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1.
Can J Anaesth ; 67(10): 1417-1423, 2020 10.
Article in English | MEDLINE | ID: covidwho-1777840

ABSTRACT

Symptom management and end-of-life care are core skills for all physicians, although in ordinary times many anesthesiologists have fewer occasions to use these skills. The current coronavirus disease (COVID-19) pandemic has caused significant mortality over a short time and has necessitated an increase in provision of both critical care and palliative care. For anesthesiologists deployed to units caring for patients with COVID-19, this narrative review provides guidance on conducting goals of care discussions, withdrawing life-sustaining measures, and managing distressing symptoms.


RéSUMé: La prise en charge des symptômes et les soins de fin de vie sont des compétences de base pour tous les médecins, bien qu'en temps ordinaire, de nombreux anesthésiologistes n'ont que peu d'occasions de mettre en pratique ces compétences. La pandémie actuelle de coronavirus 2019 (COVID-19) a provoqué un taux de mortalité significatif dans un court intervalle et a nécessité une augmentation des besoins en soins intensifs et en soins palliatifs. Destiné aux anesthésiologistes déployés dans les unités prenant soin de patients atteints de la COVID-19, ce compte rendu narratif offre des recommandations quant à la façon de mener les discussions à propos des objectifs de soins, du retrait des thérapies de soutien vital, et de la prise en charge de symptômes de détresse.


Subject(s)
Coronavirus Infections/therapy , Critical Care/organization & administration , Pneumonia, Viral/therapy , Terminal Care/organization & administration , Anesthesiologists/organization & administration , Anesthesiologists/standards , COVID-19 , Clinical Competence , Coronavirus Infections/mortality , Critical Care/standards , Humans , Palliative Care/organization & administration , Pandemics , Physicians/organization & administration , Physicians/standards , Pneumonia, Viral/mortality , Terminal Care/standards , Withholding Treatment
3.
J Hosp Palliat Nurs ; 23(4): 360-366, 2021 08 01.
Article in English | MEDLINE | ID: covidwho-1254921

ABSTRACT

Patients often receive burdensome care at the end of life in the form of interventions that may need to be removed. Heated high-flow oxygen delivered through a nasal cannula (HHFNC) is one such intervention that can be delivered in the hospital yet is rarely available outside of this setting. During the COVID-19 (coronavirus disease 2019) pandemic, health care systems continue to face the possibility of rationing critical life-sustaining equipment that may include HHFNC. We present a clinical protocol designed for weaning HHFNC to allow a natural death and ensuring adequate symptom management throughout the process. This was a retrospective chart review of 8 patients seen by an inpatient palliative care service of an academic tertiary referral hospital who underwent terminal weaning of HHFNC using a structured protocol to manage dyspnea. Eight patients with diverse medical diagnoses, including COVID-19 pneumonia, underwent terminal weaning of HHFNC according to the clinical protocol with 4 down-titrations of approximately 25% for both fraction of inspired oxygen and liter flow with preemptive boluses of opioid and benzodiazepine. Clinical documentation supported good symptom control throughout the weaning process. This case series provides preliminary evidence that the clinical protocol proposed has the ability to ensure comfort through terminal weaning of HHFNC.


Subject(s)
Airway Extubation/methods , Terminal Care/organization & administration , Ventilator Weaning/methods , Aged , Aged, 80 and over , Airway Extubation/nursing , Airway Extubation/psychology , COVID-19/epidemiology , COVID-19/nursing , Cannula/adverse effects , Clinical Protocols , Continuous Positive Airway Pressure/adverse effects , Female , Humans , Male , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2 , Terminal Care/psychology , Ventilator Weaning/nursing
4.
Br J Hosp Med (Lond) ; 82(4): 1-6, 2021 Apr 02.
Article in English | MEDLINE | ID: covidwho-1207923

ABSTRACT

In view of the high morbidity and mortality associated with COVID-19, early and honest conversations with patients about goals of care are vital. Advance care planning in its traditional manner may be difficult to achieve given the unpredictability of the disease trajectory. Despite this, it is crucial that patients' care wishes are explored as this will help prevent inappropriate admissions to hospital and to critical care, improve symptom control and advocate for patient choice. This article provides practical tips on how to translate decisions around treatment escalation plans into conversations, both face-to-face and over the phone, in a sensitive and compassionate manner. Care planning conversations for patients with COVID-19 should be individualised and actively involve the patient. Focusing on goals of care rather than ceilings of treatment can help to alleviate anxiety around these conversations and will remind patients that their care will never cease. Using a framework such as the 'SPIKES' mnemonic can help to structure this conversation. Verbally conveying empathy will be key, particularly when wearing personal protective equipment or speaking to relatives over the phone. It is also important to make time to recognise your own emotions during and/or after these conversations.


Subject(s)
Advance Care Planning/organization & administration , COVID-19/epidemiology , Communication , Terminal Care/organization & administration , Advance Care Planning/standards , Cardiopulmonary Resuscitation/standards , Empathy , Humans , Patient Care Planning , Personal Protective Equipment , SARS-CoV-2 , Telephone , Terminal Care/standards
6.
Pan Afr Med J ; 35(Suppl 2): 130, 2020.
Article in English | MEDLINE | ID: covidwho-1106476

ABSTRACT

The COVID-19 pandemic has strained health care systems beyond capacity resulting in many people not having access to life-sustaining measures even in well-resourced countries. Palliative and end-of-life care are therefore essential to alleviate suffering and ensure a continuum of care for patients unlikely to survive. This is challenging in sub-Saharan Africa where lack of trained teams on basic palliative care and reduced access to opioids limit implementation of palliative and end-of-life care. At the same time, health care providers have to cope with local cultural conceptions of death and absence of advance care directives.


Subject(s)
Betacoronavirus , Coronavirus Infections/therapy , Palliative Care/organization & administration , Pandemics , Pneumonia, Viral/therapy , Terminal Care/organization & administration , Advance Directives , Africa South of the Sahara/epidemiology , Analgesics, Opioid/supply & distribution , Analgesics, Opioid/therapeutic use , Attitude to Death , COVID-19 , Communication Barriers , Continuity of Patient Care , Coronavirus Infections/drug therapy , Coronavirus Infections/epidemiology , Coronavirus Infections/psychology , Culture , Health Services Accessibility , Humans , Palliative Care/psychology , Pneumonia, Viral/epidemiology , Pneumonia, Viral/psychology , Professional-Patient Relations , Respiratory Insufficiency/drug therapy , Respiratory Insufficiency/etiology , Respiratory Insufficiency/mortality , SARS-CoV-2 , Social Stigma , Terminal Care/psychology
7.
J Hosp Palliat Nurs ; 23(4): 316-322, 2021 08 01.
Article in English | MEDLINE | ID: covidwho-1091177

ABSTRACT

Palliative and end-of-life care has been pushed to the forefront of medical care during the pandemic caused by the coronavirus-2019 (COVID-19). Palliative care organizations have responded to the growing demand for the rapid dissemination of research, clinical guidance, and instructions for care to clinicians, patients with COVID-19, and their caregivers by creating COVID-19 resource Web pages. Here, end users can access resources that can be updated in real time. These Web pages, however, can be variable in what resources they offer and for whom they are designed for (clinicians, patients, caregivers). Therefore, this project was conducted to consolidate these resources via summary tables of specific contents available through each Web page grouped by palliative care domains (eg, care discussion and planning, communication, symptom management, care access) and to identify the target audience. This environmental scan was conducted by compiling a comprehensive list of COVID-19 resource Web pages of palliative care organizations generated by reviewing previously published research studies and consulting with palliative care research experts. Snowballing techniques were used to identify resource Web pages not captured in the initial scan. Two reviewers independently evaluated eligible Web pages for content via a form developed for the study, and Cohen κ statistic was calculated to ensure interrater reliability. The final κ statistic was 0.76. Of the 24 websites screened, 15 websites met our eligibility criteria. Among the eligible resource Web pages, most (n = 12, 80%) had specific target audiences and care settings, whereas the rest presented information targeted to all audiences. Although 11 Web pages offered resources that addressed all 4 domains, only 1 Web page conveyed all 12 subdomains. We recommend the use of this guide to all frontline clinicians who require guidance in clinically managing patients with COVID-19 receiving palliative care and/or end-of-life care.


Subject(s)
Advance Care Planning/organization & administration , Bibliographies as Topic , Hospice Care/organization & administration , Palliative Care/organization & administration , Terminal Care/organization & administration , COVID-19/epidemiology , COVID-19/therapy , Humans , Internet , Pandemics , SARS-CoV-2
10.
Palliat Support Care ; 18(4): 379-381, 2020 08.
Article in English | MEDLINE | ID: covidwho-940882

ABSTRACT

As the COVID-19 pandemic continues, more patients will require palliative and end-of-life care. In order to ensure goal-concordant-care when possible, clinicians should initiate goals-of-care conversations among our most vulnerable patients and, ideally, among all patients. However, many non-palliative care clinicians face deep uncertainty in planning, conducting, and evaluating such interactions. We believe that specialists within palliative care are aptly positioned to address such uncertainties, and in this article offer a relevant update to a concise framework for clinicians to plan, conduct, and evaluate goals-of-care conversations: the GOOD framework. Once familiar with this framework, palliative care clinicians may use it to educate their non-palliative care colleagues about a timely and critical component of care, now and beyond the COVID-19 era.


Subject(s)
Coronavirus Infections/therapy , Hospice and Palliative Care Nursing/organization & administration , Organizational Objectives , Palliative Care/organization & administration , Patient Care Planning/organization & administration , Pneumonia, Viral/therapy , Terminal Care/organization & administration , Uncertainty , Betacoronavirus , COVID-19 , Humans , Pandemics , SARS-CoV-2
12.
J Pain Symptom Manage ; 61(1): e11-e19, 2021 01.
Article in English | MEDLINE | ID: covidwho-838915

ABSTRACT

CONTEXT: Although the coronavirus disease 2019 (COVID-19) pandemic might affect important clinical routines, few studies have focused on the maintenance of good quality in end-of-life care. OBJECTIVES: The objective was to examine whether adherence to clinical routines for good end-of-life care differed for deaths because of COVID-19 compared with a reference cohort from 2019 and whether they differed between nursing homes and hospitals. METHODS: Data about five items reflecting clinical routines for persons who died an expected death from COVID-19 during the first three months of the pandemic (March-May 2020) were collected from the Swedish Register of Palliative Care. The items were compared between the COVID-19 group and the reference cohort and between the nursing home and hospital COVID-19 deaths. RESULTS: About 1316 expected deaths were identified in nursing homes and 685 in hospitals. Four of the five items differed for total COVID-19 group compared with the reference cohort: fewer were examined by a physician during the last days before death, pain and oral health were less likely to be assessed, and fewer had a specialized palliative care team consultation (P < 0.0001, respectively). Assessment of symptoms other than pain did not differ significantly. The five items differed between the nursing homes and hospitals in the COVID-19 group, most notably regarding the proportion of persons examined by a physician during the last days (nursing homes: 18%; hospitals: 100%). CONCLUSION: This national register study shows that several clinical routines for end-of-life care did not meet the usual standards during the first three months of the COVID-19 pandemic in Sweden. Higher preparedness for and monitoring of end-of-life care quality should be integrated into future pandemic plans.


Subject(s)
COVID-19/mortality , COVID-19/therapy , Clinical Protocols , Hospitalization , Nursing Homes , Terminal Care/organization & administration , Adolescent , Adult , Aged , Aged, 80 and over , Child , Child, Preschool , Cohort Studies , Female , Hospital Mortality , Humans , Infant , Infant, Newborn , Male , Middle Aged , Registries , Sweden/epidemiology , Young Adult
13.
Br J Nurs ; 29(17): 1044-1045, 2020 Sep 24.
Article in English | MEDLINE | ID: covidwho-797226

ABSTRACT

Lauren Oliver, formerly Clinical Nurse Advisor, NHS Nightingale North West, outlines the challenges faced by staff in providing good-quality end-of-life care for patients in a temporary hospital during the initial peak of the COVID-19 pandemic.


Subject(s)
Coronavirus Infections/therapy , Hospitals, State , Pandemics , Pneumonia, Viral/therapy , Terminal Care/organization & administration , COVID-19 , Coronavirus Infections/epidemiology , Humans , Personnel, Hospital/psychology , Pneumonia, Viral/epidemiology , State Medicine/organization & administration , United Kingdom/epidemiology
16.
Palliat Med ; 34(9): 1182-1192, 2020 10.
Article in English | MEDLINE | ID: covidwho-690848

ABSTRACT

BACKGROUND: The increased number of deaths in the community happening as a result of COVID-19 has caused primary healthcare services to change their traditional service delivery in a short timeframe. Services are quickly adapting to new challenges in the practical delivery of end-of-life care to patients in the community including through virtual consultations and in the provision of timely symptom control. AIM: To synthesise existing evidence related to the delivery of palliative and end-of-life care by primary healthcare professionals in epidemics and pandemics. DESIGN: Rapid systematic review using modified systematic review methods, with narrative synthesis of the evidence. DATA SOURCES: Searches were carried out in Medline, Embase, PsychINFO, CINAHL and Web of Science on 7th March 2020. RESULTS: Only five studies met the inclusion criteria, highlighting a striking lack of evidence base for the response of primary healthcare services in palliative care during epidemics and pandemics. All were observational studies. Findings were synthesised using a pandemic response framework according to 'systems' (community providers feeling disadvantaged in terms of receiving timely information and protocols), 'space' (recognised need for more care in the community), 'staff' (training needs and resilience) and 'stuff' (other aspects of managing care in pandemics including personal protective equipment, cleaning care settings and access to investigations). CONCLUSIONS: As the COVID-19 pandemic progresses, there is an urgent need for research to provide increased understanding of the role of primary care and community nursing services in palliative care, alongside hospices and community specialist palliative care providers.


Subject(s)
Coronavirus Infections/therapy , Delivery of Health Care/organization & administration , Health Personnel/psychology , Hospice and Palliative Care Nursing/organization & administration , Palliative Care/organization & administration , Pneumonia, Viral/therapy , Primary Health Care/organization & administration , Terminal Care/organization & administration , Adult , COVID-19 , Epidemics , Female , Humans , Male , Middle Aged , Pandemics , Professional Role
18.
Eur J Cancer ; 136: 95-98, 2020 09.
Article in English | MEDLINE | ID: covidwho-640854

ABSTRACT

The lack of integration between public health approaches, cancer care and palliative and end-of-life care in the majority of health systems globally became strikingly evident in the context of the coronavirus disease 2019 (COVID-19) pandemic. At the same time, the collapse of the boundaries between these domains imposed by the pandemic created unique opportunities for intersectoral planning and collaboration. While the challenge of integration is not unique to oncology, the organisation of cancer care and its linkages to palliative care and to global health may allow it to be a demonstration model for how the problem of integration can be addressed. Before the pandemic, the large majority of individuals with cancer in need of palliative care in low- and middle-income countries and the poor or marginalised in high-income countries were denied access. This inequity was highlighted by the COVID-19 pandemic, as individuals in impoverished or population-dense settings with weak health systems have been more likely to become infected and to have less access to medical care and to palliative and end-of-life care. Such inequities deserve attention by government, financial institutions and decision makers in health care. However, there has been no framework in most countries for integrated decision-making that takes into account the requirements of public health, clinical medicine and palliative and end-of-life care. Integrated planning across these domains at all levels would allow for more coordinated resource allocation and better preparedness for the inevitability of future systemic threats to population health.


Subject(s)
Coronavirus Infections/epidemiology , Delivery of Health Care/organization & administration , Healthcare Disparities , Medical Oncology/organization & administration , Neoplasms/therapy , Palliative Care/organization & administration , Pneumonia, Viral/epidemiology , Public Health , Terminal Care/organization & administration , Betacoronavirus , COVID-19 , Health Services Accessibility , Humans , Pandemics , SARS-CoV-2
19.
J Am Geriatr Soc ; 68(10): 2196-2197, 2020 10.
Article in English | MEDLINE | ID: covidwho-635389
20.
Hastings Cent Rep ; 50(3): 71-72, 2020 May.
Article in English | MEDLINE | ID: covidwho-619891

ABSTRACT

Ethicists and physicians all over the world have been working on triage protocols to plan for the possibility that the Covid-19 pandemic will result in shortages of intensive care unit beds, ventilators, blood products, or medications. In reflecting on those protocols, many health care workers have noticed that, outside the pandemic shortage situation, we routinely supply patients in the ICU with invasive and painful care that will not help the patients survive even their hospitalization. This is the kind of pointless care that even the most basic protocol would triage against. Perhaps this widespread reflection on triage standards will draw our attention to our ongoing custom of supplying burdensome and inefficacious care to those near the end of life-care that most health care providers would not want for themselves. This essay argues that reflecting on triage could help us improve end-of-life care.


Subject(s)
Coronavirus Infections/epidemiology , Health Care Rationing/ethics , Intensive Care Units/ethics , Pneumonia, Viral/epidemiology , Terminal Care/ethics , Triage/ethics , Betacoronavirus , COVID-19 , Health Care Rationing/organization & administration , Humans , Intensive Care Units/organization & administration , Pandemics , SARS-CoV-2 , Terminal Care/organization & administration , Triage/organization & administration
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