A recent article published in the British Medical Journal (BMJ) highlights palliative care strategies that can be used alongside pharmacological management of patients of severe COVID-19 as an anticipatory approach, irrespective of prognosis. The authors discuss management of agitation and anxiety in patients, development of urgent care plans, pointers for effective communication on patient status with families.

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The new coronavirus infection can cause a lot of distress among patients, primarily because of the symptoms and isolation adding to it. As per an article published in BMJ, palliative care for those suffering is important, no matter the nature of prognosis. The article titled ‘Palliative Care for Patients with Severe COVID-19’, authored by Ting R, Edmonds P, Higginson IJ, Sleeman KE guides medical professionals on how to incorporate palliative care at different stages of the treatment of COVID-19 patients.

The condition of patients with severe COVID-19 can deteriorate rapidly. Then there can be cases, for which escalation of medical treatment beyond intensive care may not help. Palliative management of patients in such scenarios can play an important role. While palliative care can be relevant even to patients who are not necessarily dying of an illness, this article only covers palliation for such critically ill patients, who may not benefit from high-dependency care in a hospital setting.

Palliation for patients of severe COVID-19 infection can help them deal with the difficulties of breathlessness or ARDS, and other pharmacological treatment-related anxiety that they may experience. Isolation and lack of communication with their loved ones can also trigger anxiety in them, and palliative care can offer the patient moral support in such situations and put them at ease. In the case of rapid deterioration of health, a member of the palliative care team can be the communication link between him and the family.

Palliative care strategies based on patient symptoms

Breathlessness: Palliative care involves communicating with the patient in a calm and a reassuring tone. The staff can apply cool wipes on the patient’s face and ensure safe disposal after each use. If prescribed, the staff can help the patient use the prone position for relief while experiencing breathlessness.

While administering oxygen therapy: Oxygen therapy calls for an individualised approach. Whether the patient has hypoxaemia or is on non-invasive ventilator support, palliative care can make them feel lesser stress or pain through the suffering. Observing the patient and checking on what makes them feel better can be covered by the palliative care staff and reported further for appropriate medical treatment.

Handling patient agitation and anxiety: Aside from the distressing symptoms, the isolation, not being able to meet family members, and the absence of ‘care’ as per pre-conceived notions (as in normal, non-pandemic situation), can make the patient highly anxious. Over time, it may also become difficult to handle the patient due to his agitation in such surroundings and that may lead to a refusal of receiving the necessary medical treatment.

1. Palliative staff can play a role in alleviating the patient’s feeling of loneliness and the resulting anxiety by arranging communication through video calls with his family members.
2. Much of the feeling of alienation among patients (due to mandatory isolation) can be eliminated if healthcare professionals could wear badges with their names and have their photos printed and pinned to their PPEs.
3. Palliative staff can help a patient understand the treatment they are receiving and how it can help them recover faster. Such a conversation with the patient can also help address a patient’s fear of dying due to COVID-19.

In case of deterioration of health and death: In a situation where the patient’s condition is worsening despite treatment, an acute medical treatment plan should be devised. However, alongside such a plan, a holistic palliative care plan must also be figured out.

1. The palliative staff has to be honest if the patient is not going to survive, but convey it to him in a kind and gentle manner to keep him from feeling aggressive or refusing treatment.
2. The palliative team member can ensure the dying patient has communicated his wishes or what is important to him, to his family.
3. If the patient is not capable of communicating anymore, the healthcare staff should explore any previously stated preferences or any information that was probably communicated to their friends or family, and accordingly make decisions in their best interest.
4. The member should also inform the family about the status of the patient in a timely manner, with clarity and compassion. This helps them convey their thoughts to their loved ones.

Key points for creating a holistic urgent care plan

Find out if the patient has ever expressed or formally documented preferences for managing a life-threatening condition. This includes whether they have legally appointed a surrogate decision-maker or created a legally binding document specifying treatment preferences (such as an advance decision to refuse treatment)

1. Explain the medical treatment escalation plan, including whether cardiopulmonary resuscitation, respiratory support, and other organ support in intensive care are medically appropriate.
2. Explain that, alongside the treatment escalation plan, there will be a plan in place for symptom management to ensure the patient’s comfort whatever the outcome maybe.
3. Ask: “Knowing what you know now of your situation, is there anything else important to you at this time?”
4. Ask: “Who should we contact in the event that you are unwell?” Ensure that their contact details are recorded clearly. (verbatim)

Communicating with patients and families

1. It is essential to communicate with patients and their immediate family members and clearly inform them of important updates in a timely manner. The frequency of communication should depend upon the condition of the patient, especially if it is worsening.
2. Talking through PPEs could lead to unclear communication. Patients should be provided some equipment to hear the healthcare staff clearly or be supported by a continuous positive airway pressure machine or high-flow oxygen to tackle the problem.
3. Video calls are highly effective when it comes to contacting relatives for conveying sensitive messages; the authors highlight the importance of ‘therapeutic presence’ of a healthcare professional in front of the family, even if virtual while conveying important messages.
4. Dealing with families while their loved one, the patient may not survive, requires healthcare professionals to balance their hope and worries. They can do this by talking in a compassionate manner and for conveying harsh truths or sensitive information, use phrases that reflect empathy.
5. The article recommends the use of the phrase “sick enough to die” for conveying the weakening of the patient’s health and acknowledging uncertainty.

Palliation may also be required in dealing with unprecedented situations that the family of a deceased patient may have to face. For example, not being able to see a loved one before his death, not expecting the death of a young relative, and not being able to attend the funeral. Such situations demand the palliative staff supports the family in their time of shock and grief. To do so, the staff can:

• Facilitate a video call or call between the patient and relatives so they can bid their final good-byes, and/or,
• Make provision for emotional and spiritual support before the death of their loved one

Support for Healthcare Professionals

Physical burnout and emotional distress are common for healthcare workers, especially in a case where the number of deaths are too many and frequent. When they are constantly exposed to grief in their surroundings, it may lead to breakdowns and anxiety among them. Hence, lending support to each other in these difficult times and acknowledging the anxiety by talking about it should be encouraged.