Palliative care in the context of a pandemic: similar but different

Human resources (specialist palliative care)

As discussed, specialist palliative care is a finite resource, and during pandemics and other healthcare emergencies, it is important that this resource is utilised appropriately to manage those patients affected by the pandemic as well as those patients who make up the ‘normal’ palliative care population (eg patients with life-limiting conditions, cancer patients requiring supportive care).

Everyone's job plan/rota should be reviewed (and invariably be amended). Moreover, this needs to be an ongoing process, since the clinical situation will change as the pandemic progresses (and eventually subsides), and as workforce issues develop (ie isolation, illness, physical fatigue, psychological fatigue / ‘burnout’). Table 1 outlines a ‘Yes, Maybe, No’ approach to job planning during pandemics and other healthcare emergencies.

It is important that job planning / task allocation reflects the person's specific knowledge and skills, and it should not be unduly influenced by what the person wants to do (eg managing acutely unwell patients) or what other people don't want to do (eg breaking ‘bad news’ to patients/carers). Nevertheless, everyone should expect to undertake activities outside their normal scope (including menial duties), and potentially outside their ‘comfort zone’. In the latter instance, it is essential that appropriate training/support is readily available.

Other resources

Pandemics and other healthcare emergencies often result in scarcities of drugs, equipment and consumables (eg personal protective equipment). Fortunately, the symptoms experienced by patients with COVID-19 are manageable with commonly available medications, and there are invariably alternatives to first-line options. For example, opioids are effective in managing shortness of breath, and while morphine is usually the first-line option, other opioids are equally effective.

Syringe pumps (‘syringe drivers’) are often used to give medication to patients at the end of life. However, syringe pumps are not essential to providing good end-of-life care, and patients’ symptoms can potentially be managed by either intermittent subcutaneous injections or the use of other routes of administration (ie intravenous, transdermal, oral transmucosal, intranasal, rectal).^4,5 Indeed, syringe pumps only became established in the early 1990s, although they had been in use for a decade or so beforehand.⁶

Guidelines

The symptoms/problems experienced by patients with COVID-19 are not unique, and the management of patients should be based on the available evidence from analogous cohorts of patients (with necessary adjustments). Unfortunately, some promoted guidance is lacking in evidence (eg benzodiazepines to manage shortness of breath per se) or is impractical in many COVID-19 patients (eg breathing/relaxation techniques for shortness of breath).

The Palliative Care Formulary is a reputable source of information about symptom control (and end-of-life care management).⁵ An alternative is the British National Formulary.⁷ Table 2 gives an overview of symptom control in patients with COVID-19 infection.^8–13 Patients with difficult-to-control symptoms / other problems should be referred to / discussed with the local specialist palliative care team in a timely manner (and advice from these teams should be available 24 hours per day / 7 days per week).

Lessons from previous pandemics

The medical literature contains a number of articles about the potential role of palliative care in healthcare emergencies,^14,15 although there are limited reports about the actual role of palliative care (or specialist palliative care services) in previous healthcare emergencies.^16,17 Indeed, there is no evidence to support any specific model of palliative care in these circumstances.¹⁸

Paladino and colleagues reported on the consequences of the Ebola outbreak in Africa in 2014–16:¹⁹ they highlighted high levels of psychological distress in Ebola survivors (eg depression, post-traumatic stress disorder (PTSD)), in the general population (eg abnormal grief response, PTSD) and also among healthcare professionals (eg burnout, PTSD). Moreover, they reported ongoing physical health problems in Ebola survivors (eg insomnia, short-term memory problems).

We need to anticipate similar problems following the COVID-19 pandemic. Moreover, we need to anticipate problems arising from the cancellation, postponement or modification of treatment given to other groups of patients during this period. For example, some patients with cancer may have gone from being ‘curable’ to only ‘treatable’, and some from being ‘treatable’ to only suitable for palliative care. Indeed, we suggest that a national strategy should be developed to manage the potential ‘iceberg scenario’ of the current pandemic (Fig 1).

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Fig 1.

‘Iceberg scenario’ (potential consequences of COVID-19 pandemic).

Lessons from current pandemic

At the time of writing, the peak of the COVID-19 pandemic was expected in 1–2 weeks (in the UK). We have all learned lessons during this pandemic, and will surely learn further lessons over the coming weeks and months. We need to reflect on our experiences, and importantly share these experiences (both positive and negative). Moreover, we should not go back to doing things ‘the old way’, if contemporary initiatives have been successful (eg telephone/video consultations).