Palliative care principles should guide the care that COVID-19 patients receive, according to the authors of a recent editorial in the Journal of Cardiopulmonary and Acute Care.
Core aspects of palliative care can provide a foundation for responding to a COVID patient’s needs, including alleviation of symptoms, multidisciplinary teams, patient-centered care, and support for patients’ families.
“I think what the current pandemic has done is really brought to the forefront how important palliative care is in the care of patients. This has really emphasized the value of palliative care — both provided by specialty palliative care providers and also the central tenants of palliative care that can really be provided by any clinician,” said Shelli Feder, with the Yale University School of Nursing, a co-author of the study.
According to the U.S. Centers for Disease Control and Prevention (CDC), people at higher risk for severe illness and complications from COVID-19 are older adults and those with serious underlying medical and comorbid conditions such as cardiac illness, cancer, congestive heart failure, and pulmonary disease. Such diagnoses common among patients who have a high need for palliative care.
Currently 72% of hospitals in the United States with 50 or more beds have a palliative care program. This is up from 67% in 2015 and 7% in 2001, according to the Center to Advance Palliative Care (CAPC). These institutions care for 87% of all hospitalized patients nationwide. Large nonprofit hospitals in large cities are the most likely to provide palliative care.
Data on the availability of community-based palliative care services are limited, but CAPC numbers show that at least half of the in-home providers of those services in the United States are hospices.
In addition to treating patients’ physical symptoms, emotional and psychosocial support for patients and their families are among the goals of palliative care. These services are increasingly necessary as patients contend with anxiety regarding the pandemic and the associated mortality risk. Families of patients who do not recover are also in need of bereavement care.
“The risk for complicated grief is extraordinarily high for families. That’s a way that we haven’t always thought about the utility of palliative care being mobilized early in other situations,” said Kathleen Akgün, co-author and palliative and intensive care nurse for Veterans Affairs-Connecticut Healthcare System (VA). “Complicated grief is grief that lasts longer and more intensely than one might expect. So these kinds of circumstances where you patients and family members are separated in the final days and at the time of death with limited abilities for communication potentially associated with complicated grief because there’s not that ability to connect to have some closure to see a loved one.”
The pandemic comes a time when the palliative care workforce is already stretched thin. The United States has 13.35 hospice and palliative care specialists for every 100,000 adults 65 and older, according to an April 2018 study. The research estimated that by 2040 the patient population will need 10,640 to 24,000 specialists; supply is expected to range between 8,100 and 19,000.
Hospice and palliative care providers also experience shortages in non-physician disciplines, including chaplains, nurses, and social workers. As far back as 2008, the U.S. Centers for Medicare & Medicaid Service (CMS) began allowing hospice providers to use contracted nursing staff because not enough nurses were available to fill permanent positions.
To truly meet the needs of the rapidly growing influx of patients during the pandemic, clinicians who do not have specialty training may need to adapt their practices to incorporate palliative care principles into the care they provide..
“There’s always been a high demand for palliative care. I think that the pandemic has really underscored the dearth of palliative care providers in a way that is really in people’s faces right now,“ co-author Dena Schulman-Green from the Yale University School of Nursing told Hospice News. “There have been a number of resources that have recently been published specifically for non-specialist clinicians who are likely are dealing with very difficult situations and are having very difficult conversations with families of sick patients. These tools are opportunities for clinicians to learn about what we mean by when we talk about non-specialist palliative care.”