COVID-19: decision making and palliative care

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.

Do-Not-ResuscitateDecision-Making during the COVID-19 Pandemic in a Teaching Hospital: Lessons Learned for the Future

Method

A cross-sectional survey study was conducted between February 2021 and April 2021 for all doctors and doctors in training, working in the Antwerp University Hospital during the COVID-19 pandemic.

Results

127 doctors participated in this study. The familiarity with the different scores used in the triage during the COVID-10 pandemic was 51% for the Clinical Frailty Scale (CFS) and 20% for the Charlson Comorbidity Index (CCI). Participants indicated that their DNR decision is based on various aspects such as clinical assessment, comorbidities, patient's wishes, age, prognosis, and functional state.

Conclusion

The familiarity with the different scores used during triage assessments is low. The total clinical picture of the patient is needed to make a considered decision, and this total picture of the patient seems to be well encompassed by frailty measurement (CFS). Although many participants indicated that the different scores do not offer much added value compared to their clinical assessment, it can help guide DNR decisions, especially for doctors in training.

Evaluation of a New Triage Protocol for Palliative Care for Patients with COVID-19 in Brazil

Objectives: To evaluate the implementation of a triage protocol for palliative care (PC) during the COVID-19 pandemic (PALI-COVID) at a referral center in Brazil. Methods: A retrospective observational study was conducted. Based on the triage protocol, patients were classified into a red group, a yellow group, and a green group (GG). Patients should receive PC as recommended for each group. Results: A total of 1517 patients were included in the analysis. About 11% (n = 162) of patients received PC. About 35% (n = 529) of all patients died. There was a significant difference in the mortality rate between the groups; the GG had the highest mortality rate. Most patients who died (77.1%) did not receive PC. Conclusion: PALI-COVID was effective in identifying patients who had a higher risk of death and needed end-of-life support. Despite the protocol, few patients received PC.

Conflict and communication gap among the critical care nurses during care of patients with COVID-19

Background

COVID-19 overwhelmed many countries' healthcare systems causing high levels of conflict amongst frontlines nurses.

Aim

Explore the conflict level and communication gap among the critical care nurses during care of patients with COVID-19.

Subjects and methods

A descriptive exploratory design was utilized on a convenience sample of (80) nurse working at the Critical Care Units affiliated to a specialized isolation hospital in Ismailia City, Egypt, from May to July 2020 using self-administered questionnaire to assess types of conflicts and Rahim Organizational Conflict Inventory-II to assess staff nurses' conflict resolution strategies.

Results

All the critical care nurses experienced conflict with significance level in female, due to recurrent contact with infected patients and fear of infection for themselves and their loved ones.

Conclusion

Around half of nurses (42.5%) had moderate conflict level, and collaborating was the most common used conflict resolution strategy.

Recommendations

Training in conflict resolution strategies during outbreaking terrorism as COVID- 19.

Evaluating methodological approaches to assess the severity of infection with SARS-CoV-2 variants: scoping review and applications on Belgian COVID-19 data

Background

Differences in the genetic material of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) variants may result in altered virulence characteristics. Assessing the disease severity caused by newly emerging variants is essential to estimate their impact on public health. However, causally inferring the intrinsic severity of infection with variants using observational data is a challenging process on which guidance is still limited. We describe potential limitations and biases that researchers are confronted with and evaluate different methodological approaches to study the severity of infection with SARS-CoV-2 variants.

Methods

We reviewed the literature to identify limitations and potential biases in methods used to study the severity of infection with a particular variant. The impact of different methodological choices is illustrated by using real-world data of Belgian hospitalized COVID-19 patients.

Results

We observed different ways of defining coronavirus disease 2019 (COVID-19) disease severity (e.g., admission to the hospital or intensive care unit versus the occurrence of severe complications or death) and exposure to a variant (e.g., linkage of the sequencing or genotyping result with the patient data through a unique identifier versus categorization of patients based on time periods). Different potential selection biases (e.g., overcontrol bias, endogenous selection bias, sample truncation bias) and factors fluctuating over time (e.g., medical expertise and therapeutic strategies, vaccination coverage and natural immunity, pressure on the healthcare system, affected population groups) according to the successive waves of COVID-19, dominated by different variants, were identified. Using data of Belgian hospitalized COVID-19 patients, we were able to document (i) the robustness of the analyses when using different variant exposure ascertainment methods, (ii) indications of the presence of selection bias and (iii) how important confounding variables are fluctuating over time.

Conclusions

When estimating the unbiased marginal effect of SARS-CoV-2 variants on the severity of infection, different strategies can be used and different assumptions can be made, potentially leading to different conclusions. We propose four best practices to identify and reduce potential bias introduced by the study design, the data analysis approach, and the features of the underlying surveillance strategies and data infrastructure.

Clinical competency and psychological empowerment among ICU nurses caring for COVID-19 patients: A cross-sectional survey study

Aim

This study aimed to determine clinical competency and psychological empowerment among ICU nurses caring for COVID‐19 patients.

Background

Nurses need clinical competency (skills pertaining to knowledge, reasoning, emotions and communication) and psychological empowerment (regard for one's organisational role and efforts) to deliver quality care.

Methods

This cross‐sectional study was conducted with 207 nurses working in ICUs in Iran. A clinical competency survey instrument consisting of basic demographic questions and the Spreitzer psychological empowerment questionnaire was completed online. Descriptive and inferential statistics were used to analyse the data in SPSS software version 13 to address the primary research question.

Results

There was a significant positive relationship between clinical competency and psychological empowerment (r = .55, p < .001). Clinical competency had a significant positive relationship with work experiences (r = .17, p = .01).

Conclusion

Clinical competency has been tied to nurse health and quality of care. Given the significant positive relationship between clinical competency and psychological empowerment, attention must be given to ways to psychologically empower nurses.

Implications for Nursing Management

Nursing managers can consider the promotion of psychological empowerment related to its significant positive relationship to clinical competency. Psychological empowerment can be bolstered through the promotion of servant leadership, organisational justice and empowering leadership practices.

How should health care providers inform about palliative sedation? A qualitative study with palliative care professionals

Objective

In Switzerland, palliative sedation consists of using sedatives to relieve terminally ill patients. It is divided into several steps, with one of them consisting of informing patients and relatives about the procedure. In the current recommendations, there is a lack of orientation about how and when this discussion should take place. Hence, we aim to explore perceptions and experiences of palliative care professionals regarding these questions.

Methods

Qualitative semi‐structured interviews with five physicians and five nurses working in specialised palliative care were conducted. They were then analysed with thematic analysis.

Results

Results showed a uniformity around definition, goals and indications of palliative sedation. However, there was a lack of consistency regarding the process of delivering this information to patients and relatives. Finally, some participants strongly opposed the idea of systematically informing patients in specialised palliative care, while others were more divided on this question.

Conclusion

Despite a common understanding of the concept of palliative sedation, there is no standard practice when informing patients on palliative sedation among palliative care professionals. Therefore, this study demonstrates the need for further guidelines on this question and calls for a better understanding and knowledge of palliative sedation among health professionals outside palliative care.

The pain in the Emergency Department: Choosing and treating wisely before and during the COVID-19 era

Pain is a frequent reason for referral to the Emergency Department (ED). Adequate management of pain is a moral and ethical imperative. If not correctly treated, acute pain can cause physical and psychological complications, and become chronic with severe consequences such as anxiety, depression, and social isolation. As consequence, emergency clinicians should treat pain as soon as possible, avoiding delays even in case of acute abdominal pain. Pain management is particularly complex in the elderly and emergency clinicians should always consider AGS Beers criteria ® to avoid inappropriate medications, severe side-effects, and drug-drug interactions. Pain is also a common cause of delirium in older patients. The SARS CoV-2 infection not only can cause acute pain, but also exacerbate chronic pain, particularly in the elderly, who are at high risk to be infected. Looking at all this evidence, emergency clinicians should treat pain with different strategies according to their experience and cultural background, making the right choice for each patient. This work is a critical review of the pain management in the ED, with a particular attention on the effects of COVID-19 in the EDs. We conducted a systematic search of the following databases: PubMed, Google Scholar, Science Direct, Medline from 2000 to 2020, using the keywords of “pain”, “emergency”, “COVID19”, “elderly”, “palliative care”, “ketamine”, “dexmedetomidine”, and “post-traumatic stress disorder”. The aim of this review is to help emergency clinicians to correctly manage pain in the ED with a new point of view regarding the pain management in COVID-19 patients.

Ethical Conflict and Its Psychological Correlates among Hospital Nurses in the Pandemic: A Cross-Sectional Study within Swiss COVID-19 and Non-COVID-19 Wards

Background: During the Covid-19 pandemic, nurses experienced increased pressure. Consequently, ethical concerns and psychological distress emerged. This study aimed to assess nurses’ ethical conflict, resilience and psychological impact, and compare these variables between nurses who worked in Covid-19 wards and nurses who did not. Methods: Design—Multicentre online survey. Setting—Multi-site public hospital; all nursing staff were invited to participate. The survey included validated tools and a novel instrument to assess ethical conflict. Spearman’s rho coefficient was used to assess correlations between ethical conflict and psychological distress, logistic regressions to evaluate relationships between nurses’ characteristics and outcome variables, and the Mann–Whitney/t-test to compare groups. Results: 548 questionnaires out of 2039 were returned (275 = Covid-19; 273 = non-Covid-19). We found a low–moderate level of ethical conflict (median = 111.5 [76–152]), which emerged mostly for seeing patients dying alone. A moderate and significant positive correlation emerged between ethical conflict and psychological distress rs (546) = 0.453, p < 0.001. Nurses working in Covid-19-ICUs (OR = 7.18; 95%CI = 3.96–13.01; p < 0.001) and Covid-19 wards (OR = 5.85; 95%CI = 3.56–9.6; p < 0.001) showed higher ethical conflict. Resilience was a protective factor for ethical conflict. Conclusions: Ethical conflict was significantly linked to psychological distress, while a higher level of resilience was found to be a protective factor. These results can be informative for nursing management in future similar crises.

COVID-19 Pandemic and Cancer: The Importance of Early Palliative Care

In terms of clinical and ethical situations, this narrative compares the COVID‐19 pandemic to the cancer endemic and shares information that may be helpful to improve the management of both future pandemics and cancer care.

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.

A Novel Causal Risk-Based Decision-Making Methodology: The Case of Coronavirus

Either in the form of nature's wrath or a pandemic, catastrophes cause major destructions in societies, thus requiring policy and decisionmakers to take urgent action by evaluating a host of interdependent parameters, and possible scenarios. The primary purpose of this article is to propose a novel risk-based, decision-making methodology capable of unveiling causal relationships between pairs of variables. Motivated by the ongoing global emergency of the coronavirus pandemic, the article elaborates on this powerful quantitative framework drawing on data from the United States at the county level aiming at assisting policy and decision makers in taking timely action amid this emergency. This methodology offers a basis for identifying potential scenarios and consequences of the ongoing 2020 pandemic by drawing on weather variables to examine the causal impact of changing weather on the trend of daily coronavirus cases.

Patient-centered approach to pharmaceutical care in the recovery of patients with post-Covid syndrome

The possibilities for pharmaceutical care in the recovery of patients with post-COVID syndrome in the context of a patient-centered approach have been explored. The global COVID-19 pandemic has necessitated a reorientation of the concept of providing healthcare to patients with COVID and post-COVID syndrome in patient-centered treatment and rehabilitation. Maximum recovery in holistic practice adopts a broader view of the patient’s health, disease and treatment process. Applying a patient-centered approach to patients who have had a coronavirus infection will lead to many benefits, both in terms of the quality of health and pharmaceutical care, and in increasing their satisfaction with their quality of life.

Perceptions of the Importance of Advance Care Planning During the COVID-19 Pandemic Among Older Adults Living With HIV

Background: The importance of advance care planning (ACP) discussions have been heightened during the COVID-19 pandemic. We assessed advance directive completion, healthcare proxy (HCP), and attitudes toward ACP among older adults ages 50+ living with HIV during the COVID-19 pandemic. Methods: Internet-based surveys were administered to 100 participants residing in the Coachella Valley, California from April to June 2020. We examined self-reported completion of an advance directive, HCP, and attitudes toward ACP before and after COVID-19. Adjusted regressions were performed on attitudes toward ACP. Results: Participants' mean age was 64.2 years, most were non-Hispanic white (88.0%), men (96.0%), and identified as sexual minorities (96.0%). Many reported having an advance directive (59.6%) or HCP (67.3%). Most (57.6%) believed ACP to be more important now compared to the pre-pandemic era. Having an advance directive was associated with increase in age, higher education, living with other people, never having an AIDS diagnosis, and current undetectable viral load (p < 0.05). Having a HCP was associated with higher education, being married/partnered, and living with other people (p < 0.05). In a logistic regression model adjusted for education and living situation, the belief that ACP was more important during COVID was associated with not having an advance directive (OR: 5.07, 95% CI: 1.78-14.40) and fear of COVID-19 infection (OR: 4.17, 95% CI: 1.61-10.76.) Conclusions: The COVID-19 pandemic presents a window of opportunity to engage people aging with HIV in ACP discussions, particularly those who do not already have an advance directive.

Religious Support as a Contribution to Face the Effects of Social Isolation in Mental Health During the Pandemic of COVID-19

Coping with the COVID-19 pandemic has required measures to contain the contagion, including social isolation. However, this and other factors have caused mental health problems, both in patients and health professionals and in family members or asymptomatic population. Religious support can be an ally for this type of confrontation. In the case of the COVID-19 pandemic, spiritual/religious care has been restricted and insufficient. When accessible to patients and frontline professionals, they are offered by virtual means, almost always by recorded media and made available in bulk. This essay argues, based on references in the areas of psychology, psychoneuroimmunology, biosafety, and military, that the face-to-face and personalized relationship between religious leaders, patients, health professionals, family members, and faith communities is as essential as possible for the dignified treatment victims, referral to spiritual needs and resilience of society, in addition to contributing to the improvement of the immune response of all. Practical examples are cited in the areas of military chaplaincy and hospital civilian chaplaincy. The essay also proposes the adoption of protocols already published by WHO and other safety measures such as the use of robotics and the recruitment/training of mass chaplains. In addition to contributing to the improvement of COVID-19 pandemic coping processes, the study also contributes to improving the delivery of spiritual/religious care as an ally to physical and mental, individual, and collective health.

Practical nursing recommendations for palliative care for people with dementia living in long-term care facilities during the COVID-19 pandemic: A rapid scoping review

BACKGROUND

The acute nature of COVID-19 and its effects on society in terms of social distancing and quarantine regulations affect the provision of palliative care for people with dementia who live in long-term care facilities. The current COVID-19 pandemic poses a challenge to nursing staff, who are in a key position to provide high-quality palliative care for people with dementia and their families.

OBJECTIVE

To formulate practice recommendations for nursing staff with regard to providing palliative dementia care in times of COVID-19.

DESIGN AND METHOD

A rapid scoping review following guidelines from the Joanna Briggs Institute. Eligible papers focused on COVID-19 in combination with palliative care for older people or people with dementia and informed practical nursing recommendations for long-term care facilities. After data extraction, we formulated recommendations covering essential domains in palliative care adapted from the National Consensus Project's Clinical Practice Guidelines for Quality Palliative Care.

DATA SOURCES

We searched the bibliographic databases of PubMed, CINAHL and PsycINFO for academic publications. We searched for grey literature using the search engine Google. Moreover, we included relevant letters and editorials, guidelines, web articles and policy papers published by knowledge and professional institutes or associations in dementia and palliative care.

RESULTS

In total, 23 documents (7 (special) articles in peer-reviewed journals, 6 guides, 4 letters to editors, 2 web articles (blogs), 2 reports, a correspondence paper and a position paper) were included. The highest number of papers informed recommendations under the domains 'advance care planning' and 'psychological aspects of care'. The lowest number of papers informed the domains 'ethical care', 'care of the dying', 'spiritual care' and 'bereavement care'. We found no papers that informed the 'cultural aspects of care' domain.

CONCLUSION

Literature that focuses specifically on palliative care for people with dementia in long-term care facilities during the COVID-19 pandemic is still largely lacking. Particular challenges that need addressing involve care of the dying and the bereaved, and ethical, cultural and spiritual aspects of care. Moreover, we must acknowledge grief and moral distress among nursing staff. Nursing leadership is needed to safeguard the quality of care and nursing staff should work together within an interprofessional care team to initiate advance care planning conversations in a timely manner, to review and document advance care plans, and to adapt goals of care as they may change due to the COVID-19 situation. Tweetable abstract: The current COVID-19 pandemic affects people living with dementia, their families and their professional caregivers. This rapid scoping review searched for academic and grey literature to formulate practical recommendations for nursing staff working in long-term care facilities on how to provide palliative care for people with dementia in times of COVID-19. There is a particular need for grief and bereavement support and we must acknowledge grief and moral distress among nursing staff. This review exposes practice and knowledge gaps in the response to COVID-19 that reflect the longstanding neglect and weaknesses of palliative care in the long-term care sector. Nursing leadership is needed to safeguard the quality of palliative care, interprofessional collaboration and peer support among nursing staff.

Ethical Challenges in Health Care Policy during COVID-19 Pandemic in Italy

Since the outbreak of the coronavirus disease 2019 (COVID-19) pandemic, Italy has proven to be one of the countries with the highest coronavirus-linked death rate. To reduce the impact of SARS-CoV-2 coronavirus, the Italian Government decision-makers issued a series of law decrees that imposed measures limiting social contacts, stopped non-essential production activities, and restructured public health care in order to privilege assistance to patients infected with SARS-CoV-2. Health care services were substantially limited including planned hospitalization and elective surgeries. These substantial measures were criticized due to their impact on individual rights including freedom and autonomy, but were justified by the awareness that hospitals would have been unable to cope with the surge of infected people who needed treatment for COVID-19. The imbalance between the need to guarantee ordinary care and to deal with the pandemic, in a context of limited health resources, raises ethical concerns as well as clinical management issues. The emergency scenario caused by the COVID-19 pandemic, especially in the lockdown phase, led the Government and health care decision-makers to prioritize community safety above the individuals' rights. This new community-centered approach to clinical care has created tension among the practitioners and exposed health workers to malpractice claims. Reducing the morbidity and mortality rates of the COVID-19 pandemic is the priority of every government, but the legitimate question remains whether the policy that supports this measure could be less harmful for the health care system.

Dying patients with COVID-19: What should Hospital Palliative Care Teams (HPCTs) be prepared for?

OBJECTIVE

The COVID-19 pandemic is a care crisis of unknown duration which has seemingly not yet reached its peak in many countries. A significant number of elderly and frail people and those with underlying serious illness will continue to develop severe forms of the COVID-19 infection. Most of them are not eligible for intensive care treatment but can still expect palliative care - in many cases provided by a Hospital Palliative Care Team (HPCT). Several teams have already gained experience in caring for these patients and their families, others are preparing for it.

METHOD

We report on a COVID-19 patient with pre-existing acute myeloid leukemia who was looked after by a HPCT until death. We discuss the challenges and difficulties while caring for COVID-19-positive palliative patients in a non-ICU setting.

RESULTS

Hospitalization of the patient in an isolation ward caused an enormous burden for the dying patient and his family. Symptom control was particularly difficult because of rapid deteriorating dyspnea and the scarce presence of medical staff in the patient's room.

SIGNIFICANCE OF RESULTS

COVID-19 patients who are not eligible for ICU treatment may have a particularly high need for palliative care. Since beds in specialist palliative care units are limited, the HPCT should be prepared to care for these patients. They may offer support in decision-making, optimize symptom control, and provide psychosocial care for patients and their families. Visiting restrictions aimed to protect the general public must be weighted against the patient's and family's suffering.

Nurses on the Frontline against the COVID-19 Pandemic: An Integrative Review

COVID-19 has affected the life and health of more than 1 million people across the world. This overwhelms many countries' healthcare systems, and, of course, affects healthcare providers such as nurses fighting on the frontlines to safeguard the lives of everyone affected. Exploring the issues that nurses face during their battle will help support them and develop protocols and plans to improve their preparedness. Thus, this integrative review will explore the issues facing nurses during their response to the COVID-19 crisis. The major issues facing nurses in this situation are the critical shortage of nurses, beds, and medical supplies, including personal protective equipment and, as reviews indicate, psychological changes and fears of infection among nursing staff. The implications of these findings might help to provide support and identify the needs of nurses in all affected countries to ensure that they can work and respond to this crisis with more confidence. Moreover, this will help enhance preparedness for pandemics and consider issues when drawing up crisis plans. The recommendation is to support the nurses, since they are a critical line of defense. Indeed, more research must be conducted in the field of pandemics regarding nursing.

Palliative Care Utilization Among Patients With COVID-19 in an Underserved Population: A Single-Center Retrospective Study

BACKGROUND

As health-care institutions mobilize resources to address the coronavirus disease 2019 (COVID-19) pandemic, palliative care may potentially be underutilized. It is important to assess the use of palliative care in response to the COVID-19 pandemic.

METHODS

This is a retrospective single-center study of patients with COVID-19 diagnosed via reverse transcriptase-polymerase chain reaction assay admitted between March 1, 2020, and April 24, 2020. An analysis of the utilization of palliative care in accordance with patient comorbidities and other characteristics was performed while considering clinical outcomes. Chi-square test was used to determine associations between categorical variables while t-tests were used to compare continuous variables.

RESULTS

The overall mortality rate was 21.5% (n = 52), and in 48% (n = 25) of these patients, palliative care was not involved. Fifty-nine percent (n = 24) of those who had palliative consults eventually elected for comfort measures and transitioned to hospice care. Among those classified as having severe COVID-19, only 40% (n = 31) had palliative care involvement. Of these patients with severe COVID-19, 68% (n = 52) died. Patients who got palliative care consults were of older age, had higher rates of intubation, a need for vasopressors, and were dead.

CONCLUSION

There was a low utilization rate of palliative care in patients with COVID-19. Conscious utilization of palliative care is needed at the time of COVID-19.

Grief During the COVID-19 Pandemic: Considerations for Palliative Care Providers

The COVID-19 pandemic is anticipated to continue spreading widely across the globe throughout 2020. To mitigate the devastating impact of COVID-19, social distancing and visitor restrictions in health care facilities have been widely implemented. Such policies and practices, along with the direct impact of the spread of COVID-19, complicate issues of grief that are relevant to medical providers. We describe the relationship of the COVID-19 pandemic to anticipatory grief, disenfranchised grief, and complicated grief for individuals, families, and their providers. Furthermore, we provide discussion regarding countering this grief through communication, advance care planning, and self-care practices. We provide resources for health care providers, in addition to calling on palliative care providers to consider their own role as a resource to other specialties during this public health emergency.

Will the COVID-19 Pandemic Change National Security and Healthcare in the Spectrum of Cardiovascular Disease?

COVID-19 pandemic changed the current state of healthcare, especially in terms of reorganization of resources. Chief complaints of patients admitted to hospitals changed drastically in the proceeding months, which worsened the treatment of many acute and chronic conditions involving cardiovascular system pathologies and resources were moved in order to fight COVID-19. Moreover, the pandemic had long-term effects not only on healthcare but also national security on global scale. The COVID-19 drastically changed perception of global health and safety, trust in healthcare professionals as well as patients’ willingness to seek medical help. The long-term effect of the epidemic, in terms of its impact cardiovascular disease progression and prognosis remain to be observed. The current paper discusses the impact of COVID-19 on healthcare and national security based on the currently available data.

[Prioritization of geriatric patients in care homes and residential homes in the context of the COVID pandemic]

Aus notfallmedizinischer Sicht sollten geriatrische Patienten in Pflege- und Seniorenheimen bereits vor einem „Massenanfall von infizierten Personen” eine Priorisierung auf der Basis des ACP(Advance Care Planning)-Konzepts erfahren.

Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India

Coronavirus disease-19 (COVID-19) pandemic is causing a worldwide humanitarian crisis. Old age, comorbid conditions, end-stage organ impairment, and advanced cancer, increase the risk of mortality in serious COVID-19. A subset of serious COVID-19 patients with serious acute respiratory illness may be triaged not to receive aggressive intensive care unit (ICU) treatment and ventilation or may be discontinued from ventilation due to their underlying conditions. Those not eligible for aggressive ICU measures should receive appropriate symptom management. Early warning scores (EWS), oxygen saturation, and respiratory rate, can facilitate categorizing COVID-19 patients as stable, unstable, and end of life. Breathlessness, delirium, respiratory secretions, and pain, are the key symptoms that need to be assessed and palliated. Palliative sedation measures are needed to manage intractable symptoms. Goals of care should be discussed, and advance care plan should be made in patients who are unlikely to benefit from aggressive ICU measures and ventilation. For patients who are already in an ICU, either ventilated or needing ventilation, a futility assessment is made. If there is a consensus on futility, a family meeting is conducted either virtually or face to face depending on the infection risk and infection control protocol. The family should be sensitively communicated about the futility of ICU measures and foregoing life-sustaining treatment. Family meeting outcomes are documented, and consent for foregoing life-sustaining treatment is obtained. Appropriate symptom management enables comfort at the end of life to all serious COVID-19 patients not receiving or not eligible to receive ICU measures and ventilation.

How to cite this article: Salins N, Mani RK, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020;24(6):435–444.