The novel coronavirus pandemic (COVID-19) has drastically increased the number of critically ill and dying patients presenting for hospitalized management of dyspnea, acute respiratory failure and other serious complications. The emergence and spread of SARS-CoV-2 has created unprecedented demands on all avenues of inpatient hospitalist medicine. One of the many services in high demand includes palliative care, with increased need for complex end of life planning.
Most patients lack a detailed advance directive, living will, or determined medical power of attorney prior to hospitalization. Code status with regards to immediate resuscitation and intubation is assessed upon every inpatient admission. However, nuanced questions of continued ventilator support in the absence of clinical recovery, anoxic brain injury following resuscitation, repeated cardiac arrest, and indications for withdrawal of care are rarely discussed with patients prior to the development of terminal illness. Palliative care physicians are experts in navigating these detailed intricacies of end of life care in the setting of serious illness.
The ongoing COVID-19 pandemic had resulted in an acute need for palliative care, which has largely overwhelmed already under-resourced care providers. Furthermore, it has been well documented in the peer-reviewed literature how patients with COVID-19, both with and without risk factors or comorbidities, can deteriorate quickly and require ventilator support. In the event of rapid deterioration resulting in intubation for ventilator support, patients are often suddenly unable to communicate their medical wishes for themselves.
Such situations force family members to struggle emotionally, spiritually and morally with questions of their loved ones’ end of life decision making. Additionally, without detailed answers regarding nuances of code status, physicians may have to uphold full code status on patients whose continued level of care is deemed medically futile. Lastly, maintaining such level of care in cases of futility could be seen as a poor use of resources within a climate of extreme demand for medical equipment, personal protective equipment, medications and staff.
Given the increased demand for palliative care consults and the high risk of rapid decline in patients with COVID-19, it has become imperative that end of life planning begins early in a patient’s hospital course. Such conversations should be approached before a patient is critically ill and well before the need for intubation. Ultimately, the patient’s wishes regarding details of their end-of-life desires beyond do not resuscitate/do not intubate (DNR/DNI) status should be ascertained while the patient is able to have such a conversation.
Integration of palliative care conversations early in a patient’s illness can ultimately alleviate health care related suffering and prevent unwanted invasive procedures. Peer-reviewed literature within oncology patients has indicated that early palliative care may have beneficial effects on quality of life, symptom intensity, and illness and prognostic understanding among patients and families. Additionally, studies of critical illness in the ICU demonstrate the emotional toll of medical decision-making on family members. Such studies suggest that early palliative care interventions in the setting of COVID-19 may similarly increase quality of life for the patients, decrease familial burden of decision making, and potentially preserve necessary medical resources.
The palliative care community has outlined ways in which palliative care services can be best utilized during the current COVID-19. Prior to the current pandemic, Quill and Abernethy emphasized that majority of end-of-life planning for patients with terminal illness should come from their primary medical teams. Furthermore, Powell and Silveira stated that in the setting of high demand for palliative care interventions, face-to-face palliative care consultations should be requested only after the primary team has done their best to address end of life concerns but continue to require additional expertise and assistance. Lastly, multiple interdisciplinary palliative care clinicians have created palliative care toolkits or “Palliative Pandemic Packs” with detailed COVID-19 resources, communication skills and symptom management. This has allowed non-palliative care clinicians to deliver quality end-of-life care. In addition to the above suggestions, hospitals may initiate early end-of-life planning protocols for all patients with COVID-19 to mitigate potential future suffering.
The peer-reviewed literature has shown increasing difficulty in predicting a patient’s rapid decline; therefore, all patients, particularly those with cardiac, renal, and immunocompromised comorbidities, should have detailed end of life conversations upon hospitalization. Such early end-of-life planning may be approached from a primary prevention perspective: treating goals of care conversations like an intervention designed to prevent potentially unwanted or unwarranted future complications. In encouraging more patients to discuss end-of-life planning, providers can uphold the primary tenants of respect for patient autonomy and patient-centered care.
HCA Disclaimer: This research was supported (in whole or part) by HCA Healthcare and/or an HCA Healthcare affiliated entity. The views expressed in this presentation represent those of the author and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.
Image credit: Desk in blue light by Brandon Holmes on Unsplash
Resident Physician Contributing Writer
USF Morsani College of Medicine
Amira Athanasios is a first year resident in internal medicine and will be pursuing a career in mental health. She is a graduate of The George Washington University School of Medicine and Scripps College. She is passionate about the intersections of health, culture, race, and personal narrative. As such, she has written on public health, health equity, and narrative medicine.