Delivering Hospice Care During the COVID-19 Pandemic: Meeting Nursing Home Residents' Needs.

This discussion article highlights the challenges of providing hospice care in nursing homes since the start of the COVID-19 (coronavirus disease 2019) pandemic and illuminates practice changes needed in nursing homes. The article provides an overview of the expectations of hospice care, explains the differences in delivering hospice care during the COVID-19 pandemic, examines social isolation and emotional loneliness and the role of familial caregivers, and describes policy changes related to the COVID-19 affecting hospice care delivery in nursing homes. This article answers the following questions: (1) How did residents receiving hospice care have their needs met during the COVID-19 pandemic? (2) What areas of nursing home care need to be improved through governmental policy and restructuring? This article also summarized the lessons learned as a result of the COVID-19 pandemic and provided practical implications for nursing, specific to changes in hospice care deliveries for nursing home residents.

Bereavement care for ethnic minority communities: A systematic review of access to, models of, outcomes from, and satisfaction with, service provision.

OBJECTIVES: To review and synthesize the existing evidence on bereavement care, within the United Kingdom (UK), for ethnic minority communities in terms of barriers and facilitators to access; models of care; outcomes from, and satisfaction with, service provision. DESIGN: A systematic review adopting a framework synthesis approach was conducted. An electronic search of the literature was undertaken in MEDLINE, Embase, PsycINFO, Social Work Abstract and CINAHL via EBSCO, Global Health, Cochrane library, the Trip database and ProQuest between 1995 and 2020. Search terms included bereavement care, ethnic minority populations and the UK setting. RESULTS: From 3,185 initial records, following screening for eligibility, and full-text review of 164 articles, seven studies were identified. There was no research literature outlining the role of family, friends and existing networks; and a real absence of evidence about outcomes and levels of satisfaction for those from an ethnic minority background who receive bereavement care. From the limited literature, the overarching theme for barriers to bereavement care was 'unfamiliarity and irregularities'. Four identified subthemes were 'lack of awareness'; 'variability in support'; 'type and format of support'; and 'culturally specific beliefs'. The overarching theme for facilitators for bereavement care was 'accessibility' with the two subthemes being 'readily available information' and 'inclusive approaches'. Three studies reported on examples of different models of care provision. CONCLUSIONS: This review reveals a stark lack of evidence about bereavement care for ethnic minority populations. In particular, understanding more about the role of family, friends and existing support systems, alongside outcomes and satisfaction will begin to develop the evidence base underpinning current provision. Direct user-representation through proactive engagement and co-design approaches may begin to determine the most appropriate models and format of bereavement care for ethnic minority communities to inform service design and delivery.

Patient and Hospital Factors Associated With Differences in Mortality Rates Among Black and White US Medicare Beneficiaries Hospitalized With COVID-19 Infection.

Importance: Black patients hospitalized with COVID-19 may have worse outcomes than White patients because of excess individual risk or because Black patients are disproportionately cared for in hospitals with worse outcomes for all. Objectives: To examine differences in COVID-19 hospital mortality rates between Black and White patients and to assess whether the mortality rates reflect differences in patient characteristics by race or by the hospitals to which Black and White patients are admitted. Design, Setting, and Participants: This cohort study assessed Medicare beneficiaries admitted with a diagnosis of COVID-19 to 1188 US hospitals from January 1, 2020, through September 21, 2020. Exposure: Hospital admission for a diagnosis of COVID-19. Main Outcomes and Measures: The primary composite outcome was inpatient death or discharge to hospice within 30 days of admission. We estimated the association of patient-level characteristics (including age, sex, zip code-level income, comorbidities, admission from a nursing facility, and days since January 1, 2020) with differences in mortality or discharge to hospice among Black and White patients. To examine the association with the hospital itself, we adjusted for the specific hospitals to which patients were admitted. We used simulation modeling to estimate the mortality among Black patients had they instead been admitted to the hospitals where White patients were admitted. Results: Of the 44 217 Medicare beneficiaries included in the study, 24 281 (55%) were women; mean (SD) age was 76.3 (10.5) years; 33 459 participants (76%) were White, and 10 758 (24%) were Black. Overall, 2634 (8%) White patients and 1100 (10%) Black patients died as inpatients, and 1670 (5%) White patients and 350 (3%) Black patients were discharged to hospice within 30 days of hospitalization, for a total mortality-equivalent rate of 12.86% for White patients and 13.48% for Black patients. Black patients had similar odds of dying or being discharged to hospice (odds ratio [OR], 1.06; 95% CI, 0.99-1.12) in an unadjusted comparison with White patients. After adjustment for clinical and sociodemographic patient characteristics, Black patients were more likely to die or be discharged to hospice (OR, 1.11; 95% CI, 1.03-1.19). This difference became indistinguishable when adjustment was made for the hospitals where care was delivered (odds ratio, 1.02; 95% CI, 0.94-1.10). In simulations, if Black patients in this sample were instead admitted to the same hospitals as White patients in the same distribution, their rate of mortality or discharge to hospice would decline from the observed rate of 13.48% to the simulated rate of 12.23% (95% CI for difference, 1.20%-1.30%). Conclusions and Relevance: This cohort study found that Black patients hospitalized with COVID-19 had higher rates of hospital mortality or discharge to hospice than White patients after adjustment for the personal characteristics of those patients. However, those differences were explained by differences in the hospitals to which Black and White patients were admitted.

Place and Underlying Cause of Death During the COVID-19 Pandemic: Retrospective Cohort Study of 3.5 Million Deaths in England and Wales, 2014 to 2020.

OBJECTIVE: To describe the place and cause of death during the coronavirus disease 2019 (COVID-19) pandemic to assess its impact on excess mortality. METHODS: This national death registry included all adult (aged ≥18 years) deaths in England and Wales between January 1, 2014, and June 30, 2020. Daily deaths during the COVID-19 pandemic were compared against the expected daily deaths, estimated with use of the Farrington surveillance algorithm for daily historical data between 2014 and 2020 by place and cause of death. RESULTS: Between March 2 and June 30, 2020, there was an excess mortality of 57,860 (a proportional increase of 35%) compared with the expected deaths, of which 50,603 (87%) were COVID-19 related. At home, only 14% (2267) of the 16,190 excess deaths were related to COVID-19, with 5963 deaths due to cancer and 2485 deaths due to cardiac disease, few of which involved COVID-19. In care homes or hospices, 61% (15,623) of the 25,611 excess deaths were related to COVID-19, 5539 of which were due to respiratory disease, and most of these (4315 deaths) involved COVID-19. In the hospital, there were 16,174 fewer deaths than expected that did not involve COVID-19, with 4088 fewer deaths due to cancer and 1398 fewer deaths due to cardiac disease than expected. CONCLUSION: The COVID-19 pandemic has resulted in a large excess of deaths in care homes that were poorly characterized and likely to be the result of undiagnosed COVID-19. There was a smaller but important and ongoing excess in deaths at home, particularly from cancer and cardiac disease, suggesting public avoidance of hospital care for non-COVID-19 conditions.

COVID-19 Pandemic Impacts on U.S. Hospice Agencies: A National Survey of Hospice Nurses and Physicians.

BACKGROUND: Hospice agencies face unique challenges during times of widespread public health emergencies. The pandemic of novel coronavirus disease COVID-19 is widely affecting global healthcare systems. AIM: This study assesses effects of the COVID-19 pandemic on U.S. hospice agencies, staff, and patients as reported by hospice agency staff. DESIGN: An anonymous electronic survey was developed. Free-text comments were assessed for impacts on hospice agencies, staff, and patients and their families. SETTING/PARTICIPANTS: The target audience was members of the American Academy of Hospice and Palliative Medicine and the Hospice and Palliative Nurses Association who self-identified as being active with hospice agencies in the United States. RESULTS: Reported impacts include inadequate supplies of personal protective equipment, changes in hospice services, and decreased access by hospice personnel to patients in long term care facilities. Flow of patients through hospice care settings was impeded. Agencies experienced changes in workforce availability and increased emotional support needs of staff. Patient and families experienced increased bereavement needs. Nearly one-third of respondents reported negative effects on patient outcomes, such as inadequate symptom management and negative psychosocial effects. CONCLUSION: Respondents indicate that the COVID-19 pandemic had negative effects on both hospice patient care and hospice agency functioning. Hospice agencies appear to face challenges unique among U.S. healthcare agencies due to their service delivery model and focus on interdisciplinary care. There is need for further exploration of the effects that the COVID-19 pandemic has on hospice agencies in order to improve care for their patient population during public health emergencies.

An audit of end-of-life symptom control in patients with corona virus disease 2019 (COVID-19) dying in a hospital in the United Kingdom.

BACKGROUND: The literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these. AIM: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19. DESIGN: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments. SETTING/PARTICIPANTS: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died). RESULTS: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10-20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death. CONCLUSION: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.

Impact of the COVID-19 Pandemic on the Utilization of Hospice Care Services: A Cohort Study in Taiwan.

CONTEXT: Hospice care focuses on improving the quality of end-of-life care and respecting patients' preferences regarding end-of-life treatment. The impact of coronavirus disease 2019 (COVID-19) on the utilization of hospice services is unknown. OBJECTIVES: To investigate the utilization of hospice care services before and during the COVID-19 pandemic. METHODS: All patients (n = 19,900) cared for at Taipei City Hospital from January 2019 to April 2020 were divided into three time points: January-April 2019 (before COVID-19), May-December 2019 (interim), and January-April 2020 (during COVID-19). This cohort study compared the monthly utilization of hospice services before and during the COVID-19 pandemic. RESULTS: There was no significant difference in hospice home visits (194 vs. 184; P = 0.686) and new enrollments (15 vs. 14; P = 0.743) to hospice home care before and during the pandemic. However, the bed occupancy rate in hospice units in the hospital was significantly reduced from 66.2% before the pandemic to 37.4% during the pandemic (P = 0.029), whereas that in nonhospice units had a nonsignificant decrease from 81.6% before the pandemic to 71.8% during the pandemic (P = 0.086). During the pandemic, the number of inpatient days was affected more severely in hospice units than in nonhospice units (-42.4% vs. -10.9%; P = 0.029). CONCLUSIONS: This study suggests that hospice home care services were maintained during the COVID-19 pandemic, while the utilization of hospice inpatient care services reduced. Home care for hospice patients is an essential component of palliative care during a pandemic.