Experts chalk out Palliative care plan for Covid 19 patients

OTTAWA - Covid 19 pandemic is growing everyday and the Global cases have crossed 850000 mark whereas figure of global deaths has gone beyond 41000 mark.

Palliative care physicians have chalked out a coronavirus disease 2019 (COVID-19) palliative care plan as an essential tool to provide care and help manage scarce resources during the pandemic.

The plan that essentially focuses on 8 critical elements -- "stuff," "staff," "space," "systems," "sedation," "separation," "communication" and "equity" has been published in CMAJ (Canadian Medical Association Journal). 

Key Points are-

The severe acute respiratory syndrome coronavirus 2 (SARS-

CoV-2) pandemic will likely strain our health care system beyond

capacity, and palliative care services will be needed across many

different care settings, including intensive care units, hospital

wards, emergency departments and long-term care.

• Shared decision-making between clinicians and patients is a

core process in planning for the end of life; however, in a

pandemic, patient autonomy to choose life-prolonging

measures or location of death could be severely restricted as a

result of public health directives and resource availability, and

some patients may necessarily be isolated at end of life.

• Previous mass casualty events have taught us much about how

best to triage patients requiring care, and some of this work can

be adapted to palliative care; but little has been written on how

to manage those who are not offered life-sustaining measures.

• We advise acting now to stockpile medications and supplies used

in palliative care, train staff to meet palliative care needs, optimize

our space, refine our systems, alleviate the effects of separation,

have critical conversations and focus on marginalized populations

to ensure that all patients are cared for equitably.

• The SARS-CoV-2 pandemic has been tragic for many people

worldwide. Failing to provide Canadians with effective palliative

care would compound that tragedy

Palliative care is a human right for patients. "The current COVID-19 pandemic will likely strain our palliative services beyond capacity," says Dr. James Downar, the head of the Division of Palliative Care at the University of Ottawa and a palliative care physician at The Ottawa Hospital and Bruyère Continuing Care. "We advise acting now to stockpile medications and supplies used in palliative care, train staff to meet palliative care needs, optimize our space, refine our systems, alleviate the effects of separation, have critical conversations, and focus on marginalized populations to ensure that all patients who require palliative care receive it."

"Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill," writes Dr. Downar with coauthors. "Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity."

The plan is an expansion of a framework developed by the US Task Force on Mass Casualty Critical Care for events with large numbers of injuries and casualties, with the addition of the last four elements, sedation, separation, communication and equity.

Stuff: medications should be stockpiled to provide comfort to patients on a larger scale, and for longer periods than usual. The authors suggest creating "palliative symptom management kits" for use by staff in long-term care facilities, paramedics and other health care professionals.

Staff: regional pandemic planning should include all health care professionals with palliative care training and involve educating others to offer palliative care.

Space: to accommodate large numbers of patients, it may be necessary to adapt specialized wards or nearby locations and ensure a quiet, peaceful environment for dying patients.

Systems: new triage systems and virtual care models may be used to allocate physicians and increase efficiency while reducing risk of infection.

Sedation: palliative sedation can provide comfort to people whose symptoms are unresponsive to standard comfort medications.

Separation: to lessen the sense of separation because of isolation measures, use video calling and technology to connect patient with family members.

Communication: open communication and understanding of a patient's wishes is critical, as many may not want to receive life-sustaining measures.

Equity: it is important to ensure marginalized groups, including people with disabilities or trauma and those living in poverty, have access to palliative care during a pandemic.

"Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right," the authors concluded.

For further reference log on to:

https://www.cmaj.ca/content/cmaj/early/2020/03/31/cmaj.200465.full.pdf