A Dual-Center Observational Review of Hospital-Based Palliative Care in Patients Dying With COVID-19

Abstract

The current coronavirus disease 2019 (COVID-19) pandemic has put significant strain on all aspects of health care delivery, including palliative care services. Given the high mortality from this disease, particularly in the more vulnerable members of society, it is important to examine how best to deliver a high standard of end-of-life care during this crisis. This case series collected data from two acute hospitals examining the management of patients diagnosed with COVID-19 who subsequently died (n ¼ 36) and compared this with national and local end-of-life audit data for all other deaths. Our results demonstrated a shorter dying phase (38.25 hours vs. 74 hours) and higher rates of syringe driver use (72% vs. 33% in local audits), although with similar average mediation doses. Of note was the significant heterogeneity in the phenotype of deterioration in the dying phase, two distinct patterns emerged, with one group demonstrating severe illness with a short interval between symptom onset and death and another group presenting with a more protracted deterioration. This brief report suggests a spectrum of mode of dying. Overall, the cohort reflects previously described experiences, with increased frailty (median Clinical Frailty Scale score of 5) and extensive comorbidity burden. This brief report provides clinicians with a contemporaneous overview of our experience, knowledge, and pattern recognition when caring for people with COVID-19 and highlights the value of proactive identification of patients and risk of deterioration and palliation.

COVID-19: guidance on palliative care from a European Respiratory Society international task force

“…Patients with serious COVID-19 with persistent symptoms and concerns despite optimal disease treatment need optimal symptom management [ 15 ]. It has been suggested that symptom burden in dying patients with COVID-19 might be higher than usual in dying patients without COVID-19 [ 32 ], resulting in challenges for staff with no or limited experience in palliative care. Therefore, palliative care has an important role for patients with serious COVID-19 and strategies have been implemented to provide in-hospital palliative care [ 27 , 33 ].…”

Palliative care for patients with severe covid-19

“…An early case series of 101 hospitalised patients with covid-19 who were referred to palliative care found that opioids were usually effective for palliation of breathlessness, with a median dose of 10 mg (range 5-30 mg) subcutaneous morphine over 24 hours 10. A retrospective audit of 36 hospitalised patients with covid-19 who died outside critical care found that 26 of them had a subcutaneous infusion at the time of death, and the total mean opioid dose (subcutaneous morphine equivalent) during the final 24 hours was 16 mg 13…”

COVID-19 and Hospital Palliative Care – A service evaluation exploring the symptoms and outcomes of 186 patients and the impact of the pandemic on specialist Hospital Palliative Care

“…6 Only recently has evidence emerged to help characterise symptom burden and outcomes in end stage COVID-19, but with small patient numbers and focussed geographical locations. [7][8][9] Our primary aim was to further characterise the symptom profile, outcomes and symptom management requirements of hospitalised patients with COVID-19 referred to Hospital Palliative Care. Our secondary aim was to contextualise Palliative Care demands from COVID-19 against a 'typical' Palliative Care caseload pre-pandemic.…”