were rapidly trained and redeployed to a newly formed psychiatry-palliative care liaison team. Under the supervision of consultation-liaison psychiatrists (who also served as team coordinators), these trainees provided circumscribed palliative care services to patients and/or their families, including goals-of-care discussions and psychosocial support. Palliative care attendings remained available to all team members for more advanced and specialized supervision. RESULTS: The psychiatry-palliative care liaison team effectively provided palliative care services during the early phase and peak of New York City's COVID-19 crisis, managing up to 16 new cases per day and provided longitudinal follow-up, thereby enabling palliative care specialists to focus on providing services requiring specialist-level palliative care expertise. CONCLUSION: By training and supervising psychiatrists and advanced psychiatry trainees in specific palliative care roles, palliative care teams could more effectively meet markedly increased service needs of varying complexity during the COVID-19 crisis. As new geographic regions experience possible COVID-19 surges in the coming months, this may serve as a model for rapidly increasing palliative care workforce.