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Turner J, Eliot Hodgson L, Leckie T, Eade L, Ford-Dunn S. A Dual-Center Observational Review of Hospital-Based Palliative Care in Patients Dying With COVID-19. J Pain Symptom Manage 2020; 60:e75-e78. [PMID: 32387139 PMCID: PMC7200379 DOI: 10.1016/j.jpainsymman.2020.04.031] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 04/25/2020] [Accepted: 04/28/2020] [Indexed: 01/08/2023]
Abstract
The current coronavirus disease 2019 (COVID-19) pandemic has put significant strain on all aspects of health care delivery, including palliative care services. Given the high mortality from this disease, particularly in the more vulnerable members of society, it is important to examine how best to deliver a high standard of end-of-life care during this crisis. This case series collected data from two acute hospitals examining the management of patients diagnosed with COVID-19 who subsequently died (n = 36) and compared this with national and local end-of-life audit data for all other deaths. Our results demonstrated a shorter dying phase (38.25 hours vs. 74 hours) and higher rates of syringe driver use (72% vs. 33% in local audits), although with similar average mediation doses. Of note was the significant heterogeneity in the phenotype of deterioration in the dying phase, two distinct patterns emerged, with one group demonstrating severe illness with a short interval between symptom onset and death and another group presenting with a more protracted deterioration. This brief report suggests a spectrum of mode of dying. Overall, the cohort reflects previously described experiences, with increased frailty (median Clinical Frailty Scale score of 5) and extensive comorbidity burden. This brief report provides clinicians with a contemporaneous overview of our experience, knowledge, and pattern recognition when caring for people with COVID-19 and highlights the value of proactive identification of patients and risk of deterioration and palliation.
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Affiliation(s)
- Jennifer Turner
- ST5 Geriatric Medicine, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
| | - Luke Eliot Hodgson
- Intensive Care Department, Worthing Hospital Western Sussex Hospitals NHS Foundation Trust, Worthing, UK; Faculty of Health & Medical Sciences, University of Surrey, Guildford, UK
| | - Todd Leckie
- ST3 Anaesthetics, Intensive Care Department, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK
| | - Lisa Eade
- Palliative Care, St Richards Hospital, Western Sussex Hospitals NHS Foundation Trust, Chichester, UK
| | - Suzanne Ford-Dunn
- Palliative Medicine, Worthing Hospital, Western Sussex Hospitals NHS Foundation Trust, Worthing, UK; St Barnabas House Hospice, Worthing, UK.
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Rosa WE, Gray TF, Chow K, Davidson PM, Dionne-Odom JN, Karanja V, Khanyola J, Kpoeh JDN, Lusaka J, Matula ST, Mazanec P, Moreland PJ, Pandey S, de Campos AP, Meghani SH. Recommendations to Leverage the Palliative Nursing Role During COVID-19 and Future Public Health Crises. J Hosp Palliat Nurs 2020; 22:260-269. [PMID: 32511171 PMCID: PMC8018720 DOI: 10.1097/njh.0000000000000665] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
With the daily number of confirmed COVID-19 cases and associated deaths rising exponentially, social fabrics on a global scale are being worn by panic, uncertainty, fear, and other consequences of the health care crisis. Comprising more than half of the global health care workforce and the highest proportion of direct patient care time than any other health professional, nurses are at the forefront of this crisis. Throughout the evolving COVID-19 pandemic, palliative nurses will increasingly exercise their expertise in symptom management, ethics, communication, and end-of-life care, among other crucial skills. The literature addressing the palliative care response to COVID-19 has surged, and yet, there is a critical gap regarding the unique contributions of palliative nurses and their essential role in mitigating the sequelae of this crisis. Thus, the primary aim herein is to provide recommendations for palliative nurses and other health care stakeholders to ensure their optimal value is realized and to promote their well-being and resilience during COVID-19 and, by extension, in anticipation of future public health crises.
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Affiliation(s)
- William E Rosa
- William E. Rosa, PhD, MBE, ACHPN, FAANP, FAAN, is Robert Wood Johnson Foundation Future of Nursing Scholar, University of Pennsylvania School of Nursing, Philadelphia. Tamryn F. Gray, PhD, RN, is research fellow, Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts. Kimberly Chow, RN, ANP-BC, ACHPN, is nurse practitioner, Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York. Patricia M. Davidson, PhD, RN, FAAN, is dean and professor, Johns Hopkins University School of Nursing, Baltimore, Maryland. J. Nicholas Dionne-Odom, PhD, MSN, MA, ACHPN, FPCN, is assistant professor, University of Alabama at Birmingham School of Nursing; and codirector, Caregiver and Bereavement Support Services, UAB Center for Palliative and Supportive Care. Viola Karanja, BSN, RN, is deputy executive director, Partners in Health Liberia, Harper. Judy Khanyola, MSc, RCHN, is Chair, Nursing and Midwifery, University of Global Health Equity, Butaro, Rwanda. Julius D. N. Kpoeh, ASN, RN, is senior clinical mentor, Partners in Health Liberia, Harper. Joseph Lusaka, BSc HM, DCM, PA, is clinical manager, Pleebo Health Centre, Liberia. Samuel T. Matula, PhD, RN, PCNS-BC, is lecturer, University of Botswana, Gaborone. Polly Mazanec, PhD, AOCN, ACHPN, FPCN, FAAN, is research associate professor, Frances Payne Bolton School of Nursing, Case Western Reserve University, Cleveland, Ohio. Patricia J. Moreland, PhD, CPNP, FAAN, is assistant clinical professor, Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia. Shila Pandey, MSN, AGPCNP-BC, ACHPN, is nurse practitioner, Supportive Care Service, Memorial Sloan Kettering Cancer Center, New York. Amisha Parekh de Campos, PhD, MPH, CHPN, Robert Wood Johnson Foundation Future of Nursing Scholar, University of Connecticut, Storrs; quality and education coordinator, Hospice Program, Middlesex Health, Connecticut. Salimah H. Meghani, PhD, MBE, RN, FAAN, is professor and term chair of Palliative Care, University of Pennsylvania School of Nursing, Philadelphia
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53
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Selman LE, Chao D, Sowden R, Marshall S, Chamberlain C, Koffman J. Bereavement Support on the Frontline of COVID-19: Recommendations for Hospital Clinicians. J Pain Symptom Manage 2020; 60:e81-e86. [PMID: 32376262 PMCID: PMC7196538 DOI: 10.1016/j.jpainsymman.2020.04.024] [Citation(s) in RCA: 131] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 04/27/2020] [Accepted: 04/28/2020] [Indexed: 01/12/2023]
Abstract
Deaths due to COVID-19 are associated with risk factors which can lead to prolonged grief disorder, post-traumatic stress, and other poor bereavement outcomes among relatives, as well as moral injury and distress in frontline staff. Here we review relevant research evidence and provide evidence-based recommendations and resources for hospital clinicians to mitigate poor bereavement outcomes and support staff. For relatives, bereavement risk factors include dying in an intensive care unit, severe breathlessness, patient isolation or restricted access, significant patient and family emotional distress, and disruption to relatives' social support networks. Recommendations include advance care planning; proactive, sensitive, and regular communication with family members alongside accurate information provision; enabling family members to say goodbye in person where possible; supporting virtual communication; providing excellent symptom management and emotional and spiritual support; and providing and/or sign-posting to bereavement services. To mitigate effects of this emotionally challenging work on staff, we recommend an organizational and systemic approach which includes access to informal and professional support.
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Affiliation(s)
- Lucy E Selman
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
| | - Davina Chao
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Ryann Sowden
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Steve Marshall
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, UK; King's College Hospital NHS Foundation Trust, Palliative Care Service, London, UK
| | - Charlotte Chamberlain
- Palliative and End of Life Care Research Group, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jonathan Koffman
- Department of Palliative Care, Policy & Rehabilitation, Cicely Saunders Institute, King's College London, London, UK
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54
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Stall NM, Farquharson C, Fan‐Lun C, Wiesenfeld L, Loftus CA, Kain D, Johnstone J, McCreight L, Goldman RD, Mahtani R. A Hospital Partnership with a Nursing Home Experiencing a COVID-19 Outbreak: Description of a Multiphase Emergency Response in Toronto, Canada. J Am Geriatr Soc 2020; 68:1376-1381. [PMID: 32441770 PMCID: PMC7280605 DOI: 10.1111/jgs.16625] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/14/2022]
Abstract
Nursing homes have become "ground zero" for the coronavirus disease 2019 (COVID-19) epidemic in North America, with homes experiencing widespread outbreaks, resulting in severe morbidity and mortality among their residents. This article describes a 371-bed acute-care hospital's emergency response to a 126-bed nursing home experiencing a COVID-19 outbreak in Toronto, Canada. Like other healthcare system responses to COVID-19 outbreaks in nursing homes, this hospital-nursing home partnership can be characterized in several phases: (1) engagement, relationship, and trust building; (2) environmental scan, team building, and immediate response; (3) early-phase response; and (4) stabilization and transition period. J Am Geriatr Soc 68:1376-1381, 2020.
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Affiliation(s)
- Nathan M. Stall
- Division of General Internal Medicine and GeriatricsSinai Health System and the University Health NetworkTorontoOntarioCanada
- Women's College Research InstituteWomen's College HospitalTorontoOntarioCanada
- Division of Geriatric Medicine, Department of MedicineUniversity of TorontoTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoTorontoOntarioCanada
| | | | - Chris Fan‐Lun
- Department of Pharmacy ServicesMount Sinai Hospital, Sinai Health SystemTorontoOntarioCanada
- Leslie Dan Faculty of PharmacyUniversity of TorontoTorontoOntarioCanada
| | - Lesley Wiesenfeld
- Department of PsychiatryMount Sinai Hospital, Sinai Health SystemTorontoOntarioCanada
- Department of PsychiatryUniversity of TorontoTorontoOntarioCanada
| | - Carla A. Loftus
- Department of PsychiatryMount Sinai Hospital, Sinai Health SystemTorontoOntarioCanada
| | - Dylan Kain
- Division of Infectious Diseases, Department of MedicineUniversity of TorontoTorontoOntarioCanada
| | - Jennie Johnstone
- Infection Prevention and ControlSinai Health SystemTorontoOntarioCanada
- Public Health OntarioTorontoOntarioCanada
- Dalla Lana School of Public HealthUniversity of TorontoTorontoOntarioCanada
- Department of Laboratory Medicine and PathobiologyUniversity of TorontoTorontoOntarioCanada
| | - Liz McCreight
- Infection Prevention and ControlSinai Health SystemTorontoOntarioCanada
| | - Russell D. Goldman
- The Temmy Latner Centre for Palliative CareSinai Health SystemTorontoOntarioCanada
- Division of Palliative Care, Department of Family and CommunityUniversity of TorontoTorontoOntarioCanada
| | - Ramona Mahtani
- The Temmy Latner Centre for Palliative CareSinai Health SystemTorontoOntarioCanada
- Division of Palliative Care, Department of Family and CommunityUniversity of TorontoTorontoOntarioCanada
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Hill L, Beattie JM, Geller TP, Baruah R, Boyne J, Stolfo GD, Jaarsma T. Palliative care: Essential support for patients with heart failure in the COVID-19 pandemic. Eur J Cardiovasc Nurs 2020; 19:469-472. [PMID: 32515212 PMCID: PMC7953953 DOI: 10.1177/1474515120932814] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University, Northern Ireland
| | | | | | | | - Josiane Boyne
- Department of Cardiology, Maastricht University Medical Centre, The Netherlands
| | - Giuseppe Di Stolfo
- Cardiovascular Department, Fondazione IRCCS Casa Sollievo della Sofferenza, Italy
| | - Tiny Jaarsma
- Department of Health, Medicine and Health Sciences, Linköping University, Sweden.,Julius Center, University Medical Center, The Netherlands
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56
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Mishra S, Biswas S, Bhatnagar S. Palliative Care Delivery in Cancer Patients in the Era of Covid-19 Outbreak: Unique Needs, Barriers, and Tools for Solutions. Indian J Palliat Care 2020; 26:S130-S141. [PMID: 33088103 PMCID: PMC7535008 DOI: 10.4103/ijpc.ijpc_194_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 06/01/2020] [Indexed: 12/19/2022] Open
Abstract
World is facing a pandemic recently due to the outbreak of COVID-19 infection. Cancer has been identified as one of the major comorbidities which cause more severe disease due to COVID-19 infection. Moreover, there are several resource limitations and restrictions to avail the standard oncological health facilities due to robust measures taken for infection control. In this situation, palliative care in cancer patients deserves special attention. Their symptom management, psychological, social, cultural needs tremendously increase during the epidemic. Thus, we need to recognize the unique palliative care needs of cancer patients during pandemic and formulate the plan to maintain continuity of services. Triaging systems are essential tools for proper resource allocation during a pandemic. Therefore, we suggest triaging tools for emergency in hospital palliative care services: community-based palliative care and end of life care for cancer patients. Incorporation of newer technologies and identifying the potential resources are the other key components of the preparedness strategy.
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Affiliation(s)
- Seema Mishra
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. Bhimrao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Swagata Biswas
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. Bhimrao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
| | - Sushma Bhatnagar
- Department of Onco-Anaesthesia and Palliative Medicine, Dr. Bhimrao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India
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57
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Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020; 24:435-444. [PMID: 32863637 PMCID: PMC7435102 DOI: 10.5005/jp-journals-10071-23400] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Coronavirus disease-19 (COVID-19) pandemic is causing a worldwide humanitarian crisis. Old age, comorbid conditions, end-stage organ impairment, and advanced cancer, increase the risk of mortality in serious COVID-19. A subset of serious COVID-19 patients with serious acute respiratory illness may be triaged not to receive aggressive intensive care unit (ICU) treatment and ventilation or may be discontinued from ventilation due to their underlying conditions. Those not eligible for aggressive ICU measures should receive appropriate symptom management. Early warning scores (EWS), oxygen saturation, and respiratory rate, can facilitate categorizing COVID-19 patients as stable, unstable, and end of life. Breathlessness, delirium, respiratory secretions, and pain, are the key symptoms that need to be assessed and palliated. Palliative sedation measures are needed to manage intractable symptoms. Goals of care should be discussed, and advance care plan should be made in patients who are unlikely to benefit from aggressive ICU measures and ventilation. For patients who are already in an ICU, either ventilated or needing ventilation, a futility assessment is made. If there is a consensus on futility, a family meeting is conducted either virtually or face to face depending on the infection risk and infection control protocol. The family should be sensitively communicated about the futility of ICU measures and foregoing life-sustaining treatment. Family meeting outcomes are documented, and consent for foregoing life-sustaining treatment is obtained. Appropriate symptom management enables comfort at the end of life to all serious COVID-19 patients not receiving or not eligible to receive ICU measures and ventilation. How to cite this article: Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020;24(6):435–444.
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Affiliation(s)
- Naveen Salins
- Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Mahe, Manipal, Karnataka, India
| | - Raj Kumar Mani
- Department of Critical Care and Pulmonology, Batra Hospital and Medical Research Centre, Delhi, India
| | - Roop Gursahani
- Department of Neurology, PD Hinduja National Hospital, Mumbai, Maharashtra, India
| | - Srinagesh Simha
- Department of Palliative Care, Karunashraya, Bengaluru, Karnataka, India
| | - Sushma Bhatnagar
- Department of Onco-anesthesia and Palliative Medicine, All India Institute of Medical Sciences, New Delhi, India
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