Characteristics and Palliative Care Needs of COVID-19 Patients Receiving Comfort-Directed Care.

Abstract

The first known coronavirus disease 2019 (COVID-19) related hospitalization in New York City was reported at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital. Since then, the rapid increase in the number of patients with COVID-19 associated with acute respiratory distress syndrome (ARDS)1 and high rates of mortality2, 3 has highlighted the critical need for high-quality end-of-life care. On March 31, 2020, an eight-bed Palliative Care Unit (PCU) was established at our institution for patients with COVID-19 whose surrogates opted to not initiate or continue life-sustaining therapies. To our knowledge, this is the first report describing COVID-19 patients receiving comfort-directed care. This case series aims to describe the characteristics and palliative care needs in patients admitted to the PCU at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital to inform other clinicians caring for this population at the end of life. Deceased patients with confirmed severe acute respiratory syndrome coronavirus 2 infection by polymerase chain reaction testing of a nasopharyngeal sample, admitted to the PCU at Columbia University Irving Medical Center/NewYork-Presbyterian Hospital between March 31, 2020, and April 10, 2020, were included. Before data collection, a waiver was obtained from the Columbia University institutional review board. Deidentified patient data were collected from the electronic medical record Epic Hyperspace and analyzed using Microsoft Excel. Laboratory testing was reviewed at PCU admission. Patient outcome data were evaluated at time of death. Due to the descriptive nature of this case series, no analysis for statistical significance was performed. A total of 30 patients were included in this case series (mean age = 84.5 years; 53% male) (Table 1). Most patients were of Hispanic origin (20 [66.7%]), followed by white (4 [13.3%]). All 30 patients had comorbidities before hospital admission, with 70% of patients having more than one comorbidity. Twenty-four patients (80%) had metabolic abnormalities, with hypernatremia observed in 17 patients (57%). Before PCU admission, all 30 patients developed ARDS, with 29 (97%) requiring supplemental oxygen. On admission to the PCU, the most common symptom observed was dyspnea (30 [100%]), followed by delirium (22 [73%]), pain (10 [33%]), and anxiety (10 [33%]) (Table 2). Intravenous morphine (23 [77%]) and hydromorphone (11 [37%]) were the most commonly used medications. A total of 62 visits and calls were made by chaplains and social workers to provide spiritual and psychosocial support (eg, offering end-of-life prayers to patients and assisting family members with funeral planning). The average length of stay in the PCU was 34.6 hours or 1.4 days. We report the characteristics and palliative care needs of patients with severe COVID-19 infection who have forgone life-sustaining treatments and received comfort-directed care. Consistent with other studies,4, 5 we observed an older age group with high rates of comorbidities. Given the high proportion of patients with metabolic abnormalities on hospital admission, further study is needed to explore the potential association between severity of metabolic disarray and its impact on patient outcomes. Dyspnea and delirium were the most commonly observed symptoms in dying patients with COVID-19. Relatively low doses of morphine, hydromorphone, and lorazepam were needed for symptom control. The present study also highlights the crucial role of social workers and chaplains in providing psychosocial and spiritual support to patients and families, especially given the limited degree of contact most family members had with their loved one. The limitations of this study include the small sample size from one hospital center, ethnic and racial makeup of the population given the location in New York City, as well as possible selection bias by admitting moribund patients who are more imminently dying due to limited bed availability in the PCU. Nonetheless, this study can be instructive to other institutions to understand and prepare for the palliative care needs in patients dying from COVID-19. The authors have no conflicts of interest to report. All authors contributed to conceptualizing, drafting, and revising this work. Drs Blinderman, Sun, and Lee oversaw patient care. Benjamin J. Meyer, Ellen L. Myers, Mia S. Nishikawa, and Jonah L. Tischler performed data extraction and analysis. No specific funding was received for this work.