We Will All Be Changed: Palliative Care Transformation in the Time of COVID-19.

Abstract

Journal of Palliative MedicineVol. 23, No. 9 Notes from the EditorFree AccessWe Will All Be Changed: Palliative Care Transformation in the Time of COVID-19Laura C. HansonLaura C. HansonAddress correspondence to: Laura C. Hanson, MD, MPH, Division of Geriatric Medicine, UNC Palliative Care Program, Chapel Hill, NC 27599, USA E-mail Address: laura_hanson@med.unc.eduSearch for more papers by this authorPublished Online:18 Aug 2020https://doi.org/10.1089/jpm.2020.0446AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Transformation began in early 2020. In December of 2019, a novel respiratory illness was described in China, and the era of the global pandemic caused by severe acute respiratory syndrome coronavirus 2 began. Coronavirus disease 2019 (COVID-19) has expanded globally to infect millions of people and to cause over half a million deaths—and these numbers are underestimates due to lack of widespread testing. By the time this article is published, this epidemiology will be far out of date, since the number of cases and deaths per day continues to rise globally and in the United States. People who are presymptomatic and minimally symptomatic will shed and share this virus that is so adapted to our human desire to touch, to interact, and to live in proximity to one another. Although most people who are infected will recover, a significant percentage will die or live on with major chronic effects on lung, renal, or neurologic function. Every facet of ordinary life is affected, from celebrations to funerals, from grocery shopping to employment, from household cleaning to visiting older relatives. And frankly, although research is progressing on treatment and vaccines, we all know this new normal will be sustained for an indefinite amount of time.Palliative care clinicians are called upon to provide rapid and adaptive education for ourselves and our colleagues. Skills in symptom management, prognostic awareness, and goals of care communication are seen as central to the response to this pandemic. Many local palliative care programs—including my own—were asked to provide training in primary palliative care skills to equip clinicians in emergency medicine and critical care medicine. Within weeks, leading educators from the Center to Advance Palliative Care, Vital Talk, and Ariadne Labs created and disseminated COVID-19–specific communication guides and training tools.1–3 Our professional organizations have also responded—websites for the American Academy of Hospice and Palliative Medicine and for the National Coalition for Hospice and Palliative Care provide links to resources for clinical care, policy, and payment changes.4,5 Our self-education and clinical skills will continue to adapt as new information emerges on infection risk, an expanding list of acute and chronic symptoms, and changing data on prognosis and outcomes.Our clinical practice is being transformed, as we develop and deploy new skills and novel collaborative care models with frontline teams. We have been called “into the room” virtually with patients struggling to breathe and with families facing agonizing decisions. Plunging into visits by phone and video connections, each of us has wondered whether we could convey compassionate human presence, replace the insights from physical examination, and fill the gaps when missing nonverbal cues. Yet together, we share emerging best practices in “webside manner,” as coined by members of the Massachusetts General Hospital palliative care team.6 Virtual visits have allowed us to console and support families shut out by visitation policy, and to bring them to the bedside through video visits with patients. These new skills remind us that before COVID-19, many families were unable to visit due to lack of transportation or ill health—and we will continue virtual visits even when COVID-19 runs its course.Palliative care clinicians seek to bring comfort in the face of suffering magnified by COVID-19 health disparities. As many teams—including ours—now know from their daily census, hospitalization rates with COVID-19 are four to five times higher for African American/black, Latinx, and native people than for people who identify as white.7 Unlike so many causes of illness and death, this one is contagious and sweeps through populations in crowded housing, nursing homes, prisons, and meat packing plants. Hospital intensive care units are filled with people of color across the United States, including the wrenching sadness of illness affecting multiple members of the same family. In an eerie echo from the Black Lives Matter movement, the cry “I can't breathe” fills crowded emergency departments serving these diverse communities. The public health emergency created by COVID-19 is surfacing social determinants of health, and clinicians and families will not forget its implications for just health care.