Conservative Management of COVID-19 Patients-Emergency Palliative Care in Action

Impacts of COVID-19 pandemic prevention measures to the palliative care in Taiwan

Background

Prevention measures for palliative care and the provision of discharge planning services for inpatients in Taiwan before and during the COVID-19 pandemic had not been investigated. This study was aimed to investigate the factors associated with heightened palliative care needs and increased mortality rates.

Methods

This research adopts a retrospective case-control study design. The investigation encompasses patients admitted before the pandemic (from January 1, 2019, to May 31, 2019) and during the COVID-19 pandemic (from January 1, 2020, to May 31, 2020). The case group consisted of 231 end-of-life inpatients during the pandemic, control group was composed of the pool of inpatients with pre-pandemic and matched with cases by sex and age in a 1:1 ratio.

Results

The results showed that the prevalence of respiratory failure symptoms (p = 0.004), residing in long-term care facilities (p = 0.017), palliative care needs assessment scores (p = 0.010), as well as the provision of guidance for nasogastric tube feeding (p = 0.002), steam inhalation (p = 0.003), turning and positioning (p < 0.001), percussion (p < 0.001), passive range of motion (p < 0.001), and blood pressure measurement (p < 0.001). Furthermore, the assessment of the necessity for assistive devices, including hospital beds, also exhibited statistically significant variations (p < 0.001). Further investigation of the factors associated with high palliative care needs and the risk of mortality for both the case and control groups. Risk factors for high palliative care needs encompassed assessments of daily activities of living, the presence of pressure ulcers, and the receipt of guidance for ambulation. Risk factors for mortality encompassed age, a diagnosis of cancer, palliative care needs assessment scores, and the provision of guidance for disease awareness.

Conclusion

This research highlights the heightened risk of COVID-19 infection among end-of-life inpatients during the COVID-19 pandemic. The findings of this study may advance care planning to alleviate avoidable suffering. To meet the needs of inpatients during pandemic, healthcare professionals should undergo comprehensive palliative care training and receive policy support.

Description and Analysis of Research on Death and Dying during the COVID-19 Pandemic, Published in Nursing Journals Indexed in SCOPUS

AIM

To offer an overall picture of the research published regarding the different aspects of death and dying during the COVID-19 pandemic in journals covering the field of nursing in the Scopus database.

DESIGN

bibliometric analysis.

METHODS

The metadata obtained were exported from Scopus for subsequent analysis through Bibliometrix. Using the VOSviewer co-word analysis function, the conceptual and thematic structure of the publications was identified.

RESULTS

A total of 119 papers were retrieved, with the participation of 527 authors. The publications were found in 71 journals covering the nursing area. The main lines of research revolved around the keywords "palliative care" and "end-of-life care" in regard to the ethical, psychological, and organizational challenges faced by the health professionals who cared for these patients.

CONCLUSION

The results obtained offer a range of data and images that characterize the scientific production published on this topic, coming to the conclusion that, due to the multifaceted and multidisciplinary approach to the experience of death, care, and accompaniment in the dying process, bibliometric maps improve the comprehensive understanding of the semantic and conceptual structure of this field of research. This study was retrospectively registered with the OSF Registries on the 14 March 2024.

A Survey of Emergency Nurses' Perceptions and Practices to Support Patients' Families as Surrogate Decision Makers

INTRODUCTION

Family members acting as surrogate decision makers for severely ill patients in emergency and critical care centers face psychological burdens. This study aimed to investigate the actual situation of emergency nurses' perceptions and practices to support patients' families and its structural elements.

METHODS

We created an original 25-item questionnaire and surveyed 164 emergency nurses from 64 emergency and critical care centers regarding their perceptions of caring for people making surrogate decisions. Participants averaged 35.6 years old and 5.1 years as emergency nurses.

RESULTS

Cronbach's α coefficients for importance and practice on the original questionnaire were 0.936 and 0.933, respectively. We identified 4 elements of necessary support for patient families making surrogate decisions according to emergency nurses: "collaboration in understanding the condition of the patient as well as empathetic support," "care that addresses the needs of patient's family members," "confirming the role of nurses and surrogate decision making," and "participation in meeting with a doctor and patient families." In addition, we identified 5 elements that indicate the current state of practice: "support from specialists such as nurses and other professionals," "compassionate care for family members and those who are providing support to family members," "empathetic support for family members," "support for making arrangements that address the needs of family members," and "considerations for family members."

DISCUSSION

According to the findings of this study, emergency nurses should coordinate with other professionals and talk with family members and physicians to increase their understanding of the need to assist in surrogate decision making. In addition, emergency nurses also need to explain to patients' relatives how to support them in surrogate decision making.

Providing End-of-Life Care for Patients Dying of COVID-19 and Their Families in Isolated Death During the Pandemic in Japan: The Providing End-of-life Care for COVID-19 Project

BACKGROUND

Death resulting from COVID-19 in a hospital during the pandemic has meant death in isolation. Although many health care providers (HCPs) have struggled with end-of-life (EOL) care for these patients, the various strategies across hospitals are not well known.

RESEARCH QUESTION

What EOL care did HCPs give patients dying of COVID-19 and their families in hospitals during the COVID-19 pandemic? What were the key themes in care?

STUDY DESIGN AND METHODS

This qualitative study used individual, semistructured, internet, and face-to-face interviews. We recruited HCPs who provided EOL care to patients with COVID-19 dying in hospitals and their families. Purposive sampling was used through the academic networks at the School of Public Health, Kyoto University. Anonymized verbatim transcripts were analyzed thematically.

RESULTS

Fifteen doctors and 18 nurses from 23 hospitals in 13 regions across Japan participated; 16 participants (48%) were women, with an age range of 20 to 59 years (most were 30-39 years of age). Participants described 51 strategies, including providing physical and psychological-spiritual care, making connections, providing death care, and arranging care environments and bereavement care for patients and their families. Four themes emerged as prominent efforts in COVID-19 EOL care: maintaining relationships with isolated patients, connecting patients and families, sharing decision-making in isolation, and creating humanistic episodes.

INTERPRETATION

Proper application and awareness of the four themes may help HCPs to implement better EOL care. To compensate for limited memories resulting from isolation and rapid progression of the disease, communicating and creating humanistic episodes are emphasized. ICU diaries and the HCPs' arrangements based on cultural funerary procedures could be provided as grief care for the family and to build trust. EOL education and building partnerships among palliative care staff and nonmedical personnel on a regular basis may enhance the capacity to deliver the necessary support for EOL care.

[Grief and palliative home-care services for patients at the end of life during the COVID-19 pandemic in Colombia. Analysis from the relatives´ perspective]

INTRODUCTION

End-of-life care is one of the most crucial experiences for both the patient and their loved ones. However, as a result of the changes generated by the COVID 19 pandemic, the dynamics of the end-of-life process has undergone changes at both the family, social and health levels. In turn, this has altered the perception and development of the grief of relatives of patients who died during the pandemic regardless of the cause of death. Then, the aim of this study is to analyze the perceptions and some aspects of bereavement of died patients` relatives during the pandemic of Covid 19.

METHODS

Through the admission evaluation and follow-up of the relatives with an adapted version of the international Care Of the Dying Evaluation (iCODE) questionnaire.

RESULTS

239 relatives were surveyed, of which 112 completed the follow-up questionnaire. Most of the patients died at home and their family members were highly involved in their care. Medical attention was considered adequate and the symptom with the highest perception was pain. 87% of those surveyed participated in funeral rites, and 42% rated them as very sober. Regarding grief, the scale of personal growth predominates, however, in the negative aspects, the feeling of pressure in the chest and frequent crying predominates.

CONCLUSIONS

The end of life of home-care patients during the pandemic was perceived as adequate, allowing family support and symptom control. The grieving process shows no complications. The training of health professionals in these fundamental aspects of patient care is important.

Stressor Factors for Spanish Nursing Students in a Pandemic Context: An Observational Pilot Survey

BACKGROUND

The context of the pandemic in Spain meant a high demand for care. The purpose of this pilot work was to determine the stress factors, conducted on final-year nursing students at a Spanish university, who volunteered to carry out healthcare tasks, in pandemic and post-pandemic contexts.

METHODS

An observational prospective cohort pilot survey was conducted with an intentional sampling of the forty-seven students. We collected sociodemographic and stressor data using the validated KEZKAK questionnaire. The STROBE checklist was used to evaluate the study.

RESULTS

The median scores obtained from nursing students incorporated as auxiliary health workers are lower than those who were not incorporated, and statistically significant differences were found: lack of skills and abilities (p = 0.016); relationship with tutors and colleagues (p = 0.004); impotence and uncertainty (p = 0.011); inability to manage the relationship with the patient (p = 0.009); emotional involvement (p = 0.032); distress caused by the relationship with patients and item overload (p = 0.039); and overload items (p = 0.011). The post-pandemic only maintained "lack of skill and abilities" (p = 0.048), from nursing students incorporated as auxiliary health workers.

CONCLUSION

This pilot study showed that nursing students who joined as auxiliary health personnel presented less perceived stress than non-incorporated nursing students. Still, more prospectively designed clinical research is needed.

Mapping the future for research in emergency medicine palliative care: A research roadmap

BACKGROUND

The intersection of emergency medicine (EM) and palliative care (PC) has been recognized as an essential area of focus, with evidence suggesting that increased integration improves outcomes. This has resulted in increased research in EM PC. No current framework exists to help guide investigation and innovation.

OBJECTIVE

The objective was to convene a working group to develop a roadmap that would help provide focus and prioritization for future research.

METHODS

Participants were identified based on clinical, operation, policy, and research expertise in both EM and PC and spanned physician, nursing, social work, and patient perspectives. The research roadmap setting process consisted of three distinct phases that were time staggered over 12 months and facilitated through three live video convenings, asynchronous input via an online document, and a series of smaller video convenings of work groups focused on specific topics.

RESULTS

Gaps in the literature were identified and informed the four key areas for future research. Consensus was reached on these domains and the associated research questions in each domain to help guide future study. The key domains included work focused on the value imperative for PC in the emergency setting, models of care delivery, disparities, and measurement of impact and efficacy. Additionally, the group identified key methodological considerations for doing work at the intersection of EM and PC.

CONCLUSIONS

There are several key domains and associated questions that can help guide future research in ED PC. Focus on these areas, and answering these questions, offers the potential to improve the emergency care of patients with PC needs.

Hospitalized patients dying with SARS-CoV-2 infection—An analysis of patient characteristics and management in ICU and general ward of the LEOSS registry

Background

COVID-19 is a severe disease with a high need for intensive care treatment and a high mortality rate in hospitalized patients. The objective of this study was to describe and compare the clinical characteristics and the management of patients dying with SARS-CoV-2 infection in the acute medical and intensive care setting.

Methods

Descriptive analysis of dying patients enrolled in the Lean European Open Survey on SARS-CoV-2 Infected Patients (LEOSS), a non-interventional cohort study, between March 18 and November 18, 2020. Symptoms, comorbidities and management of patients, including palliative care involvement, were compared between general ward and intensive care unit (ICU) by univariate analysis.

Results

580/4310 (13%) SARS-CoV-2 infected patients died. Among 580 patients 67% were treated on ICU and 33% on a general ward. The spectrum of comorbidities and symptoms was broad with more comorbidities (≥ four comorbidities: 52% versus 25%) and a higher age distribution (>65 years: 98% versus 70%) in patients on the general ward. 69% of patients were in an at least complicated phase at diagnosis of the SARS-CoV-2 infection with a higher proportion of patients in a critical phase or dying the day of diagnosis treated on ICU (36% versus 11%). While most patients admitted to ICU came from home (71%), patients treated on the general ward came likewise from home and nursing home (44% respectively) and were more frequently on palliative care before admission (29% versus 7%). A palliative care team was involved in dying patients in 15%. Personal contacts were limited but more often documented in patients treated on ICU (68% versus 47%).

Conclusion

Patients dying with SARS-CoV-2 infection suffer from high symptom burden and often deteriorate early with a demand for ICU treatment. Therefor a demand for palliative care expertise with early involvement seems to exist.

Contribution of nursing research to fighting against COVID-19 pandemic. A systematic review

Introduction: The 2019 coronavirus disease (COVID-19) pandemic, should be an opportunity to ensure greater visibility of nursing in health systems and society worldwide. Objective: Review and synthesize the patterns on COVID-19 and nursing research, identifying the main journals, country of origin, language, topics, designs, and area of applicability of the results. Materials and Methods: Systematic review. Searches in PubMed, CINAHL, LILACS, and EMBASE databases (from the inception of the pandemic to May 15, 2020) were performed. Articles of any language related were related to SARS-CoV-2 infection or COVID-19 disease and nursing in any of its roles (care, management, education, among others) and using any epidemiological design or a scientific report were included. Two reviewers independently selected the studies and extracted the data. The main findings from the included studies were summarized through narrative synthesis and descriptive tables. The characteristics of the studies were presented as absolute values and proportions. Results: Three hundred and sixty-five articles were assessed for eligibility. Thirty-eight were included, published in 28 journals. Of those, 53.57% (n=15) were nursing specific. Most articles were “narrative reviews”, accounting for 23.68% (n=9). Most studies were conducted in China (n=18, 47.37%), followed by the United Kingdom and the United States. Thirty-four (89.47%) articles were published in English, followed by Portuguese and Chinese. We identified five areas of application of the results, and the most frequent was the “clinical” setting with 47.00% (n=18). Discussion: These findings are crucial to give visibility to nursing work during the emergency of the COVID-19 pandemic. Mental health was the main research topic, while the clinical setting concentrates the major number of articles. This pattern was aligned with the challenges of the initial phase of the pandemic. Conclusion: Future research should explore the current state of evidence in the main topics identified in this review and continue to give visibility to work carried out by nursing in the emergency of the COVID-19 pandemic.

Efficacy of COVID-19 treatments among geriatric patients: a systematic review

Introduction:

A majority of the fatalities due to COVID-19 have been observed in those over the age of 60. There is no approved and universally accepted treatment for geriatric patients. The aim of this review is to assess the current literature on efficacy of COVID-19 treatments in geriatric populations.

Methods:

A systematic review search was conducted in PubMed, MedRxiv, and JAMA databases with the keywords COVID-19, geriatric, hydroxychloroquine, dexamethasone, budesonide, remdesivir, favipiravir, ritonavir, molnupiravir, tocilizumab, bamlanivimab, baricitinib, sotrovimab, fluvoxamine, convalescent plasma, prone position, or anticoagulation. Articles published from January 2019 to January 2022 with a population greater than or equal to 60 years of age were included. Interventions examined included hydroxychloroquine, remdesivir, favipiravir, dexamethasone, budesonide, tocilizumab, bamlanivimab, baricitinib, sotrovimab, convalescent plasma, prone position, and anticoagulation therapy. Outcome measures included viral load, viral markers, ventilator-free days, or clinical improvement.

Results:

The search revealed 302 articles, 52 met inclusion criteria. Hydroxychloroquine, dexamethasone, and remdesivir revealed greater side effects or inefficiency in geriatric patients with COVID-19. Favipiravir, bamlanivimab, baricitinib, and supportive therapy showed a decrease in viral load and improvement of clinical symptoms. There is conflicting evidence with tocilizumab, convalescent plasma, and anticoagulant therapy in reducing mortality, ventilator-free days, and clinical improvements. In addition, there was limited evidence and lack of data due to ongoing trials for treatments with sotrovimab and budesonide.

Conclusion:

No agent is known to be effective for preventing COVID-19 after exposure to the virus. Further research is needed to ensure safety and efficacy of each of the reviewed interventions for older adults.

Impact of coronavirus disease 2019 on chronic pain structures: data from French national survey

Aims: The authors evaluated the impact of the first coronavirus disease 2019 pandemic wave on French chronic pain structures (CPSs). Methods: An online survey assessed CPS resource allocation, workflow and perceived impact on patient care. Results: All CPS workflow was severely impacted by the reallocation of 42% of specialists. In-person appointments were cancelled by 72% of participants. Follow-up was maintained in 91% of participants (telemedicine). Skills in end-of-life decision-making/counseling were rarely solicited. The perceived impact of the crisis on the experience of patients was high (eight out of ten), with a significant increase in access-to-care delay. Conclusion: CPSs maintained patient follow-up. Special features of CPS specialists were rarely solicited by coronavirus disease 2019 teams experiencing a high workload. Recommendations on optimal CPS resource reallocations have to be standardized in crisis conditions.

Inpatient generalist palliative care during the SARS-CoV-2 pandemic - experiences, challenges and potential solutions from the perspective of health care workers

BACKGROUND

The SARS-CoV-2 pandemic has presented major challenges to the health system. Despite high acute case numbers, patients without Covid-19 still need to be cared for. Due to the severity of the disease and a possible stressful overall situation, patients with palliative care needs also require comprehensive care during pandemic times. In addition to specialized palliative care facilities, this also takes place in non palliative care wards. In order to ensure this general palliative care also in pandemic times, the experience of the staff should be used. The aim of this paper is to examine challenges and possible solutions for general palliative care inpatients in relation to the care of seriously ill and dying patients and their relatives.

METHODS

Qualitative semi-structured focus groups were conducted online for the study. Participants were staff from intensive care or isolation wards or from units where vulnerable patients (e.g. with cognitive impairment) are cared for. The focus groups were recorded and subsequently transcribed. The data material was analysed with the content structuring content analysis according to Kuckartz.

RESULTS

Five focus groups with four to eight health care professionals with various backgrounds were conducted. Fifteen main categories with two to eight subcategories were identified. Based on frequency and the importance expressed by the focus groups, six categories were extracted as central aspects: visiting regulations, communication with relatives, hygiene measures, cooperation, determination of the patients will and the possibility to say good bye.

CONCLUSION

The pandemic situation produced several challenges needing specific solutions in order to manage the care of seriously ill and dying patients. Especially visiting needs regulation to prevent social isolation and dying alone. Finding alternative communication ways as well as interprofessional and interdisciplinary cooperation is a precondition for individualised care of seriously ill and dying patients and their relatives. Measures preventing infections should be transparently communicated in hospitals.

Emergent care nurses' perceived self-competence in palliative care and its predictors: A cross-sectional study

AIM

To describe the prevalence of perceived self-competence in palliative care among emergent care nurses, and explore its predictors.

BACKGROUND

Emergent care nurses have a responsibility to develop palliative care competence to enhance the quality of life of dying patients and their families in the emergency department.

METHODS

With a convenience sample, a cross-sectional study was conducted among 415 emergent care nurses from 22 hospitals in China. Descriptive analysis, Spearman correlation analysis, and multivariate linear stepwise regression were performed.

RESULTS

Variables including marital status (single), emergency department not implementing palliative care, no palliative care training, and true cooperation dimension were selected as independent predictors and explained 19.9% of variation in the regression model.

CONCLUSIONS

Interventions to improve healthy work environments, offering palliative care training, advocating for policies in palliative care, and offering support to unmarried nurses can advance nurses' palliative care competence.

IMPLICATIONS FOR NURSING MANAGEMENT

This is the first study of emergent care nurses in China aimed at identifying predictors associated with palliative care self-competence. It is significant in that palliative care training and a cooperative work environment are required to encourage the development of palliative care.

A Qualitative Study Regarding COVID-19 Inpatient Family Caregivers' Need for Supportive Care

Background:

Family caregivers of COVID-19 inpatients are exposed to multiple sources of distress. These include not only losing friends, colleagues and members of the family, but also the fear of possible losses in sociality, finances and, impoverished communication with sick family members and health care providers.

Objective:

This study describes the psychological experience of COVID-19 inpatient family caregivers to highlight the main sources of distress, issues, concerns and unmet needs.

Methods:

Two focus groups were independently organized with COVID-19 inpatient family caregivers and health care personnel of COVID-19 wards in order to highlight family caregivers’ practical and psychological burden and related needs. A thematic analysis was conducted to analyze the data.

Results:

Family caregivers mentioned they needed more information about the patient’s condition with more attention being paid to their own emotional state. Feelings of impotence, concerns about how to deal with patient’s discharge, significant psychological distress, and anxiety were frequently reported by study participants.

Conclusion:

Study findings suggest the need to strengthen the assistance of COVID-19 patient family caregivers. In the pandemic scenario, family caregivers might represent a crucial resource, which can guarantee rapid discharges, support home health care and thus relieve pressure on hospital systems.

Implementation of an acute palliative care unit for COVID-19 patients in a tertiary hospital: Qualitative data on clinician perspectives

BACKGROUND

During the COVID-19 pandemic, it has become apparent that palliative care has dynamically adapted to the care of dying patients with and without COVID-19 and has developed new forms of collaboration. Evaluation is needed to assess which innovations should be integrated into future pandemic management.

AIM

To explore the experiences of stakeholders and staff in implementing and operating an ad hoc unit delivering acute palliative care. What lessons were learned?

DESIGN

Qualitative interview study (German Clinical Trials Register; identifier 22,473) with qualitative content analysis.

SETTING/PARTICIPANTS

During the first wave of the pandemic, the University Medical Center Freiburg (Germany) established an ad hoc unit delivering acute palliative care for COVID-19 patients likely to die. Nurses from non-palliative areas and the specialist palliative care team formed a new team working together there. Twenty-nine individuals from management and staff of this unit were interviewed.

RESULTS

Patient care and teamwork were rated positively. Joint familiarization, bedside teaching, and team/management support were evaluated as core elements for success. Challenges for the nurses from non-palliative settings included adapting to palliative care routines and culture of care. The palliative care team had to adjust the high standards of palliative care to pandemic conditions. Due to sufficient hospital-wide capacity, only three COVID-19 patients were treated, significantly fewer than anticipated at planning.

CONCLUSIONS

Results show the feasibility of an ad hoc COVID-19 acute palliative care unit. In the event of capacity constraints, such a unit can be a viable part of future pandemic management.

Complexity of the Diagnosis of COVID-19 in the Context of Pandemicity: Need for Excellence in Diagnostic Acumen

Coronavirus disease 2019 (COVID-19) is a highly infectious disease that has caused a pandemic devastating many countries worldwide. It is a complex and multifaceted disease with a unique coronavirus etiology, pathogenesis, zoonotic, and human-to-human transmission, causing acute respiratory distress syndrome with high mortality. Accurate and timely diagnosis is of utmost importance. In this study, we discussed the complexities of COVID-19 diagnostic elements in the context of pandemicity, drawing from our awareness, observations, and lessons learned from two previous coronavirus pandemics, namely SARS-CoV (severe acute respiratory syndrome coronavirus) in 2002 and MERS-CoV (Middle East respiratory syndrome-related coronavirus) in 2012, and how they applied to the diagnosis of COVID-19 today. Diagnosis of COVID-19 takes place without physician-patient personal contact due to isolation or quarantine or in the hospital setting, emergency units, and critical care units with the cumbersome barriers of personal protective equipment. Technical diagnosis is important, but we also emphasized the human impact of diagnosing COVID-19. Conveying the diagnosis of a critical disease to patients and families requires aspects of excellence in professionalism: ethics, empathy, and humility. Diagnostic skills in COVID-19 should extend to prognostication for patients suffering at the end of life, so that they will not be deprived of high-quality palliative care and comfort.

COVID-19 palliative care toolkit development and military health system deployment

BACKGROUND

During the initial phase of the pandemic, we identified a critical gap in the Military Health System's access to palliative care. Our team of nurse scientists and evidence-based practice (EBP) facilitators aimed to develop and implement an evidence-based point of care palliative care toolkit for frontline workers in inpatient settings lacking established palliative care specialists.

METHODOLOGY

We utilized Melnyk and Fineout-Overholt's (2018) seven-step EBP process. Six central themes were derived from 17 publications providing an evidence-base for toolkit resource selection and development. Our practice change implementation was piloted at a large West Coast military treatment facility. We included iPads in the toolkit for patient communication and palliative mobile application use.

RESULTS

The most significant finding was the critical and continued need for basic palliative care education and training. Integrating the palliative care toolkit into daily practice was promising yet challenging due to the high volume of deployed medical staff.

Delirium and Associated Factors in a Cohort of Hospitalized Patients With Coronavirus Disease 2019

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic dramatically increased the number of patients requiring treatment in an intensive care unit or invasive mechanical ventilation worldwide. Delirium is a well-known neuropsychiatric complication of patients with acute respiratory diseases, representing the most frequent clinical expression of acute brain dysfunction in critically ill patients, especially in those undergoing invasive mechanical ventilation. Among hospitalized patients with COVID-19, delirium incidence ranges from 11% to 80%, depending on the studied population and hospital setting.

OBJECTIVE

To determine risk factors for the development of delirium in hospitalized patients with COVID-19 pneumonia.

METHODS

We retrospectively studied consecutive hospitalized adult (≥18 y) patients with confirmed COVID-19 pneumonia from March 15 to July 15, 2020, in a tertiary-care hospital in Mexico City. Delirium was assessed by the attending physician or trained nurse, with either the Confusion Assessment Method for the Intensive Care Unit or the Confusion Assessment Method brief version, according to the appropriate diagnostic tool for each hospital setting. Consultation-liaison psychiatrists and neurologists confirmed all diagnoses. We calculated adjusted hazard ratios (aHR) with 95% confidence interval (CI) using a Cox proportional-hazards regression model.

RESULTS

We studied 1017 (64.2% men; median age, 54 y; interquartile range 44-64), of whom 166 (16.3%) developed delirium (hyperactive in 75.3%); 78.9% of our delirium cases were detected in patients under invasive mechanical ventilation. The median of days from admission to diagnosis was 14 (interquartile range 8-21) days. Unadjusted mortality rates between delirium and no delirium groups were similar (23.3% vs. 24.1; risk ratio 0.962, 95% CI 0.70-1.33). Age (aHR 1.02, 95% CI 1.01-1.04; P = 0.006), an initial neutrophil-to-lymphocyte ratio ≥9 (aHR 1.81, 95% CI 1.23-2.65; P = 0.003), and requirement of invasive mechanical ventilation (aHR 3.39, 95% CI 1.47-7.84; P = 0.004) were independent risk factors for in-hospital delirium development.

CONCLUSIONS

Delirium is a common in-hospital complication of patients with COVID-19 pneumonia, associated with disease severity; given the extensive number of active COVID-19 cases worldwide, it is essential to detect patients who are most likely to develop delirium during hospitalization. Improving its preventive measures may reduce the risk of the long-term cognitive and functional sequelae associated with this neuropsychiatric complication.

Palliative Care Practice During the COVID-19 Pandemic: A Descriptive Qualitative Study of Palliative Care Clinicians

CONTEXT

COVID-19 created unprecedented demand for palliative care at a time when in-person communication was highly restricted, straining efforts to care for patients and families.

OBJECTIVES

To qualitatively explore the challenges presented by the COVID-19 pandemic from the perspective of palliative care clinicians. Specifically we sought to: 1) Describe the strategies adopted by palliative care clinicians to cope with new challenges including patient and clinician isolation, prognostication of an emergent disease, and rapidly rising numbers of severely ill patients; 2) Identify additions or adjustments to in-person and system-related palliative care training, methods, and tools made during pandemics.

METHODS

This descriptive qualitative study utilized a thematic approach for data analysis of individual, semi-structured interviews with palliative care clinicians (n = 25). Codes, categories, and emerging themes were identified through an iterative, comparative method. Methods align with the Consolidated Criteria for Reporting Qualitative Research (COREQ) RESULTS: A theme of "Expanding the reach of palliative care for today and the future" was identified with three subthemes: 1) Redefining attitudes and hardship due to collective uncertainty, 2) Breaking with the past towards integrated concept of palliative care, and 3) Building capacity through primary palliative care training.

CONCLUSION

COVID-19 forced hospital systems to consider the inclusion of palliative care in unforeseen ways due to an uncontrollable, unpredictable disease. Faced with unprecedented uncertainty, palliative care clinicians utilized strategies for integration and innovation across hospitals, particularly in intensive care units and emergency departments. A need to build capacity through increased primary palliative care access and training was identified.

Interprofessional Communication Team for Caregivers of Patients Hospitalized in the COVID-19 Wards: Results From an Italian Experience

Background: During the COVID-19 pandemic, emergency restrictions did not allow clinician family meetings and relatives' visits. In Molinette Hospital, a new communication model between healthcare providers and families of COVID-19 affected patients was developed by a team of physicians and psychologists. The study's aims were to investigate caregivers' distress and to analyse their satisfaction with the communications provided. Methods: A cross-sectional study was conducted among caregivers of patients of Molinette Hospital COVID wards. Between April and June 2020, all caregivers were contacted 2 weeks after the patient's discharge/death to assess their satisfaction with the communications received through an online survey. Results: A total of 155 caregivers completed the survey. Caregivers' distress level was found to be higher in women than men (p = 0.048) and in caregivers whose relative died compared to the caregivers whose relative was discharged (p < 0.001). More than 85% of caregivers defined communication "excellent"/"very good"; being male was associated with higher satisfaction levels than women (β = -0.165, p = 0.046). Besides daily communication, 63 caregivers (40.6%) received additional support from a psychologist of the team. Conclusions: To our knowledge, this is the first study presenting, in an emergency, a new model of communication provided by a team of physicians and psychologists, and analyzing satisfaction with it. This model was highly appreciated by caregivers and it limited the discomfort caused by the restrictions on relatives' visits. It would be interesting to further evaluate the possibility of extending a communication model that includes doctors and psychologists in routine clinical practice.

Specialist palliative and end-of-life care for patients with cancer and SARS-CoV-2 infection: a European perspective

BACKGROUND

Specialist palliative care team (SPCT) involvement has been shown to improve symptom control and end-of-life care for patients with cancer, but little is known as to how these have been impacted by the COVID-19 pandemic. Here, we report SPCT involvement during the first wave of the pandemic and compare outcomes for patients with cancer who received and did not receive SPCT input from multiple European cancer centres.

METHODS

From the OnCovid repository (N = 1318), we analysed cancer patients aged ⩾18 diagnosed with COVID-19 between 26 February and 22 June 2020 who had complete specialist palliative care team data (SPCT+ referred; SPCT- not referred).

RESULTS

Of 555 eligible patients, 317 were male (57.1%), with a median age of 70 years (IQR 20). At COVID-19 diagnosis, 44.7% were on anti-cancer therapy and 53.3% had ⩾1 co-morbidity. Two hundred and six patients received SPCT input for symptom control (80.1%), psychological support (54.4%) and/or advance care planning (51%). SPCT+ patients had more 'Do not attempt cardio-pulmonary resuscitation' orders completed prior to (12.6% versus 3.7%) and during admission (50% versus 22.1%, p < 0.001), with more SPCT+ patients deemed suitable for treatment escalation (50% versus 22.1%, p < 0.001). SPCT involvement was associated with higher discharge rates from hospital for end-of-life care (9.7% versus 0%, p < 0.001). End-of-life anticipatory prescribing was higher in SPCT+ patients, with opioids (96.3% versus 47.1%) and benzodiazepines (82.9% versus 41.2%) being used frequently for symptom control.

CONCLUSION

SPCT referral facilitated symptom control, emergency care and discharge planning, as well as high rates of referral for psychological support than previously reported. Our study highlighted the critical need of SPCTs for patients with cancer during the pandemic and should inform service planning for this population.

The Challenges of Caring for People Dying From COVID-19: A Multinational, Observational Study (CovPall)

CONTEXT

Systematic data on the care of people dying with COVID-19 are scarce.

OBJECTIVES

To understand the response of and challenges faced by palliative care services during the COVID-19 pandemic, and identify associated factors.

METHODS

We surveyed palliative care and hospice services, contacted via relevant organizations. Multivariable logistic regression identified associations with challenges. Content analysis explored free text responses.

RESULTS

A total of 458 services responded; 277 UK, 85 rest of Europe, 95 rest of the world; 81% cared for patients with suspected or confirmed COVID-19, 77% had staff with suspected or confirmed COVID-19; 48% reported shortages of Personal Protective Equipment (PPE), 40% staff shortages, 24% medicines shortages, 14% shortages of other equipment. Services provided direct care and education in symptom management and communication; 91% changed how they worked. Care often shifted to increased community and hospital care, with fewer admissions to inpatient palliative care units. Factors associated with increased odds of PPE shortages were: charity rather than public management (OR 3.07, 95% CI 1.81-5.20), inpatient palliative care unit rather than other settings (OR 2.34, 95% CI 1.46-3.75). Being outside the UK was associated with lower odds of staff shortages (OR 0.44, 95% CI 0.26-0.76). Staff described increased workload, concerns for their colleagues who were ill, whilst expending time struggling to get essential equipment and medicines, perceiving they were not a front-line service.

CONCLUSION

Palliative care services were often overwhelmed, yet felt ignored in the COVID-19 response. Palliative care needs better integration with health care systems when planning and responding to future epidemics/pandemics.

Attitudes Toward Euthanasia: A Longitudinal Analysis of the Role of Economic, Cultural, and Health-Related Factors

CONTEXT

It is crucial that physicians understand differing attitudes toward euthanasia and which factors to consider when discussing end-of-life decisions with patients and families from diverse backgrounds.

OBJECTIVES

To investigate how attitudes toward euthanasia differ among countries, how they change, and how economic, religious, and health-related factors affect these attitudes.

METHODS

We analyzed attitudes toward euthanasia and economic, religious, and health-related indicators using longitudinal (1981-2018) World Values Survey (WVS) data. They included 62 countries with at least a 15-year, three-wave, time series (total n = 389,243 participants). Each national survey interviewed representative samples of adults (mean = 1405).

RESULTS

In the latest wave, The Netherlands had the most favorable views of euthanasia (10-point scale with 1 = least justifiable: mean = 7.47) and Jordan the least (mean = 1.50). Residents of 23 of 24 high-income countries came to view euthanasia as more justifiable, while residents of 12 of 38 middle- and low-income countries came to view it as less justifiable over time. The higher GDP per-capita at the time of survey, the more euthanasia was accepted (r = 0.703; P< 0.0001); the more important respondents viewed religion as being, the less euthanasia was accepted (r = -0.834; P< 0.0001); the higher life expectancy and the lower infant mortality were, the more euthanasia was accepted (r = 0.669; P< 0.0001/r = -0.716; P< 0.0001).

CONCLUSION

Euthanasia-related attitudes differ widely depending on the cultural context; changes over time varied in both directions; euthanasia-related attitudes were associated with economic, religious and health-related factors. With globalization increasing cultural diversity, these findings can inform physicians' communication about end-of-life decisions with patients and families from diverse backgrounds.

Respiratory Distress in Hospitalized Non-Mechanically Ventilated COVID-19 Adults: A Retrospective Multicenter Cohort Study

Background:

COVID-19 typically presents with respiratory symptoms which may progress with severe disease. There are standard guidelines for managing respiratory distress (e.g. opioids, anxiolytics) and palliative care teams are well versed in managing these symptoms.

Aim:

Determine the extent to which hospitalized COVID-19 patients with moderate respiratory distress received medications or palliative consultation for symptom management and if these interventions had any association with outcomes.

Design:

Retrospective chart review for hospitalized COVID-19+ patients from March 2-April 30, 2020.

Setting:

Large integrated health system in the New York Metropolitan area.

Patients:

312 adult patients hospitalized with COVID-19 with an order for a non-rebreather mask and meeting criteria for moderate respiratory distress on the Respiratory Distress Observation Scale: concurrent respiratory rate ≥30 and heart rate ≥110 at any point during hospitalization. Patients receiving mechanical ventilation or intensive care were excluded.

Results:

Most COVID-19 patients experiencing moderate respiratory distress did not receive medications or palliative consultation for symptom management. Patients who received medications were predominantly white, older, and had a Do-Not-Resuscitate order. Patients who received a palliative consultation were more likely to be older, female, and white, with a Do-Not-Resuscitate order. Mortality was similar between those receiving medication and those who did not.

Conclusion:

Medications and palliative expertise for symptom management were underused for patients with moderate respiratory distress due to COVID-19. Education and triggers may help providers to identify moderate respiratory distress and consider symptomatic treatment and palliative consultation when appropriate.

A Review of Web-Based COVID-19 Resources for Palliative Care Clinicians, Patients, and Their Caregivers

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.

Identifying factors that nurses consider in the decision-making process related to patient care during the COVID-19 pandemic

Background

Nurse identification of patient deterioration is critical, particularly during the COVID-19 pandemic, as patients can deteriorate quickly. While the literature has shown that nurses rely on intuition to make decisions, there is limited information on what sources of data experienced nurses utilize to inform their intuition. The objectives of this study were to identify sources of data that inform nurse decision-making related to recognition of deteriorating patients, and explore how COVID-19 has impacted nurse decision-making.

Methods

In this qualitative study, experienced nurses voluntarily participated in focused interviews. During focused interviews, expert nurses were asked to share descriptions of memorable patient encounters, and questions were posed to facilitate reflections on thoughts and actions that hindered or helped their decision-making. They were also asked to consider the impact of COVID-19 on nursing and decision-making. Interviews were transcribed verbatim, study team members reviewed transcripts and coded responses, and organized key findings into themes.

Results

Several themes related to decision-making were identified by the research team, including: identifying patient care needs, workload management, and reflecting on missed care opportunities to inform learning. Participants (n = 10) also indicated that COVID-19 presented a number of unique barriers to nurse decision-making.

Conclusions

Findings from this study indicate that experienced nurses utilize several sources of information to inform their intuition. It is apparent that the demands on nurses in response to pandemics are heightened. Decision-making themes drawn from participants’ experiences can to assist nurse educators for training nursing students on decision-making for deteriorating patients and how to manage the potential barriers (e.g., resource constraints, lack of family) associated with caring for patients during these challenging times prior to encountering these issues in the clinical environment. Nurse practice can utilize these findings to increase awareness among experienced nurses on recognizing how pandemic situations can impact to their decision-making capability.

'Saying goodbye' during the COVID-19 pandemic: A document analysis of online newspapers with implications for end of life care

BACKGROUND

News media create a sense-making narrative, shaping, reflecting and enforcing cultural ideas and experiences. Reportage of COVID-related death and bereavement illuminates public perceptions of, and responses to, the COVID-19 pandemic.

AIM

We aimed to explore British newspaper representations of 'saying goodbye' before and after a COVID-related death and consider clinical implications.

DESIGN

Document analysis of UK online newspaper articles published during 2 week-long periods in March-April 2020.

DATA SOURCES

The seven most-read online newspapers were searched: The Guardian, The Daily Mail, The Telegraph, The Mirror, The Sun, The Times and The Metro. Fifty-five articles discussed bereavement after a human death from COVID-19, published during 18/03-24/03/2020 (the UK's transition into lockdown) or 08/04-14/04/2020 (the UK peak of the pandemic's first wave).

RESULTS

The act of 'saying goodbye' (before, during and after death) was central to media representations of COVID bereavement, represented as inherently important and profoundly disrupted. Bedside access was portrayed as restricted, variable and uncertain, with families begging or bargaining for contact. Video-link goodbyes were described with ambivalence. Patients were portrayed as 'dying alone' regardless of clinician presence. Funerals were portrayed as travesties and grieving alone as unnatural. Articles focused on what was forbidden and offered little practical guidance.

CONCLUSION

Newspapers portrayed COVID-19 as disruptive to rituals of 'saying goodbye' before, during and after death. Adaptations were presented as insufficient attempts to ameliorate tragic situations. More nuanced and supportive reporting is recommended. Clinicians and other professionals supporting the bereaved can play an important role in offering alternative narratives.

Sadness, despair and anger when a patient dies alone from COVID-19: A thematic content analysis of Twitter data from bereaved family members and friends

BACKGROUND

To inform clinical practice and policy, it is essential to understand the lived experience of health and social care policies, including restricted visitation policies towards the end of life.

AIM

To explore the views and experiences of Twitter social media users who reported that a relative, friend or acquaintance died of COVID-19 without a family member/friend present.

DESIGN

Qualitative content analysis of English-language tweets.

DATA SOURCES

Twitter data collected 7-20th April 2020. A bespoke software system harvested selected publicly-available tweets from the Twitter application programming interface. After filtering we hand-screened tweets to include only those referring to a relative, friend or acquaintance who died alone of COVID-19. Data were analysed using thematic content analysis.

RESULTS

9328 tweets were hand-screened; 196 were included. Twitter users expressed sadness, despair, hopelessness and anger about their experience and loss. Saying goodbye via video-conferencing technology was viewed ambivalently. Clinicians' presence during a death was little consolation. Anger, frustration and blame were directed at governments' inaction/policies or the public. The sadness of not being able to say goodbye as wished was compounded by lack of social support and disrupted after-death rituals. Users expressed a sense of political neglect/mistreatment alongside calls for action. They also used the platform to reinforce public health messages, express condolences and pay tribute.

CONCLUSION

Twitter was used for collective mourning and support and to promote public health messaging. End-of-life care providers should facilitate and optimise contact with loved ones, even when strict visitation policies are necessary, and provide proactive bereavement support.

Symptoms, symptom relief and support in COVID-19 patients dying in hospitals during the first pandemic wave

Background

At the time of the first wave of the COVID-19 pandemic in Sweden, little was known about how effective our regular end-of-life care strategies would be for patients dying from COVID-19 in hospitals. The aim of the study was to describe and evaluate end-of-life care for patients dying from COVID-19 in hospitals in Sweden up until up until 12 November 2020.

Methods

Data were collected from the Swedish Register of Palliative Care. Hospital deaths during 2020 for patients with COVID-19 were included and compared to a reference cohort of hospital patients who died during 2019. Logistic regression was used to compare the groups and to control for impact of sex, age and a diagnosis of dementia.

Results

The COVID-19 group (1476 individuals) had a lower proportion of women and was older compared to the reference cohort (13,158 individuals), 81.8 versus 80.6 years (p < .001). Breathlessness was more commonly reported in the COVID-19 group compared to the reference cohort (72% vs 43%, p < .001). Furthermore, anxiety and delirium were more commonly and respiratory secretions, nausea and pain were less commonly reported during the last week in life in the COVID-19 group (p < .001 for all five symptoms). When present, complete relief of anxiety (p = .021), pain (p = .025) and respiratory secretions (p = .037) was more often achieved in the COVID-19 group. In the COVID-19 group, 57% had someone present at the time of death compared to 77% in the reference cohort (p < .001).

Conclusions

The standard medical strategies for symptom relief and end-of-life care in hospitals seemed to be acceptable. Symptoms in COVID-19 deaths in hospitals were relieved as much as or even to a higher degree than in hospitals in 2019. Importantly, though, as a result of closing the hospitals to relatives and visitors, patients dying from COVID-19 more frequently died alone, and healthcare providers were not able to substitute for absent relatives.

Toxicity reduction of persistent pollutants through the photo-fenton process and radiation/H2O2 using different sources of radiation and neutral pH

The presence of toxic compounds in aquatic bodies is of great concern, and the Fenton, photo-Fenton and radiation/H₂O₂ processes can be applied in the remediation of these compounds due to their efficiency and advantages. However, these processes need to be investigated to make them more viable and environmentally friendly. Thus, the reduction of toxicity was evaluated, through ecotoxicological tests with Artemia salina and Lactuca sativa, of the compounds 2,4-D, diazepam, nicotine and paracetamol (acetaminophen) by the Fenton, photo-Fenton and radiation/H₂O₂ process with UVC, UVA and natural solar radiation at neutral pH with low concentrations of Fe²⁺ and H₂O₂. The UVC/H₂O₂ process was efficient in the degradation of nicotine (74%), the photo-Fenton process was more efficient in the degradation of 2,4-D (82%), diazepam (27%) and paracetamol (85%) using solar radiation, UVA and UVC respectively. The toxicity and total organic carbon (TOC) tests showed a reduction in the toxicity of the compounds after treatment, except for diazepam, which was more resistant to the process, leading to a higher mortality of Artemia salinas (92%) and less relative seed germination of Lactuca sativa (40%).

Why and how to open intensive care units to family visits during the pandemic

Since the lockdown because of the pandemic, family members have been prohibited from visiting their loved ones in hospital. While it is clearly complicated to implement protocols for the admission of family members, we believe precise strategic goals are essential and operational guidance is needed on how to achieve them. Even during the pandemic, we consider it a priority to share strategies adapted to every local setting to allow family members to enter intensive care units and all the other hospital wards.

Missing the human connection: A rapid appraisal of healthcare workers' perceptions and experiences of providing palliative care during the COVID-19 pandemic

BACKGROUND

During infectious epidemics, healthcare workers are required to deliver traditional care while facing new pressures. Time and resource restrictions, a focus on saving lives and new safety measures can lead to traditional aspects of care delivery being neglected.

AIM

Identify barriers to delivering end-of-life care, describe attempts to deliver care during the COVID-19 pandemic, and understand the impact this had on staff.

DESIGN

A rapid appraisal was conducted incorporating a rapid review of policies from the United Kingdom, semi-structured telephone interviews with healthcare workers, and a review of mass print media news stories and social media posts describing healthcare worker's experiences of delivering care during the pandemic. Data were coded and analysed using framework analysis.

SETTING/PARTICIPANTS

From a larger ongoing study, 22 interviews which mentioned death or caring for patients at end-of-life, eight government and National Health Service policies affecting end-of-life care delivery, eight international news media stories and 3440 publicly available social media posts were identified. The social media analysis centred around 274 original tweets with the highest reach, engagement and relevance. Incorporating multiple workstreams provided a broad perspective of end-of-life care during the COVID-19 pandemic in the United Kingdom.

RESULTS

Three themes were developed: (1) restrictions to traditional care, (2) striving for new forms of care and (3) establishing identity and resilience.

CONCLUSIONS

The COVID-19 pandemic prohibited the delivery of traditional care as practical barriers restricted human connections. Staff prioritised communication and comfort orientated tasks to re-establish compassion at end-of-life and displayed resilience by adjusting their goals.

'Necessity is the mother of invention': Specialist palliative care service innovation and practice change in response to COVID-19. Results from a multinational survey (CovPall)

BACKGROUND

Specialist palliative care services have a key role in a whole system response to COVID-19, a disease caused by the SARS-CoV-2 virus. There is a need to understand service response to share good practice and prepare for future care.

AIM

To map and understand specialist palliative care services innovations and practice changes in response to COVID-19.

DESIGN

Online survey of specialist palliative care providers (CovPall), disseminated via key stakeholders. Data collected on service characteristics, innovations and changes in response to COVID-19. Statistical analysis included frequencies, proportions and means, and free-text comments were analysed using a qualitative framework approach.

SETTING/PARTICIPANTS

Inpatient palliative care units, home nursing services, hospital and home palliative care teams from any country.

RESULTS

Four hundred and fifty-eight respondents: 277 UK, 85 Europe (except UK), 95 World (except UK and Europe), 1 missing country. 54.8% provided care across 2+ settings; 47.4% hospital palliative care teams, 57% in-patient palliative care units and 57% home palliative care teams. The crisis context meant services implemented rapid changes. Changes involved streamlining, extending and increasing outreach of services, using technology to facilitate communication, and implementing staff wellbeing innovations. Barriers included; fear and anxiety, duplication of effort, information overload and funding. Enablers included; collaborative teamwork, staff flexibility, a pre-existing IT infrastructure and strong leadership.

CONCLUSIONS

Specialist palliative care services have been flexible, highly adaptive and have adopted low-cost solutions, also called 'frugal innovations', in response to COVID-19. In addition to financial support, greater collaboration is essential to minimise duplication of effort and optimise resource use.ISRCTN16561225 https://doi.org/10.1186/ISRCTN16561225.

COVID-19, promotion and provision of palliative care: reaching out, accounting for linguistic diversity

The combined forces of economic globalization and international migration have resulted in specific challenges to palliative care systems. The COVID-19 pandemic has and is still greatly affecting elder populations as well as those across the age continuum living with long-standing chronic conditions or with pre-existing diverse unmet needs. While health promotion and palliative care may appear to be conceptually opposing fields, we argue that palliative care can and should fit under the umbrella of the health promotion continuum. This commentary seeks to discuss the importance of linguistic literacy and communication imperatives in the context of access to palliative care, given the broad, diversified and sensitive scope of care. While the pandemic has demonstrated that the public health responses of migrant host societies are deeply intertwined with policies as well as local rules and constraints, the promotion and provision of safe, timely and appropriate palliative care can be achieved through a sensitive assessment of differential contexts of diversity. The pandemic has painfully illustrated the need for a strong, respectful and equitable working partnership within the professions as well as with the civic society in order for the palliative needs of those exposed to a sustained risk not to be forgotten.

COVID-19 emergency and palliative medicine: an intervention model'

OBJECTIVES

The aim of this work is to describe the multidisciplinary model of intervention applied and the characteristics of some COVID-19 patients assisted by the hospital palliative care unit (UCP-H) of an Italian hospital in Lombardy, the Italian region most affected by the COVID-19 pandemic.

METHODS

A retrospective study was conducted on patients admitted to the A. Manzoni Hospital (Lecco, Lombardy Region, Italy) and referred to the UCP-H between 11 March 2020 and 18 April 2020, the period of maximum spread of COVID-19 in this area. Data were collected on the type of hospitalisation, triage process, modality of palliative care and psychological support provided.

RESULTS

146 COVID-10 patients were referred to the UCP-H. Of these, 120 died during the observation time (82%) while 15 (10.2%) improved and were discharged from the UCP-H care. 93 had less favourable characteristics (rapid deterioration of respiratory function, old age, multiple comorbidities) and an intensive clinical approach was considered contraindicated, while 48 patients had more favourable presentations. Mean follow-up was 4.8 days. A mean of 4.3 assessments per patient were performed. As to respiratory support, 94 patients were treated with oxygen only (at different volumes) and 45 with Continuous Positive Airway Pressure (CPAP).

CONCLUSION

The ongoing pandemic highlighted the need for dedicated palliative care teams and units for dying patients. This work highlights how palliative medicine specialist can make a fundamental contribution thanks to their ability and work experience in an organised multiprofessional context.

Experience of Palliative Care Services at Tertiary Comprehensive Cancer Center during COVID-19 Lockdown Phase: An Analytical Original Study

Background

Recent pandemic Coronavirus disease 2019 has brought the whole world to a standstill. In India too, phases of the lockdown of the country were declared. This hampered the availability of essential health-care services to needy patients. With full emphasis on the pandemic, patients suffering from other diseases and palliative oncology patients requiring essential palliative care services were affected due to the shutting down of regular health-care services.

Aim

In this study, we emphasize that in the middle of a pandemic, we need to continue serving the needs of palliative care patients, and simultaneously, necessary steps should be taken for the prevention of the spread of virus by following guidelines, training, support, and monitoring.

Materials and Methods

In this study, we analyzed electronic medical record of 1161 patients who received palliative care from our institute in the first two lockdown periods, regarding their demographics, extent of travel, type of malignancy, and opioid utilization.

Results

Of 1161 patients, male outnumbered female and the patient suffering from head-and-neck malignancy were in the maximum number (48.7%). Our essential opioids utilization rate was 34.2%, and patients who traveled from different states were 21.6%.

Conclusion

During this pandemic, we cannot overlook the need for essential palliative care services. We can continue regular services with proper precautions as advised and by training the staff. Collaboration with different palliative centers across the country should be done to minimize patient movement.

Attitudes of Front-Line Nurses Toward Hospice Care During the COVID-19 Pandemic

OBJECTIVE

The aim of this study was to understand the attitudes of front-line clinical nurses toward hospice care in the fight against the COVID-19 pandemic, to provide a source of reference for hospice care education and training in hospitals treating patients with COVID-19.

METHOD

Front-line nurses from a designated COVID-19 hospital in Wuhan, China, participated. Participants completed the Chinese versions of the General Information Questionnaire, the Frommelt Attitudes Toward Care of the Dying Scale, the Jefferson Scale of Empathy, and the General Self-Efficacy Scale.

RESULTS

A total of 149 questionnaires were included in the analysis. The median total hospice care attitudes score was median 102.00(interquartile range, 95.5-120.50). The nurses' attitudes toward hospice care were significantly associated with their age, knowledge of hospice care, level of empathy, and self-efficacy.

CONCLUSION

The attitudes of front-line nurses toward hospice care need to be improved. Hospital departments should establish an effective public health emergency strategy, provide training to increase front-line nurses' knowledge and practical experience of hospice care, cultivate nurses' empathy, and enhance their sense of self-efficacy, in order to improve the quality of hospice care for patients and their families.

The need for early referral to palliative care especially for Black, Asian and minority ethnic groups in a COVID-19 pandemic: Findings from a service evaluation

BACKGROUND

Palliative care services face challenges in adapting and responding to the COVID-19 pandemic. Understanding how palliative care needs and outcomes have changed during the pandemic compared to before the pandemic is crucial to inform service planning and research initiatives.

AIM

To evaluate the impact of COVID-19 on symptoms, clinical characteristics, and outcomes for patients referred to a hospital-based palliative care service in a district general hospital in London, UK.

DESIGN

A retrospective service evaluation. Data were extracted from the electronic patient records.

SETTING/PARTICIPANTS

The first 60 inpatients with confirmed COVID-19 infection, referred to the hospital palliative care service between 1 March 2020 and 23 April 2020, and another 60 inpatients, referred to the hospital palliative care service between 11 March 2019 and 23 April 2019, were included from a district general hospital in East London, UK.

RESULTS

Patients with COVID-19 have lower comorbidity scores, poorer performance status, and a shorter time from referral to death compared to patients without COVID-19. Breathlessness, drowsiness, agitation, and fever are the most prevalent symptoms during COVID-19 compared to pain and drowsiness pre-COVID-19. Time from admission to referral to palliative care is longer for Black, Asian and minority ethnic patients, especially during COVID-19.

CONCLUSION

Early referral to palliative care is essential in COVID-19, especially for Black, Asian and minority ethnic groups. There is urgent need to research why Black, Asian and minority ethnic patients are referred late; how palliative care services have changed; and possible solutions to setting up responsive, flexible, and integrated services.

Design of Paracetamol Delivery Systems Based on Functionalized Ordered Mesoporous Carbons

The oxidized ordered mesoporous carbons of cubic and hexagonal structure obtained by two templating methods (soft and hard) were applied for the first time as delivery systems for paracetamol—the most common antipyretic and analgesic drug in the world. The process of carbon oxidation was performed using an acidic ammonium persulfate solution at 60 °C for 6 h. The functionalization was found to reduce the specific surface area and pore volume of carbon materials, but it also led to an increasing number of acidic oxygen-containing functional groups. The most important element and the novelty of the presented study was the evaluation of adsorption and release ability of carbon carriers towards paracetamol. It was revealed that the sorption capacity and the drug release rate were mainly affected by the materials’ textural parameters and the total amount of surface functional groups, notably different in pristine and oxidized samples. The adsorption of paracetamol on the surface of ordered mesoporous carbons occurred according to different mechanisms: donor–acceptor complexes and hydrogen bond formation. The adsorption kinetics was assessed using pseudo-first- and pseudo-second-order models. The regression results indicated that the adsorption kinetics was more accurately represented by the pseudo-second-order model. Paracetamol was adsorbed onto the carbon materials studied following the Langmuir type isotherm. The presence of oxygen-containing functional groups on the surface of ordered mesoporous carbons enhanced the amount of paracetamol adsorbed and its release rate. The optimal drug loading capacity and expected release pattern exhibited oxidized ordered mesoporous carbon with a hexagonal structure obtained by the hard template method.

Predictive Value of 5 Early Warning Scores for Critical COVID-19 Patients

Objectives:

A simple evaluation tool for patients with novel coronavirus disease 2019 (COVID-19) could assist the physicians to triage COVID-19 patients effectively and rapidly. This study aimed to evaluate the predictive value of 5 early warning scores based on the admission data of critical COVID-19 patients.

Methods:

Overall, medical records of 319 COVID-19 patients were included in the study. Demographic and clinical characteristics on admission were used for calculating the Standardized Early Warning Score (SEWS), National Early Warning Score (NEWS), National Early Warning Score2 (NEWS2), Hamilton Early Warning Score (HEWS), and Modified Early Warning Score (MEWS). Data on the outcomes (survival or death) were collected for each case and extracted for overall and subgroup analysis. Receiver operating characteristic curve analyses were performed.

Results:

The area under the receiver operating characteristic curve for the SEWS, NEWS, NEWS2, HEWS, and MEWS in predicting mortality were 0.841 (95% CI: 0.765-0.916), 0.809 (95% CI: 0.727-0.891), 0.809 (95% CI: 0.727-0.891), 0.821 (95% CI: 0.748-0.895), and 0.670 (95% CI: 0.573-0.767), respectively.

Conclusions:

SEWS, NEWS, NEWS2, and HEWS demonstrated moderate discriminatory power and, therefore, offer potential utility as prognostic tools for screening severely ill COVID-19 patients. However, MEWS is not a good prognostic predictor for COVID-19.

COVID-19: guidance on palliative care from a European Respiratory Society international task force

BACKGROUND

Many people are dying from coronavirus disease 2019 (COVID-19), but consensus guidance on palliative care in COVID-19 is lacking. This new life-threatening disease has put healthcare systems under pressure, with the increased need of palliative care provided to many patients by clinicians who have limited prior experience in this field. Therefore, we aimed to make consensus recommendations for palliative care for patients with COVID-19 using the Convergence of Opinion on Recommendations and Evidence (CORE) process.

METHODS

We invited 90 international experts to complete an online survey including stating their agreement, or not, with 14 potential recommendations. At least 70% agreement on directionality was needed to provide consensus recommendations. If consensus was not achieved on the first round, a second round was conducted.

RESULTS

68 (75.6%) experts responded in the first round. Most participants were experts in palliative care, respiratory medicine or critical care medicine. In the first round, consensus was achieved on 13 recommendations based upon indirect evidence and clinical experience. In the second round, 58 (85.3%) out of 68 of the first-round experts responded, resulting in consensus for the 14th recommendation.

CONCLUSION

This multi-national task force provides consensus recommendations for palliative care for patients with COVID-19 concerning: advance care planning; (pharmacological) palliative treatment of breathlessness; clinician-patient communication; remote clinician-family communication; palliative care involvement in patients with serious COVID-19; spiritual care; psychosocial care; and bereavement care. Future studies are needed to generate empirical evidence for these recommendations.

The pathway to comfort: Role of palliative care for serious COVID-19 illness

The novel coronavirus disease (COVID-19) pandemic has led to significant distress among people of all age groups. Patients with advanced age and severe life-limiting illnesses are at increased risk of death from COVID-19. Not all patients presenting with severe illness will be eligible for aggressive intensive treatment. In limited resource setting, patients may be triaged for supportive care only. This subset of patients should be promptly identified and receive appropriate palliative care with adequate symptom control strategies and psychosocial support. Breathlessness, delirium, pain, and noisy breathing are main symptoms among these patients which can add to the suffering at end-of-life. The COVID-19 pandemic also contributes to the psychological distress due to stigma of the illness, uncertainty of the illness course, fear of death and dying in isolation, and anticipatory grief in families. Empathetic communication and holistic psychosocial support are important in providing good palliative care in COVID-19 patients and their families.

Operationalization of critical care triage during a pandemic surge using protocolized communication and integrated supportive care

Triage becomes necessary when demand for intensive care unit (ICU) resources exceeds supply. Without triage, there is a risk that patients will be admitted to the ICU in the sequence that they present, disadvantaging those who either present later or have poorer access to healthcare. Moreover, if the patients with the best prognosis are not allocated life support, there is the possibility that overall mortality will increase. Before formulating criteria, principles such as maximizing lives saved and fairness ought to have been agreed upon to guide decision-making. The triage process is subdivided into three parts, i.e., having explicit inclusion/exclusion criteria for ICU admission, prioritization of patients for allocation to available beds, and periodic reassessment of all patients already admitted to the ICU. Multi-dimensional criteria offer more holistic prognostication than only using age cutoffs. Appointed triage officers should also be enabled to make data-driven decisions. However, the process does not merely end with an allocation decision being made. Any decision has to be sensitively and transparently communicated to the patient and family. With infection control measures, there are challenges in managing communication and the psychosocial distress of dying alone. Therefore, explicit video call protocols and social services expertise will be necessary to mitigate these challenges. Besides symptom management and psychosocial management, supportive care teams play an integral role in coordination of complex cases. This scoping review found support for the three-pronged, triage-communication-supportive care approach to facilitate the smooth operationalization of the triage process in a pandemic.

A blueprint for leadership during COVID-19

Minimizing burnout and moral distress among the nursing workforce.

Resolution of coronavirus disease 2019 (COVID-19)

INTRODUCTION

Coronavirus disease 2019 (COVID-19) was first detected in China in December, 2019, and declared as a pandemic by the World Health Organization (WHO) on March 11, 2020. The current management of COVID-19 is based generally on supportive therapy and treatment to prevent respiratory failure. The effective option of antiviral therapy and vaccination are currently under evaluation and development.

AREAS COVERED

A literature search was performed using PubMed between December 1, 2019-June 23, 2020. This review highlights the current state of knowledge on the viral replication and pathogenicity, diagnostic and therapeutic strategies, and management of COVID-19. This review will be of interest to scientists and clinicians and make a significant contribution toward development of vaccines and targeted therapies to contain the pandemic.

EXPERT OPINION

The exit strategy for a path back to normal life is required, which should involve a multi-prong effort toward development of new treatment and a successful vaccine to protect public health worldwide and prevent future COVID-19 outbreaks. Therefore, the bench to bedside translational research as well as reverse translational works focusing bedside to bench is very important and would provide the foundation for the development of targeted drugs and vaccines for COVID-19 infections.

Dying individuals and suffering populations: applying a population-level bioethics lens to palliative care in humanitarian contexts: before, during and after the COVID-19 pandemic

BACKGROUND

Humanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care-a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, the WHO released a guide on 'Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises'-the first guidance on the topic by an international body.

AIMS

This paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.

IMPLICATIONS

In parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance.