A View from the Frontline: Palliative and Ethical Considerations of the COVID-19 Pandemic.

Abstract

Journal of Palliative MedicineVol. 24, No. 2 Personal ReflectionFree AccessA View from the Frontline: Palliative and Ethical Considerations of the COVID-19 PandemicDonald R. Sullivan and J. Randall CurtisDonald R. SullivanAddress correspondence to: Donald R. Sullivan, MD, MA, MCR, Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239-3098, USA E-mail Address: sullivad@ohsu.eduDivision of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA.Health Services Research and Development, Center of Innovation, Veterans Affairs Portland Health Care System, Portland, Oregon, USA.Search for more papers by this author and J. Randall CurtisDivision of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Cambia Palliative Care Center of Excellence, UW Medicine, Seattle, Washington, USA.Search for more papers by this authorPublished Online:15 Jan 2021https://doi.org/10.1089/jpm.2020.0426AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail In the United States and other nations, palliative care is under-resourced and there are not enough specialists to consistently meet the needs of patients suffering from serious illness.1,2 Nonetheless, palliative care is an integral component of care in the intensive care unit (ICU), as the ICU is designed for patients with life-threatening illnesses. In general, palliative care needs are best met through a combination of specialty and primary palliative care and the ideal approach depends on setting and context.3 Palliative care needs have been magnified by the COVID-19 pandemic with the hospitalization of hundreds of thousands of patients with COVID-19, many requiring critical care. Furthermore, hospitals are required to limit family presence, further complicating our ability to address patients' palliative care needs.A major oversight of the World Heath Organization4 report on how to maintain essential health services during the pandemic, which discussed maternal care, emergency care, and chronic diseases among others, was the omission of palliative care. As a result of specialty palliative care resource scarcity, especially in community settings, intensivists are increasingly called upon to provide this supportive care, increasing their workload in a time of great stress. Although prehospital goals of care discussions may lesson this impact, palliative care needs still must be addressed in our ICUs.5 We explored frontline clinicians' perspectives from two hospital systems (see Note section), which both had early surges in ICU patients with COVID-19, to describe their experiences with palliative care in this context. We describe five themes based on personal reflections of two intensivists and three palliative care physicians that arose from frontline experiences.Balance between Primary and Specialty Palliative CarePhysicians in both health care systems describe an “all hands on deck” approach to the delivery of palliative care. However, this was experienced differently in an academic compared with a community-based health care system. Although there was increased delivery of primary palliative care (i.e., palliative care delivered by nonpalliative care clinicians) by the ICU teams at both health care systems, UW Medicine was more easily able to redistribute physician effort, utilizing physician-scientists and physician-educators who specialize in palliative care and have scheduled nonclinical time to meet the added needs. Personnel resources were more limited at EvergreenHealth, necessitating increased primary palliative care by the ICU teams. These efforts were supported by the rapid development and deployment of resource libraries and training materials to enhance primary palliative care.Importance of Upstreaming Advance Care PlanningUpstreaming advance care planning and palliative care6 has been advocated for some time, but the pandemic heightened the urgency for proactive advance care planning and goals-of-care discussions.5 During the pandemic, clinicians in both institutions described the importance of promoting goals-of-care discussions in prehospital settings (e.g., nursing homes), emergency departments, and acute care settings. Many of the patients with critical illness from COVID-19 were older and were more likely to have had prior goals-of-care discussions. Palliative care providers, where available, were able to help identify these prior discussions and support their implementation into care plans.Challenges with Family CommunicationFrequent family communication was a crucial and time-consuming component of supportive care in the ICU to provide families with patient updates, obtain surrogate consent, and discuss transitions in goals of care. These functions are particularly salient during the pandemic, as many of the hospitalized patients required mechanical ventilation7 generally necessitating substituted judgments by health care proxies.8 Face-to-face family meetings, usually an integral component of establishing trust and rapport in the ICU, were rare due to the restrictive family presence policies. As a result, clinicians described a transition in “family meetings” to phone or video conferencing. Restrictive family presence policies also necessitated more frequent family contact by phone to replace interactions on ICU rounds and at the bedside. Furthermore, clinicians talked about how without body language clues, a heightened sensitivity to speech flow and intonation was essential. The acceptability of remote options for ICU family communication may provide lasting lessons for reducing logistical barriers in the future.Clinicians described families of critically ill patients as incredibly gracious and understanding during this difficult time, being sympathetic to the logistical and emotional challenges ICU teams were experiencing. Families also expressed fear, frustration, and confusion given all of the misinformation that exists in the media, especially regarding treatments, appreciating an opportunity to sort out fact versus fiction with ICU teams. Clinicians struggled with the challenges of prognostication and its central role in decision making in the ICU because of the rapidly changing evidence base.9 However, clinicians noted that COVID-19 ICU patients were generally more homogeneous than usual with one disease process (usually single organ failure), often requiring several weeks of mechanical ventilation. This allowed clinicians to provide a clearer picture to patients' families, compared with other critical illnesses, of the COVID-19 illness trajectory helping to guide families' expectations.Ethical Dilemmas and Clinician DistressEthical dilemmas of critical care practice were rare as neither institution had to enact crisis standards of care. However, clinicians describe heightened moral distress and anxiety related to the potential need for allocation of scarce resources. In efforts to preserve personal protective equipment and reduce staff risks, clinicians described more intentional and proactive conversations with patients and families to reduce the use of nonbeneficial cardiopulmonary resuscitation among patients who are unlikely to benefit.5 However, blanket policies such as do not resuscitate orders for COVID-19 patients were not seriously considered at either institution.Providing patient and family support dramatically changed for ICU and palliative care teams, as there is reduced ability to provide any physical contact or to “be present” to support patients and families at the end of life. Clinicians described patients as being more isolated than previous that contributed to clinicians' heightened sense of moral distress. For families who are usually able to get a sense for the care their loved ones are receiving by visiting or even sleeping in patients' ICU rooms, clinicians reviewed the day-to-day care and routines by phone or videoconferencing daily, to keep families connected.Typically when critically ill patients with acute respiratory failure are admitted to an ICU, they are already intubated or in acute distress, limiting communication with clinicians. However, during the pandemic, clinicians also describe some patients with slowly increasing oxygen demands over several days before intubation, allowing more personal interactions than usual and clinicians to develop connections with patients. Clinicians reported these personal relationships with patients contributed to increased emotional distress when patients they developed relationships with later succumbed to their illness. This distress was intensified by the lack of family at the bedside and the feeling among clinicians that the only human contact patients experienced came from staff. Clinicians reported that an estimation of the true personal impact of the pandemic (e.g., feelings of burnout or post-traumatic stress disorder) is not possible, as they note that the pace and severity of the pandemic have limited the time for introspection.SummaryThe COVID-19 pandemic has highlighted the complimentary role of primary and specialty palliative care in the ICU, while creating some unique challenges. The availability of specialty palliative care to surge to meet the needs of critically ill patients varies tremendously across health care systems and shapes the balance of the two types of palliative care. Likewise, the pandemic has reinvigorated strategies to address goals of care before hospitalization and/or ICU admission among high-risk populations. Families and clinicians have been forced to adapt to the dynamic ICU environment during the pandemic, but the perseverance and sense of community in the face of seemingly insurmountable odds are evident.NoteEvergreenHealth is an integrated two-hospital community health care system that was at the center of the coronavirus outbreak in the Pacific Northwest and was home to one of the early clusters of COVID-19 patients in the United States, mainly attributed to a nearby nursing home outbreak. UW Medicine is an academic health care system that includes a university hospital, a safety net, and Level-1 Trauma Center, and two community hospitals, responsible for delivering advanced critical care services in the Seattle area.Authors' ContributionsD.R.S. and J.R.C. conceived of the presented idea. All authors discussed the content and contributed to the final article.AcknowledgmentsThe authors thank the following physicians for sharing their experiences during the COVID pandemic: Dr. Michael Bundesmann, Division of Pulmonary and Critical Care Medicine, EvergreenHealth Pulmonary Group; Dr. Laura Johnson, Hospice and Palliative Care, EvergreenHealth Palliative Care; Dr. Lindsay Gibbon, Division of General Internal Medicine and Palliative Care, Harborview Medical Center UW Medicine; and Dr. Margaret Isaac, Division of General Internal Medicine and Palliative Care, Harborview Medical Center UW Medicine.Funding InformationThis work was not funded.Author Disclosure StatementNo competing financial interests exist. Dr. Sullivan reports receipt of grants from the National Institutes of Health (NIH), Borchard Foundation, American Thoracic Society, and American Lung Association outside the submitted work. Dr. Curtis reports receipt of grants from the NIH and from Cambia Health Foundation outside the submitted work.