Lessons from the Literature

2020; Volume 21, No 5, May

Lessons from the Literature

Under My Microscope

Dr. Tania Pastrana. Used with permission.

IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.

Characteristics, Symptom Management and Outcomes of 101 Patients with COVID-19 Referred for Hospital Palliative Care

Lovell N, Maddocks M, Etkind SN, Taylor K, Carey I, et al. J Pain Symptom Manage | Online — 20 April 2020. DOI: 10.1016/j.jpainsymman.2020.04.015. Full text.

On April 24, 2020, the WHO confirmed more than 2.5 million cases of COVID-19 and almost 182,000 deaths worldwide due to COVID-19,1 a mortality rate of 6.9% of reported cases. Despite efforts to find a treatment, no therapies have yet been proven effective.2 What remains is symptom control and the humanized care of patients and their families that palliative care is able to provide. Many countries have already experienced the first wave: in others the “tsunami of suffering”3 is arriving. But what is expected of us during the COVID-19 pandemic?

A team at King’s College in London, led by Dr. Katherine Sleeman, reviewed the charts of the first 101 patients with COVID-19 referred for palliative care at a London hospital. The characteristics of this cohort of patients was: mostly male (64), “median [IQR] age of 82 years [72-89], Elixhauser Comorbidity Index 6 [2-10], Australian-modified Karnofsky Performance Status 20 [10-20]), and were most frequently referred for end-of-life care or symptom control.” This cohort confirms other reports about high-risk patients.

Most prevalent symptoms were breathlessness (n=67), agitation (43), drowsiness (36), pain (23) and delirium (24). Fifty-eight patients were prescribed a subcutaneous infusion, controlled in most cases using relatively small doses of opioid (morphine, 10-30 mg4; fentanyl, 100-200 mcg; alfentanil 500-1000 mcg), and benzodiazepine (midazolam, 10-20 mg).

Most patients (n=75) died in fewer than three days (median 2 [IQR 1–4] days under the palliative care team), 13 had been discharged to home or hospice, and 13 were continuing to receive inpatient palliative care.

The authors conclude, “Palliative care is an essential component to the COVID-19 response, and teams must rapidly adapt with new ways of working.” The palliative care praxis is changing. Availability of essential medicines and equipment — such as subcutaneous infusion pumps — should be guaranteed, but equally important is palliative care training for all professionals.

References

1. https://covid19.who.int/

2. Sanders JM, Monogue ML, Jodlowski TZ, Cutrell JB. Pharmacologic Treatments for Coronavirus Disease 2019 (COVID-19): A review. JAMA. Published online April 13, 2020. DOI: 10.1001/jama.2020.6019

3. Radbruch L, Knaul FM, de Lima L, de Joncheere C, Bhadelia A. The Key Role of Palliative Care in Response to the COVID-19 Tsunami of Suffering. Published online April 22, 2020. DOI: 10.1016/S0140-6736(20)30964-8

4. Median-maximum dose/24h.


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Media Watch

The articles below update topics of prior contributions to Media Watch by Barry Ashpole.

International Palliative Care Research Priorities: A systematic review

BMC Palliative Care | Online – 3 February 2020 – The authors call attention to the need for more end users in research priority setting exercises, therefore, researchers and funding bodies should develop new strategies to ensure meaningful participation of palliative care (PC) patients and families, building in structures and processes to account for the vulnerability often present within this population. Findings of this review provide an initial blueprint for PC research funders and policymakers to contribute to the future research agenda for PC from a patient and healthcare professional perspective. Given that funding resources are limited, the importance of collaboration and international approaches to PC is growing, these findings may help to inform this debate.

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The Role and Response of Palliative Care and Hospice Services in Epidemics and Pandemics: A rapid review to inform practice during the COVID-19 pandemic

Journal of Pain & Symptom Management | Online – 8 April 2020 – The authors conclude that hospice and PC services have an essential role in the response to COVID-19 by: 1) Responding rapidly and flexibly; 2) Ensuring protocols for symptom management are available, and training non-specialists in their use; 3) Being involved in triage; 4) Considering shifting resources into the community; 5) Considering redeploying volunteers to provide psychosocial and bereavement care; 6) Facilitating camaraderie among staff and adopt measures to deal with stress; 7) Using technology to communicate with patients and carers; and, 8) Adopting standardised data collection systems to inform operational changes and improve care.

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Fully Integrated Oncology and Palliative Care Services at a Local Hospital in Mid-Norway: Development and operation of an innovative care delivery model

Pain & Therapy | Online – 9 April 2020 – The authors describe the development and operation of an innovative, fully early integrated one-stop oncology and palliative care (PC) outpatient clinic at a local hospital in a rural region of Mid-Norway. In this fully integrated clinic, cancer and PC were provided by one team of healthcare providers. The fully integrated clinic communicated and collaborated closely with its local hospital, its affiliated tertiary hospital and community health and care services to provide timely referral, enhanced continuity, and improved coordination and quality of care. This model of care is particularly relevant to the early integration of cancer and PC in a smaller hospital and the provision of cancer and PC in a rural district.

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The Desire To Die in Palliative Care: A sequential mixed methods study to develop a semi-structured clinical approach

BMC Palliative Care | Online – 15 April 2020 – The major achievement of this study is the creation of the first consensus-based semi-standardized approach for (proactively) assessing and optimally responding towards desire to die based on literature review, patient interviews and expert consent. The fact that more practitioners participated than originally planned shows their great interest in the topic and its particular relevance in palliative care. The semi-structured clinical approach thus became a tool tailored directly towards everyday practice of people working in the field. This can include all professions directly in contact with palliative patients provided they have partaken in the mandatory training course: physicians, nurses, psychologists, social and spiritual care workers as well as volunteers.

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Current Issues with Implementing a Palliative Approach in Long-Term Care: Where do we go from here?

Palliative Medicine | Online – 10 April 2020 – Most countries are witnessing a changing profile of long-term care (LTC) residents, with many entering LTC very frail with multiple comorbidities, resulting in more complex care for staff to manage. The length of stay for residents are shorter than ever before, and LTC homes are becoming more hospice-like; but unlike hospices, they are heavily regulated with little flexibility to provide person-centered care. Even more troubling is the fact that capacity within LTC homes has not progressed at the same pace to meet the acuity level of this growing population, nor are they equipped to implement a palliative approach to care, evidenced by numerous reports of poor outcomes and costly reliance on hospitals to manage care for residents at end of life.

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Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.


For more reliable information on COVID-19, see the new IAHPC web page:

Resources Relevant to Palliative Care and COVID-19

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