Nationwide strategies employed to provide and integrate palliative care to patients with covid-19

Background: Little is known on what palliative care (PC) has been provided to patients with COVID-19. Aims: To understand what PC was provided nationwide to patients with COVID-19 and strategies implemented to overcome barriers during the pandemic. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing PC to patients with COVID-19. Thematic analysis was used to describe and interpret overarching themes. Results: Twelve specialized PC (SPC) and 11 primary PC (PPC) were interviewed. Interim analysis of 16 coded interviews demonstrated SPC and PPC physicians used traditional strategies (such as opioids, oxygen and serious illness conversations) to manage symptoms, support end of life, and engage patients and families in goals of care conversations (GOC). Neither SPC nor PPC indicated strong adoption of GOC and symptom management tools circulated early in the pandemic. Both SPC and PPC indicated a shift to virtual communication due to restrictive visitor policies, highlighting the need for distanced support and planned communication. Care coordination for PC patients was challenged by a lack of community resources, family infected with COVID-19, prolonged hospital stays, and increased number of PC patients discharged to rehabilitation services. New PC structures included;GOC teams that functioned in the emergency department and medicine floors, integrated clinical rounding by non-PC clinicians with PC teams, and hospital-based PC outreach to long term care. Strategies to improve PC implementation included: virtual technologies, team collaboration, patient and family engagement tools, and symptom management and GOC conversations tools. Conclusions: While PC management approaches to support patients with COVID-19 were mostly unchanged, new structures and strategies were developed to ensure patients and their families were provided with support.

Barriers and facilitators to specialized palliative care integration for patients with COVID-19

Background: Specialized palliative care (SPC) teams are well placed to support patients with advanced COVID-19 in Canada, but evidence indicates integration so far has been variable. Aim: To understand barriers and facilitators of SPC integration in the management of patients with COVID-19. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing care to patients with COVID-19. Thematic analysis was used to describe and interpret overarching themes. Results: Twenty-three physicians (12 SPC, 5 intensivists, 6 general internists) were interviewed. Interim analysis of 16 coded interviews demonstrated that facilitators/barriers to providing COVID-19 care fell into 5 main categories: patient-related, provider-related, Disease-specific, SPC service, and leadership factors. Patient-related items included age, comorbidities, goals, speed of decline and clustering of patients. Non- SPC provider-related factors included experience providing palliative care and working with the SPC team, time, and motivation. Uncertainty around COVID-19 progression, management and infection control practices were identified disease-specific barriers. SPC service factors included stigma related to palliative care, the accessibility, availability, and readiness of SPC services to meet the perceived needs of patients with COVID-19. Leadership facilitators included institutional mandated or supported integration, and SPC? presence at COVID-19 planning tables. Ways to improve integration included educational initiatives, relationship building, formal integrated structures and presence at institutional COVID-19 planning tables. Conclusion: Preliminary analysis highlights the need for high-level support for formal SPC integrated structures, a SPC role in pandemic planning, and the need for ongoing educational and relationship building initiatives to overcome barriers of SPC integration in COVID-19 care.

Identifying the consequences of restrictive visitor policies on palliative care providers, their patients and caregivers

Background: Restrictive institution visitor policies were implemented to minimize infection risks during the COVID-19 pandemic. Little data exists on the relationship between these policies and the provision of palliative care(PC). Aim: To describe the experiences and reflections of PC physicians on the effects of restrictive visitor policies. Methods: Semi-structured interviews were conducted with physicians about their experience providing PC in institutions with restrictive visitor policies. Thematic analysis was used to describe and interpret overarching themes. Results: Twelve specialized PC and 11 primary PC were interviewed. Interim analysis of 16 coded interviews demonstrates 4 main thematic categories including patient, caregiver, provider, and system effects. Patient-related items included isolation, dying alone, lack of caregiver advocacy and forced care decisions to allow for visitor presence. Caregiver factors included the inability to support or provide care to patients, poor communication with care teams, poor illness understanding, the need to make distanced care decisions, and challenges in identifying visitors. Provider factors included increased time and effort on communication, lack of caregiver input on patient status, increased complaints, the need to be a caregiver surrogate, visitor advocate or gatekeeper. System effects included the increased interest to be provided care in the community and the lack of interest in palliative care units. These factors were often exacerbated by several issues including the lack of clear evidence on their validity, and inconsistent enforcement or interpretation of policies at the unit, which led to patient and caregiver anger and distrust, and provider frustration. Conclusion: Preliminary analysis highlights substantial negative consequences of restrictive visitor policies at the patient, caregiver, provider and system levels which were exacerbated by their lack of evidence and inconsistent enforcement.

Health care providers' experiences with establishing goals of care for patients with covid-19

Background: Exploring patients' goals of care (GOC) is integral to palliative care practice. COVID-19 may present new challenges to establishing GOC. Aim: To describe the experiences and reflections of physicians regarding exploring GOC for patients with COVID-19. Methods: Semi-structured interviews were conducted with physicians about their experience assessing GOC for patients with COVID-19. Thematic analysis was used to describe and interpret over-arching themes. Results: Twenty-three physicians (12 Palliative Care, 5 Internal Medicine, and 6 Critical Care) were interviewed. Interim analysis of 16 coded interviews revealed 4 thematic categories of factors influencing establishment of GOC: resource availability, COVID-19 factors, patients' baseline health, and unusual communication challenges between health care providers and substitute decision makers (SDMs) or patients. Resourcerelated factors included impact of ICU/ventilator availability and personal protective equipment (PPE) shortages on GOC discussions. COVID-19 factors affecting GOC conversations included physician uncertainty of the course of illness;lack of definitive, evidence-based treatment;patient and family preconceived ideas about COVID-19;and risk of rapid decline. Factors associated with patients' baseline health included comorbid disease and ability to treat comorbid disease in parallel with COVID-19. Unusual communication challenges impacting GOC discussions included a high level of SDM involvement for GOC conversations, visitor policies potentially limiting SDMs' illness understanding, and virtual discussions or discussions taking place under layers of PPE creating barriers to effective communication between physicians, patients, and SDMs. Conclusion: Preliminary analysis highlights the unique challenges faced by both health care providers and patients/SDMs to facilitate and participate in GOC conversations in the context of the COVID-19 pandemic.

Reflections and experiences of physicians working during the COVID-19 pandemic: A qualitative study

Background: The need to recognize and attend to physician health and wellness has recently been emphasized, due to high levels of documented distress and burnout. The global pandemic has imposed even greater stressors and novel work demands on clinicians. Aim: To understand the experiences of physicians providing care during a global pandemic. Methods: Semi-structured interviews were conducted with physicians across Canada about their experiences providing care to patients during the COVID-19 pandemic. Thematic analysis methodology was used to describe overarching themes. Results: Twenty-three physicians (12 specialized palliative care, 5 intensivists, 6 general internists) were interviewed. Interim analysis of 16 coded interviews revealed 8 main categories: confusion and uncertainty;exhaustion and burnout;trauma;ethical considerations;isolation;professional re-evaluation;altruism;and cohesion. Confusion and uncertainty related mainly to the novel virus, leadership, and institutional preparedness. Exhaustion and burnout encompassed workload, personal protective equipment, family life, and complexity. The trauma theme included visitor policies, family surrogates, and patient management. Ethical considerations included job demands vs personal and family safety. Isolation was largely related to infection control measures. Professional re-evaluation items included job satisfaction due to changed patient encounters or novel structuring. Altruism items included unique personal contribution to pandemic response and societal needs. Cohesion items included supporting each other and team building. Conclusion: Preliminary analysis revealed trauma and distress, but also altruism and cohesion. These findings may inform interventions for physician health and wellness, as well as indicating ways to integrate meaning and purpose into negative experiences to promote resilience.