ABSTRACT
Introduction: The COVID-19 pandemic necessitated multiple changes to the format of myeloma clinics to minimise the risk of infection among patients and staff. These included changing in-person clinic appointments to telephone appointments when there was no medical need for face-to- face review and instituting a courier service for delivery of oral or self-administered medications. As COVID-19 restrictions relaxed, we sought to investigate the acceptability of these changes to our patients and to determine which, if any, of the new arrangements should continue. Method(s): Patients who attended the Myeloma Clinic at The Royal Marsden Hospital, both in-person and by telephone, on four separate dates in August and September 2022 were asked to complete a questionnaire to provide their opinions using a combination of multiple-choice, Likert scale and free-text questions. These covered the main domains of change outlined above along with questions about blood test location and attendance with family and friends. Result(s): Questionnaires were returned by 59 patients, 11 relating to in-person appointments and 48 to telephone appointments. 86.0% of patients were in favour of continuing the option of telephone appointments, with many highlighting their convenience and the avoidance of long travel and waiting times, with some also mentioning their COVID-19 security. However, a number of patients expressed concerns including communication difficulties, the inability to effectively assess physical health with an examination and a lack of reassurance. Furthermore, those who attended in-person appointments felt they were very COVID-secure, assigning them a mean of score of 4.5, where 1 was very insecure and 5 very secure. Several suggested that the optimum schedule would include regular telephone appointments with occasional in-person meetings. Interestingly, only 25.5% of patients wanted a video calling option. Patients were also very positive about receiving medications by courier, with 94.1% of patients receiving their medications within two working days of their clinic appointment. 81.8% of patients expressed a wish for this option to continue, highlighting the increased convenience and reduction in waiting times. Conclusion(s): These results suggest that changes made to the Myeloma Clinic in response to the COVID-19 pandemic have improved the patient experience. A mixture of telephone and in-person appointments may be preferable for this cohort of patients, many of whom require regular appointments for chemotherapy approval but are medically stable, and whose frailty makes long travel and waiting times challenging. These findings have implications for the planning of myeloma clinics across the UK.
ABSTRACT
Background: Covid-19 infection is associated with significant risk of death, particularly in older, comorbid patients. Emerging evidence supports use of non-invasive respiratory support (CPAP and high-flow nasal oxygen [HFNO]) in this context, but little is known about its use in patients receiving end-of-life care. Methods: This was a retrospective study of 33 patients who died of Covid-19 on the Respiratory High Dependency Unit at the John Radcliffe Hospital, Oxford between 28/03/20 and 20/05/20. Data was sourced via retrospective review of electronic patient records and drug charts. Results: Patients dying from Covid-19 on the Respiratory HDU were comorbid with median Charlson Comorbidity Index 5 (IQR 4-6); median age 78 (IQR 72-85). Respiratory support was trialled in all but one case with CPAP being the most common form of first line respiratory support (84.8%) however, was only tolerated in 44.8% of patients. Median time to death was 10.7 days from symptom onset (IQR 7.5-14.6) and 4.9 days from hospital admission (IQR 3.1-8.3). 48.5% of patients remained on respiratory support at the time of death. Conclusions: End-of-life care for patients with Covid-19 remains a challenge. Patients tend to be frail and comorbid with a rapid disease trajectory. Non-Invasive Respiratory Support may play a key role in symptom management in select patients, however, further work is needed in order to identify patients who will most benefit from Respiratory Support and those for whom withdrawal may prevent unnecessary distress at the end of life or potential prolongation of suffering.