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1.
Curr Opin Psychiatry ; 34(4): 357-362, 2021 07 01.
Article in English | MEDLINE | ID: covidwho-1636164

ABSTRACT

PURPOSE OF REVIEW: Opioid use is prevalent in the United Kingdom and prior to the COVID-19 pandemic it had been recognized that the safety of opioids was an important issue to be monitored by the UK medicines regulatory agency. With the emergence of COVID-19, this requirement has been even greater. This review was undertaken to determine the impact of the pandemic on safety and surveillance of opioids in the United Kingdom. RECENT FINDINGS: During the COVID-19 pandemic, the surveillance of opioids in the United Kingdom continued, although primary research was often conducted with data prior to the pandemic. Of those studies that were conducted while the pandemic was ongoing, access to opioids (or opioid substitution therapy) and the subsequent effect on patient safety was the main theme. SUMMARY: In the United Kingdom, changes in accessibility to the healthcare system and how healthcare providers operated during the COVID-19 pandemic may have had unintended consequences on use and safety of opioids, due to the shift in focus to preventing COVID-19 from overwhelming the healthcare system. The findings from this review support the need to continue surveillance in the United Kingdom, including the impact of the COVID-19 pandemic on opioid utilization and safety.


Subject(s)
Analgesics, Opioid/administration & dosage , COVID-19/prevention & control , Drug Misuse/prevention & control , Opiate Substitution Treatment/methods , Opioid-Related Disorders/prevention & control , Analgesics, Opioid/adverse effects , Health Services Accessibility , Humans , Opioid-Related Disorders/therapy , Palliative Care/methods , Pandemics , SARS-CoV-2 , Terminal Care/methods , United Kingdom/epidemiology
2.
Crit Care Med ; 49(10): e1037-e1039, 2021 10 01.
Article in English | MEDLINE | ID: covidwho-1475866

ABSTRACT

OBJECTIVES: To determine if a restrictive visitor policy inadvertently lengthened the decision-making process for dying inpatients without coronavirus disease 2019. DESIGN: Regression discontinuity and time-to-event analysis. SETTING: Two large academic hospitals in a unified health system. PATIENTS OR SUBJECTS: Adult decedents who received greater than or equal to 1 day of ICU care during their terminal admission over a 12-month period. INTERVENTIONS: Implementation of a visit restriction policy. MEASUREMENTS AND MAIN RESULTS: We identified 940 adult decedents without coronavirus disease 2019 during the study period. For these patients, ICU length of stay was 0.8 days longer following policy implementation, although this effect was not statistically significant (95% CI, -2.3 to 3.8; p = 0.63). After excluding patients admitted before the policy but who died after implementation, we observed that ICU length of stay was 2.9 days longer post-policy (95% CI, 0.27-5.6; p = 0.03). A time-to-event analysis revealed that admission after policy implementation was associated with a significantly longer time to first do not resuscitate/do not intubate/comfort care order (adjusted hazard ratio, 2.2; 95% CI, 1.6-3.1; p < 0.0001). CONCLUSIONS: Policies restricting family presence may lead to longer ICU stays and delay decisions to limit treatment prior to death. Further policy evaluation and programs enabling access to family-centered care and palliative care during the ongoing coronavirus disease 2019 pandemic are imperative.


Subject(s)
COVID-19/mortality , Decision Making , Health Policy , Visitors to Patients/statistics & numerical data , Adult , Aged , COVID-19/complications , COVID-19/psychology , Critical Illness/mortality , Critical Illness/therapy , Female , Humans , Male , Middle Aged , Terminal Care/methods , Terminal Care/psychology , Terminal Care/standards
4.
PLoS One ; 16(7): e0254056, 2021.
Article in English | MEDLINE | ID: covidwho-1327975

ABSTRACT

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic is posing major challenges for health care systems. In Germany, one such challenge has been that adequate palliative care for the severely ill and dying (with and without COVID-19), as well as their loved ones, has not been available at all times and in all settings., the pandemic has underlined the significance of the contribution of general practitioners (GPs) to the care of severely ill and dying patients. OBJECTIVES: To describe GPs' experiences, challenges and perspectives with respect to end-of-life care during the first peak of the pandemic (spring 2020) in Germany. MATERIALS AND METHODS: In November and December 2020, a link to an Unipark online survey was sent to GPs registered on nationwide distribution lists. RESULTS: In total, 410 GPs responded; 61.5% indicated that the quality of their patients' end-of-life care was maintained throughout the pandemic, 36.8% reported a decrease in quality compared to pre-pandemic times. Of the GPs who made home visits to severely ill and dying patients, 61.4% reported a stable number of visits, 28.5% reported fewer visits. 62.7% of the GPs reported increased telephone contact and reduced personal contact with patients; 36.1% offered video consultations in lieu of face-to-face contact. The GPs reported that relatives were restricted (48.5%) or prohibited from visiting (33.4%) patients in nursing homes. They observed a fear of loneliness among patients in nursing homes (91.9%), private homes (87.3%) and hospitals (86.1%). CONCLUSIONS: The present work provides insights into the pandemic management of GPs and supports the development of a national strategy for palliative care during a pandemic. To effectively address end-of-life care, GPs and palliative care specialists should be involved in COVID-19 task forces on micro, meso and macro levels of health care.


Subject(s)
COVID-19/psychology , General Practitioners , Terminal Care/methods , Aged , Attitude of Health Personnel , COVID-19/epidemiology , Female , General Practitioners/psychology , General Practitioners/statistics & numerical data , Germany/epidemiology , Humans , Male , Middle Aged , Palliative Care/methods , Palliative Care/psychology , Palliative Care/trends , Referral and Consultation , SARS-CoV-2/isolation & purification , Surveys and Questionnaires , Telephone , Terminal Care/statistics & numerical data
7.
J Soc Work End Life Palliat Care ; 17(2-3): 173-185, 2021.
Article in English | MEDLINE | ID: covidwho-1177220

ABSTRACT

Comfort care homes are community-run, residential homes that provide end-of-life care to terminally ill individuals who lack safe, secure housing and a reliable caregiver system. As nonprofit, non-medical facilities, these homes have faced both new and magnified challenges due to the COVID-19 pandemic. This article highlights the value of collaborative interagency partnerships and shares reflections on the unique pandemic pressures faced by comfort care homes. Innovative ideas for improving community-based end-of-life care and implications for social work practice are included.


Subject(s)
COVID-19/therapy , Caregivers/psychology , Nursing Homes/organization & administration , Patient Comfort/methods , Terminal Care/methods , COVID-19/psychology , Clinical Competence , Humans , Palliative Care/methods , Terminal Care/psychology
8.
J Healthc Qual Res ; 36(3): 156-159, 2021.
Article in Spanish | MEDLINE | ID: covidwho-1099180

ABSTRACT

INTRODUCTION: The SARS-CoV-2 pandemic has generated a mortality rate 10times higher than normal influenza according to the World Health Organization (WHO), yet they do not mention palliative care in their action guidelines on maintaining essential health services during this crisis. The aim of this study was to analyse the death process of patients who died from SARS-CoV-2 at the Hospital Costa del Sol. MATERIAL AND METHODS: Descriptive cross-sectional study of the period in which all patients who died of SARS-CoV-2 from February to April 2020 were analysed. Sociodemographic characteristics, sample characterization and a set of variables related to the death process were collected in the death event. RESULTS: A total of 16 deaths were recorded out of a total of 103 admissions positive for SARS-CoV-2. Limitation of therapeutic effort was decided in 68.8% of the patients, and admission to the intensive care unit was refused in 56.3%. Support devices had not been removed in any of the cases on the day of death, 43.8% had palliative sedation, and 18.8% were in induced coma. CONCLUSIONS: Quality standards were maintained in the death process in patients who died from SARS-CoV-2, although there were aspects that could be improved. Palliative care is an essential component of the response to SARS-CoV-2 that must be incorporated into all health care settings.


Subject(s)
COVID-19/physiopathology , Death , Palliative Care , SARS-CoV-2 , Terminal Care/methods , Advance Care Planning , Aged , Aged, 80 and over , COVID-19/mortality , COVID-19/therapy , Coma/chemically induced , Comorbidity , Critical Care/methods , Cross-Sectional Studies , Female , Humans , Male , Palliative Care/statistics & numerical data , Parenteral Nutrition , Patient Isolation , Respiration, Artificial , Resuscitation , Socioeconomic Factors , Spain/epidemiology , Terminal Care/statistics & numerical data , Visitors to Patients , Withholding Treatment
9.
Adv Drug Deliv Rev ; 160: 234-243, 2020.
Article in English | MEDLINE | ID: covidwho-1023400

ABSTRACT

The Coronavirus disease 2019 (COVID-19) pandemic has led to a surge in need for alternative routes of administration of drugs for end of life and palliative care, particularly in community settings. Transmucosal routes include intranasal, buccal, sublingual and rectal. They are non-invasive routes for systemic drug delivery with the possibility of self-administration, or administration by family caregivers. In addition, their ability to offer rapid onset of action with reduced first-pass metabolism make them suitable for use in palliative and end-of-life care to provide fast relief of symptoms. This is particularly important in COVID-19, as patients can deteriorate rapidly. Despite the advantages, these routes of administration face challenges including a relatively small surface area for effective drug absorption, small volume of fluid for drug dissolution and the presence of a mucus barrier, thereby limiting the number of drugs that are suitable to be delivered through the transmucosal route. In this review, the merits, challenges and limitations of each of these transmucosal routes are discussed. The goals are to provide insights into using transmucosal drug delivery to bring about the best possible symptom management for patients at the end of life, and to inspire scientists to develop new delivery systems to provide effective symptom management for this group of patients.


Subject(s)
COVID-19/drug therapy , COVID-19/epidemiology , Drug Delivery Systems/methods , Palliative Care/methods , Terminal Care/methods , Administration, Mucosal , COVID-19/metabolism , Humans , Pandemics
13.
Cuad Bioet ; 31(102): 203-222, 2020.
Article in Spanish | MEDLINE | ID: covidwho-761285

ABSTRACT

The crisis in the health system caused by COVID-19 has left some important humanitarian deficits on how to care for the sick in their last days of life. The humanization of the dying process has been affected in three fundamental aspects, each of which constitutes a medical and ethical duty necessary. In this study, I analyze why dying accompanied, with the possibility of saying goodbye and receiving spiritual assistance, constitutes a specific triad of care and natural obligations that should not be overlooked - even in times of health crisis - if we do not want to see human dignity violated and violated some fundamental rights derived from it.


Subject(s)
Attitude to Death , Betacoronavirus , Coronavirus Infections , Pandemics , Pneumonia, Viral , Spirituality , Terminal Care/ethics , COVID-19 , Dehumanization , Emotions , Humans , Interpersonal Relations , Moral Obligations , Palliative Care , Patient Comfort , Patient Isolation/ethics , Patient Rights , Personhood , Physician's Role , Religion , SARS-CoV-2 , Terminal Care/methods , Terminal Care/psychology , Visitors to Patients
14.
Am J Hosp Palliat Care ; 37(11): 992-997, 2020 Nov.
Article in English | MEDLINE | ID: covidwho-696572

ABSTRACT

Telemedicine technology has become essential to healthcare delivery in the COVID-19 era, but concerns remain regarding whether the intimacy and communication that is central to high-quality palliative care will be compromised by the use of this technology. We employed a business model approach to identify the need for system innovation in palliative care, and a quality improvement approach to structure the project. Products from this project included a standard operating procedure for safe use of tablet computers for inpatient palliative care consultations and family visitations; tablet procurement with installation of video telehealth software; and training and education for clinical staff and other stakeholders. We describe a case illustrating the successful use of palliative care telehealth in the care of a COVID-19-positive patient at the end of life. Successful use of video telehealth for palliative care involved overcoming inertia to the development of telehealth infrastructure and learning clinical video telehealth skills; and engaging front-line care staff and family members who were open to a trial of telehealth for communication. Information gleaned from family about the patient as a person helped bedside staff to tailor care toward aspects meaningful to the patient and family and informed best practices to incorporate intimacy into future palliative video consultations and family visit.


Subject(s)
Betacoronavirus , Coronavirus Infections/therapy , Palliative Care/methods , Pneumonia, Viral/therapy , Telemedicine/methods , Terminal Care/methods , COVID-19 , Family/psychology , Humans , Male , Pandemics , Quality Improvement , SARS-CoV-2 , Visitors to Patients
15.
Palliat Med ; 34(9): 1235-1240, 2020 10.
Article in English | MEDLINE | ID: covidwho-616769

ABSTRACT

BACKGROUND: Hospital clinicians have had to rapidly develop expertise in managing the clinical manifestations of COVID-19 including symptoms common at the end of life, such as breathlessness and agitation. There is limited evidence exploring whether end-of-life symptom control in this group requires new or adapted guidance. AIM: To review whether prescribing for symptom control in patients dying with COVID-19 adhered to existing local guidance or whether there was deviation which may represent a need for revised guidance or specialist support in particular patient groups. DESIGN/SETTING: A retrospective review of the electronic patient record of 61 hospital inpatients referred to the specialist palliative care team with swab-confirmed COVID-19 who subsequently died over a 1-month period. Intubated patients were excluded. RESULTS: In all, 83% (40/48) of patients were prescribed opioids at a starting dose consistent with existing local guidelines. In seven of eight patients where higher doses were prescribed, this was on specialist palliative care team advice. Mean total opioid dose required in the last 24 h of life was 14 mg morphine subcutaneous equivalent, and mean total midazolam dose was 9.5 mg. For three patients in whom non-invasive ventilation was in place higher doses were used. CONCLUSION: Prescription of end-of-life symptom control drugs for COVID-19 fell within the existing guidance when supported by specialist palliative care advice. While some patients may require increased doses, routine prescription of higher starting opioid and benzodiazepine doses beyond existing local guidance was not observed.


Subject(s)
Biopharmaceutics/statistics & numerical data , Coronavirus Infections/drug therapy , Delirium/drug therapy , Dyspnea/drug therapy , Pneumonia, Viral/drug therapy , Practice Guidelines as Topic , Terminal Care/methods , Terminal Care/standards , Adult , Aged , Aged, 80 and over , Analgesics, Opioid/therapeutic use , Betacoronavirus , COVID-19 , Female , Humans , Hypnotics and Sedatives/therapeutic use , Male , Midazolam/therapeutic use , Middle Aged , Morphine/therapeutic use , Pandemics , Retrospective Studies , SARS-CoV-2
16.
BMJ Support Palliat Care ; 10(3): 343-349, 2020 Sep.
Article in English | MEDLINE | ID: covidwho-602096

ABSTRACT

BACKGROUND: Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. AIMS AND OBJECTIVES: To investigate UK and Ireland clinicians' experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. METHODS: Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. RESULTS: Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. CONCLUSIONS: The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.


Subject(s)
Caregivers , Drug Administration Routes , Palliative Care/methods , Practice Patterns, Physicians'/statistics & numerical data , Terminal Care/methods , Administration, Buccal , Administration, Sublingual , Analgesics, Non-Narcotic/administration & dosage , Analgesics, Opioid/administration & dosage , Betacoronavirus , COVID-19 , Coronavirus Infections/epidemiology , Fentanyl/administration & dosage , General Practitioners , Hospice Care/methods , Hospices , Humans , Hypnotics and Sedatives/administration & dosage , Ireland/epidemiology , Lorazepam/administration & dosage , Methotrimeprazine/administration & dosage , Muscarinic Antagonists/administration & dosage , Nurse Specialists , Palliative Medicine , Pandemics , Physicians , Pneumonia, Viral/epidemiology , Practice Guidelines as Topic , SARS-CoV-2 , Surveys and Questionnaires , Telemedicine/methods , Transdermal Patch , United Kingdom/epidemiology
17.
BMJ Support Palliat Care ; 11(1): 40-44, 2021 Mar.
Article in English | MEDLINE | ID: covidwho-596028

ABSTRACT

The COVID-19 pandemic is expected to surpass the healthcare system's capacity to provide intensive care to all patients who deteriorate as a result of the disease. This poses a unique challenge to healthcare teams of rationing care during pandemic when resources are scarce. Healthcare providers will need to acquire new skills in care decision making and effective symptom control for patients who do not receive life-saving measures. In this review, we describe some of the important palliative care considerations that need to be incorporated into COVID-19 pandemic planning. The main aspects to be considered include decision algorithms for rationing care, training on effective symptoms management, alternative delivery methods of palliative care services such as telemedicine and finally death and bereavement support for surviving family members who are likely to be isolated from their loved one at the moment of death.


Subject(s)
COVID-19/therapy , Delivery of Health Care , Health Care Rationing , Hospice Care/methods , Palliative Care/methods , Terminal Care/methods , Algorithms , Clinical Decision-Making , Family , Health Personnel , Health Planning , Humans , Pandemics , SARS-CoV-2 , Telemedicine , United States
19.
J Pain Symptom Manage ; 60(2): e70-e74, 2020 Aug.
Article in English | MEDLINE | ID: covidwho-197457

ABSTRACT

Bereavement care is considered an integral component of quality end-of-life care endorsed by the palliative care movement. However, few hospitals and health care institutions offer universal bereavement care to all families of patients who die. The current coronavirus disease 2019 pandemic has highlighted this gap and created a sense of urgency, from a public health perspective, for institutions to provide support to bereaved family members. In this article, drawing on the palliative care and bereavement literature, we offer suggestions about how to incorporate palliative care tools and psychological strategies into bereavement care for families during this pandemic.


Subject(s)
Bereavement , Coronavirus Infections , Family/psychology , Pandemics , Pneumonia, Viral , COVID-19 , Cognitive Behavioral Therapy , Coronavirus Infections/psychology , Coronavirus Infections/therapy , Humans , Palliative Care/methods , Palliative Care/psychology , Pneumonia, Viral/psychology , Pneumonia, Viral/therapy , Terminal Care/methods , Terminal Care/psychology
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