End-of-life care in natural disasters including epidemics and pandemics: a systematic review

Assessing the ripple effects of natural disasters on healthcare systems: a narrative review

PURPOSE OF REVIEW

Natural disasters are on the rise, driven by shifts in climatic patterns largely attributed to human-induced climate change. This relentless march of climate change intensifies the frequency and severity of these disasters, heightening the vulnerability of communities and causing significant harm to both lives and socio-economic systems. Healthcare services are particularly strained during extreme weather events, with impacts felt not only on infrastructure but also on patient care.

RECENT FINDINGS

This narrative review explored the overarching impact of natural disasters on healthcare infrastructure. We delved into how these disasters impact diverse health conditions, the healthcare systems of low and middle-income countries (LMICs), the psychological toll on both clinicians and survivors, and the ramifications for end-of-life care.

SUMMARY

Natural disasters significantly impact healthcare, especially in LMICs due to their limited resources. Patients with cancer or chronic diseases struggle to access care following a natural disaster. Those in need for palliative care experience delay due to shortages in medical resources. Psychological consequences like posttraumatic stress disorder on disaster survivors and healthcare providers highlight the need for mental health support. Addressing challenges requires proactive disaster preparedness policies and urgent public policy initiatives are needed for optimal disaster response.

Palliative care needs of people and/or their families with serious and/or chronic health conditions in low- or middle-income country (LMIC) humanitarian settings-a systematic scoping review protocol

BACKGROUND

Palliative care in low- or middle-income country (LMIC) humanitarian settings is a new area, experiencing a degree of increased momentum over recent years. The review contributes to this growing body of knowledge, in addition to identifying gaps for future research. The overall aim is to systematically explore the evidence on palliative care needs of patients and/or their families in LMIC humanitarian settings.

METHODS

Arksey and O'Malley's (Int J Soc Res Methodol. 8:19-32, 2005) scoping review framework forms the basis of the study design, following further guidance from Levac et al. (Implement Sci 5:1-9, 2010), the Joanna Briggs Institute (JBI) Peters et al. (JBI Reviewer's Manual JBI: 406-452, 2020), and the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) from Tricco et al. (Ann Intern Med 169:467-73, 2018). This incorporates a five-step approach and the population, concept, and context (PCC) framework. Using already identified key words/terms, searches for both published research and gray literature from January 2012 to October 2022 will be undertaken using databases (likely to include Cumulative Index of Nursing and Allied Health (CINAHL), MEDLINE, Embase, Global Health, Scopus, Applied Social Science Index and Abstracts (ASSIA), Web of Science, Policy Commons, JSTOR, Library Network International Monetary Fund and World Bank, Google Advanced Search, and Google Scholar) in addition to selected pre-print sites and websites. Data selection will be undertaken based on the inclusion and exclusion criteria and will be reviewed at each stage by two reviewers, with a third to resolve any differences. Extracted data will be charted in a table. Ethical approval is not required for this review.

DISCUSSION

Findings will be presented in tables and diagrams/charts, followed by a narrative description. The review will run from late October 2022 to early 2023. This is the first systematic scoping review specifically exploring the palliative care needs of patients and/or their family, in LMIC humanitarian settings. The paper from the review findings will be submitted for publication in 2023.

COVID-19 and End of Life in a Quaternary Australian Hospital: Referral for Palliative Care Consultation

Background

The coronavirus disease 2019 (COVID-19) pandemic resulted in complex physical and psychosocial symptom burden at end of life. The benefit of specialist palliative care input in other disease states has been established, however, there is little evidence on referral patterns to these services in patients dying from COVID-19.

Objectives

This retrospective audit investigated the referral patterns for patients who died from COVID-19 at a quaternary hospital in South Australia (the Royal Adelaide Hospital) over a six-month period in 2022, and whether demographic features or COVID-19 specific factors had an impact on whether these patients received specialist palliative care services (PCS). The second aim was to identify prescription patterns for patients in the last 24 hours of life, and whether this was impacted by referral.

Method

Data were obtained from electronic medical records and analyzed using binary logistic regressions for referral to PCS versus no referral based on various predictors.

Results

There was no significant difference comparing patient demographics or COVID-19 specific factors with referral to PCS. There was statistical significance between patients who received referral to PCS and those who had a higher oral morphine equivalent daily dose (OMEDD) in the 24 hours before death, as well as the presence of a continuous subcutaneous infusion. Although the cause of this relationship is undetermined, it may represent the prescription patterns of the palliative care physicians during consultation or potentially higher symptom burden prompting referral. There was also a higher proportion of patients who received hydromorphone compared with other opioids, though the OMEDD was consistent with other published literature.

How initial policy responses to COVID-19 contributed to shaping dying at home preferences and care provision: key informant perspectives from Canada

OBJECTIVES

In response to COVID-19's first wave, provincial governments rapidly implemented several public health directives, including isolation measures and care facility visitor restrictions, which profoundly affected healthcare delivery at the end of life and dying experiences and perceptions. The objective of this study was to identify implications of early policy changes for dying at home.

METHODS

Analysis of interviews with 29 key informants with expertise in the policy and practice context of dying at home and care for those dying at home was conducted as part of a larger mixed-methods study on dying at home in Canada.

RESULTS

Initial pandemic policy responses, especially visitor restrictions and limitations to home care services, shaped dying at home in relation to three themes: (1) increasing preferences and demand for, yet constrained system ability to support dying at home; (2) reinforcing and illuminating systemic reliance on and need for family/friend caregivers and community organizations, while constraining their abilities to help people die at home; and (3) illuminating challenges in developing and implementing policy changes during a pandemic, including equity-related implications.

CONCLUSION

This study contributes to broader understanding of the multifaceted impacts of COVID-19 policy responses in various areas within Canadian healthcare systems. Implications for healthcare delivery and policy development include (1) recognizing the role of family/friend caregivers and community organizations in end-of-life care, (2) recognizing health inequities at the end of life, and (3) considering possible changes in future end-of-life preferences and public attitudes about dying at home and responsibility for end-of-life care.

Barriers to and facilitators of advance care planning implementation for medical staff after the COVID-19 pandemic: an overview of reviews

OBJECTIVE

The COVID-19 pandemic has impacted the capacity for advance care planning (ACP) among patients, families and healthcare teams. We sought to identify and review the barriers to and facilitators of ACP implementation for medical staff in different settings (eg, hospitals, outpatient palliative care, nursing and care homes) during the pandemic.

DESIGN

This study employed an overview of reviews design. We searched the MEDLINE, CENTRAL, Web of Science and Embase databases for studies published between 8 December 2019 and 30 July 2023. We used AMSTAR 2 to assess the risk of bias.

RESULTS

We included seven reviews. Common barriers to ACP implementation included visitation restrictions, limited resources and personnel and a lack of coordination among healthcare professionals. In care and nursing homes, barriers included a dearth of palliative care physicians and the psychological burden on facility staff. Using telemedicine for information sharing was a common facilitator across settings. In hospitals, facilitators included short-term training in palliative care and palliative care physicians joining the acute care team. In care and nursing homes, facilitators included ACP education and emotional support for staff.

CONCLUSIONS

Visitation restrictions and limited resources during the pandemic posed obstacles; however, the implementation of ACP was further hindered by insufficient staff education on ACP in hospitals and facilities, as well as a scarcity of information sharing at the community level. These pre-existing issues were magnified by the pandemic, drawing attention to their significance. Short-term staff training programmes and immediate information sharing could better enable ACP.

PROSPERO REGISTRATION NUMBER

CRD42022351362.

Hospice and Palliative Care during Disasters: A Systematic Review

Providing and maintaining hospice and palliative care during disasters poses significant challenges. To understand the impact of disasters on the provision of hospice and palliative care and the disaster preparedness initiatives in the field, a systematic review was undertaken. Eligibility criteria for the selection of studies were: peer-reviewed original research papers addressing HPC during disasters published between January 2001 and February 2023 in English. The databases CINAHL, MEDLINE, APA PsycInfo, APA PsycArticles, and SocINDEX were searched with textword and MeSh-terms between October 2022 and February 2023. The Mixed Methods Appraisal Tool (MMAT) was used to assess the quality of the studies. Content analysis was performed. The results are presented in the form of a narrative synthesis. Of 2581 studies identified, 57 met the inclusion criteria. Most studies were published recently on the impact of the COVID-19 pandemic. Four main themes were identified in the literature: disruption of the system, setting-specific differences, emotional challenges, and system adaptation. Overall, strategies to tackle hospice and palliative care needs have been poorly integrated in disaster preparedness planning. Our findings highlight the need to strengthen the resilience of hospice and palliative care providers to all types of disasters to maintain care standards.

A bad time to die? Exploring bereaved families/wha-nau experiences of end-of-life care under COVID-19 restrictions: a qualitative interview study

Background

There have been international concerns raised that, during the COVID-19 pandemic, there was an absence of good palliative care resulting in poor end-of-life care experiences. To date, there have been few studies considering the pandemic's impact on people dying from non-COVID-19 causes and their families and friends. In particular, there has been very less empirical research in relation to end-of-life care for Indigenous, migrant and minoritised ethnic communities.

Objectives

To explore bereaved next-of-kin's views and experiences of end-of-life care under COVID-19 pandemic regulations.

Design

This qualitative study involved in-depth one-off interviews with 30 ethnically diverse next-of-kin who had a family member die in the first year of the pandemic in Aotearoa, New Zealand.

Methods

Interviews were conducted by ethnically matched interviewers/interviewees. A reflexive thematic analysis was used to explore and conceptualise their accounts.

Results

A key finding was that dying alone and contracting COVID-19 were seen as equally significant risks by bereaved families. Through this analysis, we identified five key themes: (1) compromised connection; (2) uncertain communication; (3) cultural safety; (4) supported grieving and (5) silver linings.

Conclusion

This article emphasises the importance of enabling safe and supported access for family/whanau to be with their family/wha-nau member at end-of-life. We identify a need for wider provision of bereavement support. We recommend that policy makers increase resourcing of palliative care services to ensure that patients and their families receive high-quality end-of-life care, both during and post this pandemic. Policy makers could also promote a culturally-diverse end-of-life care work force and the embedding of culturally-safety practices across a range of institutions where people die.

"I can't make all this work." End of life care provision in natural disasters: a qualitative study

BACKGROUND

Natural disasters are becoming more frequent and severe and profoundly impact the end-of-life care experience, including service provision. There is a paucity of research examining healthcare workers' experiences in responding to care demands when disasters strike. This research aimed to fill this gap by exploring end-of-life care providers' perceptions of the impact of natural disasters on end-of-life care.

METHODS

Between Feb 2021-June 2021 ten in-depth semi-structured interviews were conducted with healthcare professionals providing end-of-life care during recent natural disasters, COVID-19, and/or fires and floods. Interviews were audio-recorded, transcribed, and analysed using a hybrid inductive and deductive thematic approach.

RESULTS

The overarching theme from the healthcare workers' accounts was of being unable to provide effective compassionate and quality care - "I can't make all this work." They spoke of the considerable burdens the system imposed on them, of being overextended and overwhelmed, having their roles overturned, and losing the human element of care for those at end-of-life.

CONCLUSION

There is urgent need to pioneer effective solutions to minimise the distress of healthcare professionals in delivering end-of-life care in disaster contexts, and to improve the experience of those dying.

Dying during the COVID-19 Pandemic in Sweden: Relatives' Experiences of End-of-Life Care (the CO-LIVE Study)

Background: The COVID-19 pandemic has seen many deaths, but the majority were for causes other than COVID-19. However, end-of-life care in all settings has been affected by measures limiting the spread of the virus, for patients with and without COVID-19. The Swedish coronavirus strategy was different compared to many other countries, which might have affected end-of-life care. The aim was to describe the experiences of end-of-life care for bereaved relatives in Sweden during the “first wave” and to compare the experiences for deaths due to COVID-19 with the experiences for deaths for other reasons. Methods: A random sample of addresses for 2400 people who died during March−September 2020 was retrieved from the Swedish Person Address Registry. Relatives were contacted with a questionnaire regarding their experience of end-of-life care, with a focus on communication, participation, and trust. Results: In total, 587 relatives (25% response rate) answered the questionnaire (14% COVID-19-deaths, 65% non-COVID-19-deaths, 21% uncertain). In the COVID-19 group 28% of the relatives were allowed visits without restrictions compared to 60% in the non-COVID-19 group (p < 0.01). Only 28% of the relatives in the COVID-19 group reported that the person received “enough care from physicians”, significantly fewer than the non-COVID group (65%, p < 0.01). Conclusion: Relatives’ experience of end-of-life care for persons with COVID-19 was significantly worse than relatives of persons without COVID-19, but relatives for persons without COVID-19 were also negatively affected.

Impact of COVID-19 on the End-of-Life Care of Cancer Patients Who Died in a Korean Tertiary Hospital: A Retrospective Study

Purpose

Social distancing and strict visitor restrictions at hospitals have been national policies since the onset of the coronavirus disease 2019 (COVID-19) pandemic. This has challenged the concept of a good death in comfort with the opportunity to say goodbye. Little is known about how these measures have influenced end-of-life (EOL) care among cancer patients who die in acute care hospitals. This study examined changes in the EOL care of cancer patients during the COVID-19 pandemic.

Methods

We retrospectively analyzed 1,456 adult cancer patients who died in 2019 (n=752) and 2020 (n=704) at a tertiary hospital. Data on EOL care-symptom control and comfort care in an imminently dying state, preparation for death, place of death, and aggressive care in the last month-were reviewed.

Results

The 1,456 patients had a median age of 67 years, and 62.5% were men. Patients who died in 2020 were more likely to experience agitation or delirium before death (17.2% vs. 10.9%), to use inotropes/vasopressors near death (59.2% vs. 52.3%), and to receive cardiopulmonary resuscitation in their last months (16.3% vs. 12.5%) than those who died in 2019. Additionally, the number of deaths in the emergency room doubled in 2020 compared to 2019 (from 7.1% to 14.1%).

Conclusion

This study suggests that EOL care for cancer patients who died in a tertiary hospital deteriorated during the COVID-19 pandemic. The implementation of medical care at the EOL and the preferred place of death should be discussed carefully in advance for high-quality EOL care.

Palliative Care Early in the Care Continuum among Patients with Serious Respiratory Illness: An Official ATS/AAHPM/HPNA/SWHPN Policy Statement

Background: Patients with serious respiratory illness and their caregivers suffer considerable burdens, and palliative care is a fundamental right for anyone who needs it. However, the overwhelming majority of patients do not receive timely palliative care before the end of life, despite robust evidence for improved outcomes. Goals: This policy statement by the American Thoracic Society (ATS) and partnering societies advocates for improved integration of high-quality palliative care early in the care continuum for patients with serious respiratory illness and their caregivers and provides clinicians and policymakers with a framework to accomplish this. Methods: An international and interprofessional expert committee, including patients and caregivers, achieved consensus across a diverse working group representing pulmonary-critical care, palliative care, bioethics, health law and policy, geriatrics, nursing, physiotherapy, social work, pharmacy, patient advocacy, psychology, and sociology. Results: The committee developed fundamental values, principles, and policy recommendations for integrating palliative care in serious respiratory illness care across seven domains: 1) delivery models, 2) comprehensive symptom assessment and management, 3) advance care planning and goals of care discussions, 4) caregiver support, 5) health disparities, 6) mass casualty events and emergency preparedness, and 7) research priorities. The recommendations encourage timely integration of palliative care, promote innovative primary and secondary or specialist palliative care delivery models, and advocate for research and policy initiatives to improve the availability and quality of palliative care for patients and their caregivers. Conclusions: This multisociety policy statement establishes a framework for early palliative care in serious respiratory illness and provides guidance for pulmonary-critical care clinicians and policymakers for its proactive integration.

Identifying barriers and facilitators to palliative care integration in the management of hospitalized patients with COVID-19: A qualitative study

BACKGROUND

Palliative care is well suited to support patients hospitalized with COVID-19, but integration into care has been variable and generally poor.

AIM

To understand barriers and facilitators of palliative care integration for hospitalized patients with COVID-19.

METHODS

Internists, Intensivists and palliative care physicians completed semi-structured interviews about their experiences providing care to patients with COVID-19. Results were analysed using thematic analysis.

RESULTS

Twenty-three physicians (13 specialist palliative care, five intensivists, five general internists) were interviewed; mean ± SD age was 42 ± 11 years and 61% were female. Six thematic categories were described including: patient and family factors, palliative care knowledge, primary provider factors, COVID-19 specific factors, palliative care service factors, and leadership and culture factors. Patient and family factors included patient prognosis, characteristics that implied prognosis (i.e., age, etc.), and goals of care. Palliative care knowledge included confidence in primary palliative care skills, misperception that COVID-19 is not a 'palliative diagnosis', and the need to choose quantity or quality of life in COVID-19 management. Primary provider factors included available time, attitude, and reimbursement. COVID-19 specific factors were COVID-19 as an impetus to act, uncertain illness trajectory, treatments and outcomes, and infection control measures. Palliative care service factors were accessibility, adaptability, and previous successful relationships. Leadership and culture factors included government-mandated support, presence at COVID planning tables, and institutional and unit culture.

CONCLUSION

The study findings highlight the need for leadership support for formal integrated models of palliative care for patients with COVID-19, a palliative care role in pandemic planning, and educational initiatives with primary palliative care providers.

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.

Are public health measures and individualised care compatible in the face of a pandemic? A national observational study of bereaved relatives' experiences during the COVID-19 pandemic

BACKGROUND

COVID-19 public health restrictions have affected end-of-life care experiences for dying patients and their families.

AIM

To explore bereaved relatives' experiences of quality of care and family support provided during the last days of life; to identify the impact of factors associated with perceived support.

DESIGN

A national, observational, open online survey was developed and disseminated via social media, public fora and professional networks (June-September 2020). Validated instruments and purposively designed questions assessed experiences. Analysis used descriptive statistics, logistic regression and thematic analysis of free-text responses.

PARTICIPANTS

Individuals (⩾18 years) who had experienced the death of a relative/friend (all care settings) within the United Kingdome during the COVID-19 pandemic.

RESULTS

Respondents (n = 278, mean 53.4 years) tended to be female (n = 216, 78%); over half were 'son/daughter' (174, 62.6%) to the deceased. Deceased individuals (mean 81.6 years) most frequently died in their 'usual place of care' (n = 192, 69.3%). Analysis established five conceptual themes affecting individualised care: (1) public health restrictions compounding the distress of 'not knowing'; (2) disparate views about support from doctors and nurses; (3) challenges in communication and level of preparedness for the death; (4) delivery of compassionate care; (5) emotional needs and potential impact on grief. Male respondents (OR 2.9, p = 0.03) and those able to visit (OR 2.2, p = 0.04) were independently associated with good perceptions of family support.

CONCLUSION

Despite public health restrictions, individualised care can be enabled by proactive, informative communication; recognising dying in a timely manner and facilitating the ability to be present before death.