|Year : 2020 | Volume
| Issue : 7 | Page : 3169-3175
Community-based palliative care during the COVID 19 pandemic
Shrikant Atreya1, Raman Kumar2, Naveen Salins3
1 Department of Palliative Care and Psycho-Oncology, Tata Medical Center, Kolkata, West Bengal, India
2 Academy of Family Physicians of India, New Delhi, India
3 Department of Palliative Medicine and Supportive Care, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
|Date of Submission||10-Jun-2020|
|Date of Acceptance||12-Jun-2020|
|Date of Web Publication||30-Jul-2020|
Dr. Shrikant Atreya
Consultant in Palliative Medicine, Department of Palliative Care and Psychooncology, Tata Medical Center, 14 MAR (E-W), New Town, Rajarhat, Kolkata, West Bengal - 700160
Source of Support: None, Conflict of Interest: None
Novel Coronavirus (COVID 19) has usurped human peace and mobility. Since December 2019, the virus has claimed the lives of 87,816 people across the globe as of April 9, 2020 with India reporting a high case fatality of 3.4%. Among the vulnerable population, elderly people, and patients with comorbidities such as diabetes, chronic life-threatening illnesses, such as COPD and advanced malignancies are susceptible to COVID-19 infection and may have poor clinical outcomes. Considering the imbalance in demand and supply of healthcare resources, initiating palliative care will be essential to alleviate the suffering of such patients. The current paper deliberates on the following aspects of palliative care delivery in the community; the need for palliative care in a pandemic crisis, the role of telemedicine in palliative care delivery in the community, the vital role of a family physician in providing primary palliative care in the community and a “wholistic” community palliative care package to serve the needy in the community.
Keywords: Community based palliative care, COVID 19, primary palliative care
|How to cite this article:|
Atreya S, Kumar R, Salins N. Community-based palliative care during the COVID 19 pandemic. J Family Med Prim Care 2020;9:3169-75
| Introduction|| |
December 2019 evidenced the beginning of a global deluge, with a series of cases of novel virus causing respiratory tract infections in humans in Wuhan, Hubei province of China which eventually turned into a global pandemic. On Jan 30, 2020, World Health Organization (WHO) declared the current novel coronavirus disease 2019 (COVID-19) epidemic a Public Health Emergency of International Concern.
The novel virus was named “severe acute respiratory syndrome coronavirus 2 (2019-nCoV/SARS-CoV-2)” and was first isolated on 7 January 2020. Patients who are asymptomatic at the outset may develop mild symptoms such as upper respiratory symptoms which may progress to pneumonia, respiratory failure, and death. SARS-CoV-2 belongs to the Beta coronavirus genera, an enveloped, single-stranded RNA virus that is initially transmitted, from animal to human and later human-to-human transmission occurs with a rapid spread among the contact population. Genetic analysis of the full-length genome sequence revealed SARS-CoV-2 to be most closely related to bat coronavirus termed Bat CoV RaTG13, indicating bats as the likely origin. The glycosylated cell surface protein of the virus contains two functional domains (S1 and S2); S1 domain strongly binds to host angiotensin-converting enzyme 2 (ACE 2) receptor thus initiating the cell surface adhesion and the S2 domain facilitates fusion of the viral cell membrane with the host cell required for cellular infiltration., Further to this, the lungs and the virus are rich in enzyme “furin”, a protein convertase responsible to cellular cleavage.,
The total confirmed cases of coronavirus disease globally until April 9, 2020 are 1.48 million with a mortality of 87,816 with India alone reporting 5736 and 166 confirmed cases and deaths, respectively. A steep rise in the number of COVID positive cases are seen after 50 years of age with the highest reporting of cases (30.4%) in the age range of 50-60 years followed by 25.5% cases in the age range of 60-70 years. India has reported a case fatality rate of 3.4%.
| Vulnerable Population|| |
With improvements in healthcare, the elderly population is surviving longer which makes them highly susceptible to COVID infection and resultant mortality. With the rising trends in the nuclear families in the country, the elderly population has to depend on external support system such as a paid caregiver or nursing home facilities, which increases their susceptibility to infection. With the implementation of lockdown, patients face challenges in seeking healthcare and transportation to healthcare facilities. Elderly patients also suffer from multiple comorbidities such as diabetes, COPD, and other life-limiting lung and cardiovascular diseases. It can have a deleterious effect on the already compromised immune system increasing their susceptibility to infection and resultant mortality. Previous studies have demonstrated a 3.4 fold rise in the risk of developing severe acute respiratory illness (SARI) in H7N9 patients with pre-existing comorbidities. Patients with Covid-19 are highly susceptible to respiratory failure and death., Diabetes is one of the common comorbidities seen in the elderly. In a study at Wuhan, China, of the 41 patients, 32% patients had comorbidities and 20% of them had diabetes. Studies have shown high levels of ACE2 in the islets cells of the pancreas predisposing them to COVID 19 adhesion and attack. Viral infection can lead to wide fluctuation in the blood glucose level in diabetic patients with resultant poor recovery and detrimental prognosis. Higher expression of ACE2 in patients with hypertension and CVD has been postulated to enhance susceptibility to SARS-CoV2 which can portend a poor prognosis and recovery from a heart transplant. There is a lack of formal treatment guidelines at this time. Cancer and its treatment can make the patients susceptible to SARI following COVID 19 infection due to poor immunity in these sets of patients. Studies have shown a case fatality rate of 5.6% as compared to the general population where the case fatality rate is 2.3%. Patients with lung cancer, those with poor baseline lung function, and immunosuppressive chemotherapy are more prone to hypoxia and tend to deteriorate faster. Patients with debilitating chronic lung diseases may present with hypoxemia secondary to COVID infection and may have poor clinical outcomes. Overcrowding is a major challenge in many slums/remand homes/home for orphans or senior citizens. People living in such environment are highly susceptible to infection as it is challenging to follow the social distancing norm or self-isolation. This is further exacerbated by inequities in health care-seeking behavior and healthcare service delivery for such population. Handwashing and hygiene are reduced because of minimal access to soap, water, disinfectants, and bathrooms. In addition, access to basic essential commodities such as food is scarce due to limited availability and accessibility.
Although measures were implemented to identify suspect carriers at the port of entry, mathematical models have shown to delay the epidemic by a maximum of 3 days and not weeks. There is a high likelihood of missing more than 50% of the infected travelers on account of being asymptomatic and being unaware of exposure, emphasizing the need for post-travel symptom tracking. Thus, accounting for such fallacies at screening, as a measure to mitigate the crisis, the Indian government announced a countrywide lockdown for three weeks starting at midnight on 24 March to slow the spread of COVID-19 as the number of people testing positive in the country reached 563 and mathematical models suggest a lockdown of 49 days to reduce the case numbers below 10. However, this may pose a great challenge to the national economy.
The health care institutions in the country have been gearing up to battle the situation by increasing the production of personal protective equipment and ventilators in order to care for patients with severe respiratory illnesses, however, the supply may not be commensurate with the rising demand. It will thus be mandated to triage patients where some patients with respiratory distress may need aggressive intervention in the intensive care unit (ICU), while a few with multi-organ failure or coexisting comorbidity might not benefit from aggressive measures and will need palliative care and symptom management to alleviate physical, psychosocial and spiritual suffering.
The pandemic has created an unprecedented shift in the healthcare delivery for patients requiring palliative care. In the pretext to lessen the exposure of both patients and healthcare workers and the challenges associated with travel to health care facility in view of the lockdown, many institutions are shifting their focus from face to face consultation to teleconsultation.
Family physicians play a vital role in the continuum of care for patients in the community and help patients and families navigate through the journey of chronic life-threatening disease. The proximity of family physicians and accessibility to care raise the importance of family physicians in community-based care. The family physicians are in a better position to provide home-based care, counsel the patient/family through the difficult decision making in the pandemic, and support families in the bereavement phase. Family physicians can be an interface between patients in the community and palliative care specialists in the hospital.
[Table 1] depicts the triage model that can be used for the liaison primary palliative care. The family physician could obtain a thorough history and do a physical examination and the trio (family physician, palliative care physician, and palliative care nurse) could determine the need for a patient to be brought in for a face to face consultation to the hospital.
For patients who have mild to moderate symptoms, who have developed new symptoms that warrant physical examination and/or need a change of prescription, it will be prudent to liaise with family physician who could examine the patient and in consultation with palliative care team could provide the prescription.
Patients who have mild symptoms/asymptomatic or need a titration in the existing doses can continue to be supported over teleconsultation by the palliative care team. It is essential to document the discussion and record of the same be retained with the palliative care team.
| Symptom Management and Palliative Care|| |
Patients with COVID infection may present with severe respiratory distress that may often be exacerbated in co-existing chronic lung disorders and malignancy involving the lung. In some cases, the respiratory distress may be refractory to conventional medical management or oxygen therapy., The intensity of breathlessness can be assessed using a numerical rating scale such as dyspnoea numerical rating scale (score of 0-10; with 0 being no dyspnoea, 1-4 being mild dyspnoea, 5-6 being moderate dyspnoea and 7-10 being severe dyspnoea. The experience of breathlessness is also influenced by emotional, environmental, cultural and social factors, and optimal management requires a holistic approach [Table 2].
Cough in acute viral infection could be attributed to inflammation, epithelial damage, mucus impaction, and neuromodulatory changes. There is limited knowledge in the management of cough. Because of concurrent breathlessness, opioids may also help in alleviating cough. For management please refer to [Table 2].
Delirium in common in medical illness and almost universal in last days or hours of life. There could be fluctuation in the levels of sensorium and patients often manifest with hypoactive or mixed delirium. Delirium could be attributed to sepsis, metabolic derangement, hypoxia, use of certain medications such as opioids and terminal disease. For management please refer to [Table 2].
Patients may have comorbid conditions such as metastatic cancer, age-related degenerative changes such as osteoarthritis or acute or chronic cough which makes them susceptible to pain. Pain can aggravate physical and psychological distress and portend a poor quality of life. Basic assessment tools such as numerical rating scale can help is assessing the intensity of pain. A holistic approach is necessary to alleviate pain and suffering associated with it [Table 2].
Feelings of grief, sadness, despair, fear, anxiety, stigma, and loneliness are common emotional response in a pandemic crisis. Some patients cope effectively and the underlying mechanism for attainment of a degree of peace include good communication and trust among patient, family, and clinical team, the ability to share fears and concerns, as well as meticulous attention to physical comfort and psychological and spiritual concerns.
Thus, timely identification, assessment, and management is key to successful alleviation of psychological symptoms. Family physicians must be well equipped with tools for identifying and assessing patients with psychological concern and adequately trained in managing the concerns using pharmacological and non-pharmacological measures. Benzodiazepines, antipsychotic, and antidepressants must be made a part of essential and emergency drugs.
Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred. Spirituality may influence the way patients cope with the disease and the situation where in it is essential to identify spiritual distress and assess spirituality using standardized tools and find interventions to alleviate spiritual distress. Resolution of spiritual concerns is not about meeting needs but in being sensitive to the concerns, giving the time and space to patient to explore their anxieties about life in the present crisis, death and their perceptions about the causation of their illness and their desire to be at peace with oneself, the moment, the crisis or the deity.
In view of the present crisis, it may be possible to have a family tele-meeting, however, one must ensure privacy and confidentiality of the information shared in the meeting. Most palliative care patients must have had a discussion with the palliative care team with documented evidence that may aid in the discussion. During the meeting following points should be addressed;
- Chronic life-threatening illnesses refractory to disease directed treatment that may not benefit from intensive care management or disease directed treatment.
- Elderly population with comorbidities who may not benefit from life support.
- Symptom management as an alternative to intensive care treatment to alleviate suffering including a peaceful and dignified death.
- Conflict resolution between family and physician and between family members.
- The details of the communication are best documented by the primary physician and signed by the healthcare professionals involved in the discussion and patient and family members. Patient's condition must be communicated to the patient and family in a compassionate manner and the information provided must be clear and the physician must ensure that all the concerns are addressed. [Table 3] provides some do's and don't's of communication.
Discussion about goals of care and advance care planning
It is important that goals of care and futility of intensive care management be discussed with patients who have a chronic life-threatening illness as this may be relevant in COVID 19 pandemic where ICU care may be restrictive due to limitations in resources., Of relevance in this pandemic would be documenting the goals of care including place and extent of care and having a documentation of the same for every patient with chronic life threatening illness This reduces the likelihood of emergency visits or hospital admissions including inappropriate interventions, ensure assessment of meaningful outcomes, and reduce psychological morbidity of bereaved family.,,
Bereavement and grief support
Death is the only predictable event in an otherwise unpredictable human journey. As a physician, we have a broader responsibility at not only providing physical care to patients but also to address the bereavement needs of dying patients and family. A stronger patient-perceived relationship with a physician is associated with improved caregiver bereavement adjustment as caregivers have a feeling of being heard and supported. A strong alliance between physician and caregiver can be cultivated by a combination of clear communication, respecting caregiver values and preference; providing empathic and emotional support; helping caregivers anticipate and prepare for the patient's death, and by attending to caregiver's coping, stress, and anticipatory grief.,
| Conclusion|| |
Patients with chronic life-threatening illnesses and concomitant COVID 19 infection have equal rights to adequate symptom control and a dignified life. There is thus a need for a concerted effort by the palliative care team and family physician to ensure a seamless palliative care delivery to such patients in the community. A liaison primary palliative care model with the help of the family physician will help serve large majority of the patients in the community who are unable to travel to the hospital because of the present crisis and ensure that the patient continues to receive quality care seamlessly.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]