COVID‐19 end‐of‐life care: symptoms and supportive therapy use in an Australian hospital

Abstract

Background Descriptions of symptoms and medication use at end of life in COVID‐19 are limited to small cross‐sectional studies, with no Australian longitudinal data. Aims To describe end‐of‐life symptoms and care needs of people dying of COVID‐19. Methods This retrospective cohort study included consecutive admitted patients who died at a Victorian tertiary referral hospital from 1 January to 30 September directly due to COVID‐19. Clinical characteristics, symptoms and use of supportive therapies, including medications and non‐pharmacological interventions in the last 3 days of life were extracted. Results The cohort comprised 58 patients (median age 87 years, interquartile range (IQR) 81–90) predominantly admitted from home (n = 30), who died after a median of 11 days (IQR 6–28) in the acute medical (n = 31) or aged care (n = 27) wards of the hospital. The median Charlson Comorbidity Score was 7 (IQR 5–8). Breathlessness (n = 42), agitation (n = 36) and pain (n = 33) were the most frequent clinician‐reported symptoms in the final 3 days of life, with most requiring opioids (n = 52), midazolam (n = 40), with dose escalation commonly being required. While oxygen therapy was commonly used (n = 47), few (n = 13) required an anti‐secretory agent. Conclusions This study presents one of the first and largest Australian report of the end of life and symptom experience of people dying of COVID‐19. This information should help clinicians to anticipate palliative care needs of these patients, for example, recognising that higher starting doses of opioids and sedatives may help reduce prevalence and severity of breathlessness and agitation near death.

Palliative Sedation in COVID-19 End-of-Life Care. Retrospective Cohort Study

“…The main medications used were morphine and midazolam, in line with previous studies [ 4 , 5 , 6 , 8 , 12 , 13 ]. Other opioids like alfentanil, fentanyl, buprenorphine, hydromorphone, and oxycodone, associated with a finer approach to alleviating refractory symptoms prior to death, were not used.…”

“…The most commonly reported symptoms in the final days of life were dyspnea at rest, pain, and delirium/agitation, as reported elsewhere [ 4 , 5 , 6 , 8 , 12 , 13 ]. Cough is often a presenting symptom of COVID-19 but was not an ongoing issue in our cohort, unlike others [ 12 ].…”

“…The clinicians who prescribed palliative sedation in our patients were on-call or regular staff, not palliative care specialists. Palliative sedation was used for short periods of time (median 21.8 h), less than in other studies where medical staff or advising physicians from palliative care units prescribed the palliative sedation for a longer period for symptom management [ 6 , 8 ].…”

“…COVID-19 has a high mortality rate in patients requiring hospitalization, especially in older patients [ 1 , 2 , 3 ], prompting reflection on the need for palliative care in this population [ 3 ]. To date, studies have analyzed the support and involvement of the palliative medicine unit in end-of-life care in COVID-19 [ 4 , 5 ], the experience of palliative departments and hospital palliative care with these patients [ 6 , 7 , 8 ], the management of COVID-19 end-of-life care by clinicians who are not specialists in palliative care [ 9 ], and the changes that COVID-19 has brought about in the care of oncological and non-oncological palliative patients [ 10 , 11 , 12 ].…”

“…It consists of inducing a state of decreased or absent awareness (unconsciousness) and relieving the burden of otherwise intractable suffering until death. The use of palliative sedation is an indicator of the quality of end-of-life care [ 8 ].…”