Palliative Care and Covid-19: The WCM Experience
Randi R. Diamond, MD
Assistant Professor of Clinical Medicine
Director, Liz Claiborne Center for Humanism in Medicine
Division of Geriatrics and Palliative Medicine
Weill Cornell Medicine
At the peak and epicenter of the pandemic, Weill Cornell Medicine (WCM) had 481 COVID-19 patients in the hospital, 237 in an ICU and 216 on ventilators. While new ICU beds were created, the WCM Palliative Care Consultation Service (WCM PCCS) was initially unusually quiet, but it quickly became apparent that the staff in the ICUs and the families of the hospitalized patients were struggling---with the restrictions on visitation, with how incredibly sick many of the previously healthy patients were, with their own anxiety about the patients and about themselves.
As articulated by the Center for Advancement of Palliative Care (CAPC), PC is ideally equipped with many of the communication skills needed to help in this kind of crisis. In addition to focusing on improving quality of life for people living with a serious illness, palliative care specialists’ expertise in symptom management and skilled communication is essential to the care of people with COVID-19, including the majority of patients who will survive the disease. Given that palliative care teams are a scarce resource, CAPC urged them to lead their colleagues so that they can rapidly enhance and deploy best practices in communication and symptom management.
The WCM PCCS partnered with the ICUs to provide an extra layer of support for those families who were particularly anxious or struggling to process the medical information, collaborating with the ICU teams for medical updates and intended messaging. In the process, our team identified unique challenges for families during the pandemic including visitation limits, difficulty envisioning and understanding the gravity of their loved one’s illness, the need for complex decision-making in face of inability to communicate with sedated or delirious loved ones with impaired decision-making capacity, difficulty developing a trusting relationship with medical teams who were overburdened and limited in time to communicate, and fear and confusion related to constant mixed messages about COVID-19 from the news media. In response, the PC team worked to call families regularly, convey messages and pictures from family via frontline staff, arrange video visits and spiritual support often including recorded or remote prayer.
Evolving role for evolving needs
In addition, we established an Emergency Department Rapid Response Goals of Care Teamandramped up our virtual educational efforts using tools from Vital Talks and CAPC (3) for hospitalists, surgical, Emergency Medicine and psychiatry residents, anticipating need for a larger workforce to do Goals of Care (GOC) discussions and support calls. We created and distributed laminated cards with key communication suggestions. Realizing the waiting list for tracheostomy and common misunderstanding among family members, we developed and shared talking points for GOC around Tracheostomy Placement. We highlighted the need to help families explore and understand expected recovery (survival vs. institution vs. home vs. normal life), expected length of ventilator dependence, potential for prolonged disability and vulnerability, and alternatives to tracheostomy (if not concordant with patient’s GOC).
Nevertheless, many patients continued having one serious complication after another in the ICU, prompting the opening of a new inpatient PC/hospice unit where the greatest symptom management challenges included dyspnea and agitated delirium (requiring more aggressive pharmacologic management than usual and clear communication with families).
Finally PC team members made themselves available to be present for staff experiencing distress around caring for sick colleagues, feeling abandoned, angry, guilty and overwhelmed by being surrounded by death and dying.
COVID-19 continues, many patients with severe post-critical illness, as does concern about another surge but we are in a better position to respond based on lessons learned from our past experiences.
References
https://www.capc.org/covid-19/role-palliative-care-teams-dedicated-covid-19-sites/
https://journals.sagepub.com/doi/pdf/10.1177/1049909120931506
https://www.vitaltalk.org/guides/covid-19-communication-skills/
Bice, T, Nelson, J Carson, SS. To Trach or not to Trach: Uncertainty in the Care of the Chronically Critically Ill. Semin Respir Crit Care Med. 2015 Dec; 36(6): 851–858.
Sun H, et al. Characteristics and Palliative Care Needs of COVID-19 Patients Receiving Comfort Directed Care. JAGS. 2020 Apr 24.
Sanders BJ, et al. Hyperactive Delirium Requires More Aggressive Management in Patients with COVID-19: Temporarily Rethinking “Low and Slow”. JPSM;2020.05.013.