Palliative Care for Patients on Extracorporeal Membrane Oxygenation for COVID-19 Infection

Abstract

Background: Critically ill patients with COVID-19 infection on extracorporeal membrane oxygenation (ECMO) face high morbidity and mortality. Palliative care consultation may benefit these patients and their families. Prior to the pandemic, our institution implemented a policy of automatic palliative care consultation for all patients on ECMO due to the high mortality, medical complexity, and psychosocial distress associated with these cases. Objectives: The main objective was to describe the role of the palliative care team for patients on ECMO for COVID-19 infection. The secondary objective was to describe the clinical outcomes for this cohort. Design: Case series. Settings/Subjects: All patients age 18 or older infected by the novel coronavirus who required cannulation on ECMO from March through July of 2020, at an urban, academic medical center in the United States. Inter-disciplinary palliative care consultation occurred for all patients. Results: Twenty-three patients (median age 43 years [range 28-64], mean body mass index 34.9 kg/m2 [SD 9.2], 65% Hispanic ethnicity) were cannulated on ECMO. Eleven patients died during the hospitalization (48%). Patients older than 50 years of age demonstrated a trend toward increased odds of death compared to those younger than 50 years of age (OR 9.1, P = 0.07). Patients received an average of 6.8 (SD 3.7) palliative clinical encounters across all disciplines. The actions provided by the palliative care team included psychosocial support and counseling, determination of surrogate decision maker (for 100% of patients), pain management (83%), and non-pain symptom management (83%). Conclusions: Here, we present one of the first studies describing the patient characteristics, outcomes, and palliative care actions for critically ill patients with COVID-19 on ECMO. Almost half of the patients in this cohort died during their hospitalization. Given the high morbidity and mortality of this condition, we recommend involvement of palliative care for patients/families with COVID-19 infection who are on ECMO. The impact of palliative care on patient and family outcomes, such as symptom control, satisfaction with communication, rates of anxiety, and grief experience merits further investigation.

Palliative Care Impact on COVID-19 Patients Requiring Extracorporeal Membrane Oxygenation

“…One prior study by Rao et al explored the role of automated PCC for 23 COVID patients on ECMO. 8 The population in the Rao study was similar to ours – primarily young, Hispanic men. Rao et al described primarily offering psychosocial support and counseling, surrogate identification, and pain and non-pain symptom management (83% of patients).…”

“… 7 Various studies highlight the prolonged hospitalization course of both survivors and decedents requiring ECMO for COVID, often over a month. 8 , 9 PCC is known to play a role in the care of patients with chronic critical illness, and early integration may be helpful in family-centered ICU care when patients are on ECMO. 10 Given the sudden onset of the COVID pandemic and the unique and relatively broad application of ECMO in tertiary care settings for the management of COVID, there was at that time no data regarding the impact of automated PCC on patient outcomes, despite the recommendation that PCC be routinely applied for this patient cohort.…”

Prognostic factors associated with mortality among patients receiving venovenous extracorporeal membrane oxygenation for COVID-19: a systematic review and meta-analysis

“…In the second analysis, we excluded adjusted analyses from studies with a potential risk of bias due to poor adherence to best practice methodological guidelines for prediction model development. 35 , 36 , 37 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 We considered the use of metaregression to further explore subgroups of interest, but did not have a sample size of ten or more studies per adjusted variable, as recommended by Cochrane guidance. 47 For the unadjusted analyses, we decided not to use study-level metaregression because it was unlikely to further benefit the analysis.…”

Psychologische Aspekte während und nach intensivmedizinischer Behandlung von ARDS

“…Aufgrund der hohen Morbidität und Mortalität und zumeist verlängerter Hospitalisierung von Patienten mit therapierefraktärer Hypoxämie werden eine bedarfsorientierte psychosoziale Unterstützung der Patienten und Angehörigen sowie der frühzeitige Einbezug palliativmedizinischer Expertise empfohlen [32,35,36]. Nur dann können in der dafür erforderlichen Zeit, in der der Patient schwer krank, aber unter ECMO stabilisiert ist, tragfähige Beziehungen zu Patient und Familie aufgebaut werden, die für eine adäquate Unterstützung in der palliativen Situation bzw.…”

“…Nur dann können in der dafür erforderlichen Zeit, in der der Patient schwer krank, aber unter ECMO stabilisiert ist, tragfähige Beziehungen zu Patient und Familie aufgebaut werden, die für eine adäquate Unterstützung in der palliativen Situation bzw. in der Sterbephase nötig sind [32,35,36].…”