BACKGROUND: The COVID-19 pandemic has aggressively reached the most vulnerable, not only the elderly but also patients with chronic conditions such as cancer. In this study, we present the outlines of ethical thinking and the measures implemented to try to respect our basic values of care, in the specific environment of an oncology hospital.
METHODS: Our ethics committee created an ethical watch system based on 24/7 shifts to assist practitioners in their daily decisions. We discuss the challenges faced by patients with cancer during the pandemic, such as access to critical care and ethical dilemmas in the context of resource scarcity, as well as the issue of isolation of patients. We also debate the restrictions in access to oncology care in a health context strongly 'prioritised' against COVID-19.
RESULTS: In all areas of an ethical dilemma, either for sorting out access to critical care or for the dramatic consequences of prolonged isolation of patients, our common thread was our attempt to protect, whenever possible, the principles of deontological ethics by strictly resisting utilitarian pressure. Respecting democratic health decision-making processes is a cornerstone of ethically relevant decisions, including in the context of a sanitary crisis.
CONCLUSION: The role of an ethics committee related to real-life situations includes not only a reflexive perspective in respect of fundamental principles, but also the help to enlighten and resolve ethical dilemmas in complex clinical situations. This ethical watch team assists physicians in decision-making, promoting the supportive and palliative dimension of care with a holistic approach.
Background: New Orleans, Louisiana served as a central location for a surge of novel coronavirus cases during the months of March 2020 to May 2020. To provide guidance to palliative care teams naive to the palliative care demand associated with a surge of coronavirus cases, we document our protocol to best optimize palliative care resources. This report aims to present this information and reflect upon what was most beneficial/least beneficial to serve as a roadmap for palliative teams facing this pandemic.
Objective: To pilot a team-based structured protocol to categorize severity of COVID-19 intensive care unit (ICU) admissions and subsequently collaborate with the palliative interdisciplinary team to assess physical, spiritual, and psychosocial needs.
Design: New ICU consults were categorized into color-coded clinical severity "pots" during daily ICU interdisciplinary rounds. Clinical decision making and communication with patient/next of kin were based on "pot" classification.
Settings/Subjects: Palliative medicine consults were placed on all COVID-19 positive patients admitted to the ICU between March 29, 2020, and May 1, 2020.
Measurements: A retrospective chart review was performed to analyze the effect of palliative care consultation on completion of goals-of-care conversations and the life-sustaining treatment (LST) document, an advance directive form specific to the Veterans Affairs hospital system between March 29, 2020 and May 1, 2020.
Results: Of the palliative consults evaluated by a palliative provider, 74% resulted in completion of a LST document, 58% resulted in video contact with family members, and 100% incorporated a goals-of-care discussion.
Conclusions: We found that standardizing palliative care consultation on all COVID-19 positive ICU admissions subjectively alleviated the burden on ICU providers and staff in the midst of a crisis, resulted in increased documentation of patient goals-of-care preferences/LSTs, facilitated clinical updates to family members, and better distributed clinical burden among palliative team members.
L’Espace national de réflexion éthique sur la maladie d’Alzheimer et les maladies neuro-dégénératives EREMAND, animé par l’Espace de réflexion éthique de la région Île-de-France, a conduit au début de l’épidémie de Covid-19 une enquête nationale pour identifier les difficultés rencontrées par les professionnels du grand âge et de l’autonomie, les familles et les bénévoles, et les initiatives que ceux-ci ont mises en oeuvre. Sept difficultés
majeures sont identifiées : l’isolement induit par l’interdiction des visites, le manque de matériels de protection et de tests, les difficultés des personnes en difficulté cognitive à comprendre les mesures pour éviter la propagation de l’épidémie, la soutenabilité de la surcharge de travail pour les professionnels, l’inquiétude des familles des résidents, les
situations complexes à domicile et les difficultés d’accès aux soins. Quatre initiatives sont mises en oeuvre : information et formation des équipes, compensation de l’interruption des visites, concertations et échanges entre professionnels, actions au bénéfice des personnes vivant à domicile. L’épidémie de Covid-19 est venue percuter le secteur du grand
âge à un moment très particulier de son histoire, de plusieurs années d’effort du secteur pour se réinventer autour de valeurs fortes. Elles ont été des ressources au cours de cette période de crise. Une ambitieuse loi grand âge et autonomie, apparaît dès lors, comme une nécessité.
La vie du pôle de gériatrie de Mulhouse a basculé le 3 mars 2020.
Les premiers patients Covid-19 affluent dans les services de réanimation et de médecine interne du Groupe hospitalier de la Région de Mulhouse et Sud-Alsace (GHRMSA). Dès le 4 mars, le pôle de gériatrie de Mulhouse
est en marche pour le front. Il s’engage immédiatement dans une réorganisation de son fonctionnement pour transformer le court-séjour en une unité Covid initialement de 11 lits. Les 25 patients présents jusqu’alors dans l’unité sont transférés dans d’autres services du GHRMSA en moins de 48 heures. Une logistique intense se met en place et les premiers patients Covid-19 sont accueillis le 5 mars avec des formes graves d’emblée. Dès le 7 mars, le déferlement de patients contraint le court-séjour à ouvrir ses 25 lits pour les malades Covid-19 puis une unité supplémentaire de 13 lits quelques jours après.
La pandémie de Covid-19 est particulièrement sévère chez la personne âgée.
Notre objectif était d’identifier, à partir de la littérature internationale, les symptômes les plus fréquents chez la personne âgée infectée par le virus SARS-CoV-2. Cette revue systématique de la littérature a été conduite à partir de Medline sur la période du 1er décembre 2019 au 13 avril 2020. L’analyse des biais a été réalisée selon une méthode d’évaluation de
la qualité méthodologique des séries de cas et rapports de cas. Sur 260 articles initialement identifiés, seules deux études ont finalement été incluses dans la synthèse qualitative. L’âge moyen était peu élevé, entre 71 et 74 ans en moyenne. Les symptômes de Covid-19 étaient les suivants : fièvre, toux sèche, dyspnée, asthénie, anorexie, oppression thoracique, diarrhées, et dans une moindre mesure myalgies, pharyngite, nausées, vertiges, céphalées, douleurs abdominales et enfin vomissements. Une lymphopénie était retrouvée à la numération
sanguine. En conclusion, cette revue systématique de la littérature internationale révèle un manque de données concernant la sémiologie du Covid-19 chez la personne âgée, notamment chez les très âgés fragiles qui définissent communément la population gériatrique. L’enquête nationale de la Société française de gériatrie et gérontologie permettra
de combler ce scotome sémiologique.
L’épidémie de Covid-19 qui avait débuté en novembre en Chine est devenue une épidémie en France à partir du 16 mars 2020 avec la déclaration du confinement de la population afin de diminuer la propagation du virus. Dès le 17 mars et jusqu’au 27 mars 2020, la cellule de veille de la Société française de gériatrie et gérontologie décide de mener une enquête pour analyser la mise en place de la mobilisation des structures de gériatrie, étant donné que cette épidémie avait montré qu’elle entraînait une surmortalité majoritairement chez les personnes âgées. L’enquête a pu réunir la réponse de 34 structures, dont neuf étaient situées en zone cluster de forte épidémie. Des services de court séjour gériatriques
dédiés pour les patients infectés par le Covid-19 étaient présents dans huit établissements, uniquement hors des zones clusters. Neuf soins de suite et de rééducation gériatriques ont été dédiés, une activité supplémentaire de télémédecine concernait 35 % des établissements, et des moyens d’écoute des familles, d’animation et de communication par tablettes concernaient 36% des établissements. Cette enquête est une photographie d’un moment initial de l’épidémie. Elle donne l’occasion de décrire le contexte dans lequel cette épidémie est survenue en ce qui concerne la politique gériatrique, et d’apprécier la réactivité et l’inventivité de ces services pour répondre aux besoins des personnes âgées.
BACKGROUND: The coronavirus disease 2019 pandemic has led to escalating infection rates and associated deaths worldwide. Amid this public health emergency, the urgent need for palliative care integration throughout critical care settings has never been more crucial.
OBJECTIVE: To promote palliative care engagement in critical care; share palliative care resources to support critical care nurses in alleviating suffering during the coronavirus disease 2019 pandemic; and make recommendations to strengthen nursing capacity to deliver high-quality, person-centered critical care. Methods Palliative and critical care literature and practice guidelines were reviewed, synthesized, and translated into recommendations for critical care nursing practice.
RESULTS: Nurses are ideally positioned to drive full integration of palliative care into the critical care delivery for all patients, including those with coronavirus disease 2019, given their relationship-based approach to care, as well as their leadership and advocacy roles. Recommendations include the promotion of healthy work environments and prioritizing nurse self-care in alignment with critical care nursing standards.
CONCLUSIONS: Nurses should focus on a strategic integration of palliative care, critical care, and ethically based care during times of normalcy and of crisis. Primary palliative care should be provided for each patient and family, and specialist services sought, as appropriate. Nurse educators are encouraged to use these recommendations and resources in their curricula and training. Palliative care is critical care. Critical care nurses are the frontline responders capable of translating this holistic, person-centered approach into pragmatic services and relationships throughout the critical care continuum.
The COVID-19 pandemic has highlighted the need for healthcare providers skilled in rapid, flexible decision-making, effective and anticipatory leadership, and in dealing with trauma and moral distress. Palliative care (PC) workers have been an essential part of the COVID-19 response in advising on goals of care, symptom management and difficult decision-making, and in supporting distressed healthcare workers, patients and families. We describe GPEC (Global Palliative Education Collaborative), a training partnership between Harvard, UCSF, and Tulane medical schools in the US; and two international PC programs in Uganda and India. GPEC offers US-based PC fellows participation in an international elective to learn about resource-limited PC provision, gain perspective on global challenges to caring for patients at the end of life, and cultivate resiliency. International PC colleagues have much to teach about practicing compassionate PC amidst resource constraints and humanitarian crisis. We also describe a novel educational project that our GPEC faculty and fellows are participating in - the Resilience Inspiration Storytelling Empathy (RISE) Project - and discuss positive outcomes of the project.
Background: COVID-19 has directly and indirectly caused high mortality worldwide.
Aim: To explore patterns of mortality during the COVID-19 pandemic and implications for palliative care, service planning and research.
Design: Descriptive analysis and population-based modelling of routine data.
Participants and setting: All deaths registered in England and Wales between 7 March and 15 May 2020. We described the following mortality categories by age, gender and place of death: (1) baseline deaths (deaths that would typically occur in a given period); (2) COVID-19 deaths and (3) additional deaths not directly attributed to COVID-19. We estimated the proportion of people who died from COVID-19 who might have been in their last year of life in the absence of the pandemic using simple modelling with explicit assumptions.
Results: During the first 10 weeks of the pandemic, there were 101,614 baseline deaths, 41,105 COVID-19 deaths and 14,520 additional deaths. Deaths in care homes increased by 220%, while home and hospital deaths increased by 77% and 90%, respectively. Hospice deaths fell by 20%. Additional deaths were among older people (86% aged >= 75 years), and most occurred in care homes (56%) and at home (43%). We estimate that 22% (13%–31%) of COVID-19 deaths occurred among people who might have been in their last year of life in the absence of the pandemic.
Conclusion: The COVID-19 pandemic has led to a surge in palliative care needs. Health and social care systems must ensure availability of palliative care to support people with severe COVID-19, particularly in care homes.
Background: This retrospective cohort study aims to define the clinical findings and outcomes of every patient admitted to a district general hospital in Surrey with COVID-19 in March 2020, providing a snapshot of the first wave of infection in the UK. This study is the first detailed insight into the impact of frailty markers on patient outcomes and provides the infection rate among healthcare workers.
Methods: Data were obtained from medical records. Outcome measures were level of oxygen therapy, discharge and death. Patients were followed up until 21 April 2020.
Results: 108 patients were included. 34 (31%) died in hospital or were discharged for palliative care. 43% of patients aged over 65 died. The commonest comorbidities were hypertension (49; 45%) and diabetes (25; 23%). Patients who died were older (mean difference ±SEM, 13.76±3.12 years; p<0.0001) with a higher NEWS2 score (median 6, IQR 2.5–7.5 vs median 2, IQR 2–6) and worse renal function (median differences: urea 2.7 mmol/L, p<0.01; creatinine 4 µmol/L, p<0.05; eGFR 14 mL/min, p<0.05) on admission compared with survivors. Frailty markers were identified as risk factors for death. Clinical Frailty Scale (CFS) was higher in patients over 65 who died than in survivors (median 5, IQR 4–6 vs 3.5, IQR 2–5; p<0.01). Troponin and creatine kinase levels were higher in patients who died than in those who recovered (p<0.0001). Lymphopenia was common (median 0.8, IQR 0.6–1.2; p<0.005). Every patient with heart failure died (8). 26 (24%) were treated with continuous positive airway pressure (CPAP; median 3 days, IQR 2–7.3) and 9 (8%) were intubated (median 14 days, IQR 7–21). All patients who died after discharge (4; 6%) were care home residents. 276 of 699 hospital staff tested were positive for COVID-19.
Conclusions: This study identifies older patients with frailty as being particularly vulnerable and reinforces government policy to protect this group at all costs.
BACKGROUND: Preparation for an impending death through EOL (end-of-life) discussions and human presence when a person is dying is important for both patients and families.
OBJECTIVE: The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from Covid-19, comparing deaths in nursing homes and hospitals.
DESIGN: The national Swedish Register of Palliative Care (SRPC) was used. All expected deaths from Covid-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019).
SETTING AND SUBJECTS: A total of 1346 expected Covid-19 deaths in nursing homes (n=908) and hospitals (n=438) were analyzed.
RESULTS: Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (p<0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, p<0.001) and dying with someone present was much more uncommon (59% vs. 83%, p<0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, p<0.0001) and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, p<0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (p<0.001). The corresponding figures for staff were 52% and 38% (p<0.0001).
CONCLUSION: Dying from Covid-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.
BACKGROUND: The COVID-19 pandemic has highlighted the essential role of palliative care to support the delivery of compassionate, goal-concordant patient care. We created the web-based application, PalliCOVID (https://pallicovid.app/), in April 2020 to provide all clinicians with convenient access to palliative care resources and support. PalliCOVID features evidence-based clinical guidelines, educational content, and institutional protocols related to palliative care for COVID-19 patients. It is a publicly available resource accessible from any mobile device or desktop computer that provides clinicians with access to palliative care guidance across a variety of care settings, including the emergency department, hospital ward, intensive care unit, and primary care practice.
OBJECTIVE: The primary objective of this study was to evaluate usage patterns of PalliCOVID to understand user behavior in relation to this palliative care content platform during the period of the local peak of COVID-19 infection in Massachusetts.
DESIGN: We retrospectively analyzed de-identified usage data collected by Google Analytics from the first day of PalliCOVID's launch on April 7, 2020 until May 1, 2020, the time period that encompassed the local peak of the COVID-19 surge in Massachusetts.
MEASURE: ments: User access data was collected and summarized by Google Analytics software that had been integrated into the PalliCOVID web application.
RESULTS: 2,042 users accessed PalliCOVID and viewed 4,637 pages from April 7 to May 1, 2020. Users spent an average of 2 minutes and 6 seconds per session. 81% of users were first-time visitors, while the remaining 19% were return visitors. The majority of users accessed PalliCOVID from the United States (87%), with a large proportion of users coming from Boston and the surrounding cities (32% of overall users).
CONCLUSIONS: PalliCOVID is one example of a scalable digital health solution that can bring palliative care resources to frontline clinicians. Analysis of PalliCOVID usage patterns has the potential to inform the improvement of the platform to better meet the needs of its user base and guide future dissemination strategies. The quantitative data presented here, although informative about user behavior, should be supplemented with future qualitative research to further define the impact of this tool and extend our ability to deliver clinical care that is compassionate, rational, and well-aligned with patients' values and goals.
BACKGROUND: The global COVID-19 pandemic has left health and social care systems facing the challenge of supporting large numbers of bereaved people in difficult and unprecedented social conditions. Previous reviews have not comprehensively synthesised the evidence on the response of health and social care systems to mass bereavement events.
AIM: To synthesise the evidence regarding system-level responses to mass bereavement events, including natural and human-made disasters as well as pandemics, to inform service provision and policy during the COVID-19 pandemic and beyond.
DESIGN: A rapid systematic review was conducted, with narrative synthesis. The review protocol was registered prospectively (www.crd.york.ac.uk/prospero, CRD 42020180723).
DATA SOURCES: MEDLINE, Global Health, PsycINFO and Scopus databases were searched for studies published between 2000 and 2020. Reference lists were screened for further relevant publications, and citation tracking was performed.
RESULTS: Six studies were included reporting on system responses to mass bereavement following human-made and natural disasters, involving a range of individual and group-based support initiatives. Positive impacts were reported, but study quality was generally low and reliant on data from retrospective evaluation designs. Key features of service delivery were identified: a proactive outreach approach, centrally organised but locally delivered interventions, event-specific professional competencies and an emphasis on psycho-educational content.
CONCLUSION: Despite the limitations in the quantity and quality of the evidence base, consistent messages are identified for bereavement support provision during the pandemic. High quality primary studies are needed to ensure service improvement in the current crisis and to guide future disaster response efforts.
Background: the literature contains limited information on the problems faced by dying patients with COVID-19 and the effectiveness of interventions to manage these.
Aim: The aim of this audit was to assess the utility of our end-of-life care plan, and specifically the effectiveness of our standardised end-of-life care treatment algorithms, in dying patients with COVID-19.
Design: The audit primarily involved data extraction from the end-of-life care plan, which includes four hourly nursing (ward nurses) assessments of specific problems: patients with problems were managed according to standardised treatment algorithms, and the intervention was deemed to be effective if the problem was not present at subsequent assessments.
Setting/participants: This audit was undertaken at a general hospital in England, covered the 8 weeks from 16 March to 11 May 2020 and included all inpatients with COVID-19 who had an end-of-life care plan (and died).
Results: Sixty-one patients met the audit criteria: the commonest problem was shortness of breath (57.5%), which was generally controlled with conservative doses of morphine (10–20 mg/24 h via a syringe pump). Cough and audible respiratory secretions were relatively uncommon. The second most common problem was agitation/delirium (55.5%), which was generally controlled with standard pharmacological interventions. The cumulative number of patients with shortness of breath, agitation and audible respiratory secretions increased over the last 72 h of life, but most patients were symptom controlled at the point of death.
Conclusion: Patients dying of COVID-19 experience similar end-of-life problems to other groups of patients. Moreover, they generally respond to standard interventions for these end-of-life problems.
BACKGROUND: Hospital palliative care is an essential part of the COVID-19 response, but relevant data are lacking. The recent literature underscores the need to implement protocols for symptom control and the training of non-specialists by palliative care teams.
AIM: The aim of the study was to describe a palliative care unit's consultation and assistance intervention at the request of an Infectious Diseases Unit during the COVID-19 pandemic, determining what changes needed to be made in delivering palliative care.
DESIGN: This is a single holistic case study design using data triangulation, for example, audio recordings of team meetings and field notes.
SETTING/PARTICIPANTS: This study was conducted in the Palliative Care Unit of the AUSL-IRCCS hospital of Reggio Emilia, which has no designated beds, consulting with the Infectious Diseases Unit of the same hospital.
RESULTS: A total of 9 physicians and 22 nurses of the Infectious Diseases Unit and two physicians of the Palliative Care Unit participated in the study.Our Palliative Care Unit developed a feasible 18-day multicomponent consultation intervention. Three macro themes were identified: (1) new answers to new needs, (2) symptom relief and decision-making process, and (3) educational and training issues.
CONCLUSION: From the perspective of palliative care, some changes in usual care needed to be made. These included breaking bad news, patients' use of communication devices, the limited time available for the delivery of care, managing death necessarily only inside the hospital, and relationships with families.
BACKGROUND: Palliative care services face challenges in adapting and responding to the COVID-19 pandemic. Understanding how palliative care needs and outcomes have changed during the pandemic compared to before the pandemic is crucial to inform service planning and research initiatives.
AIM: To evaluate the impact of COVID-19 on symptoms, clinical characteristics, and outcomes for patients referred to a hospital-based palliative care service in a district general hospital in London, UK.
DESIGN: A retrospective service evaluation. Data were extracted from the electronic patient records.
SETTING/PARTICIPANTS: The first 60 inpatients with confirmed COVID-19 infection, referred to the hospital palliative care service between 1 March 2020 and 23 April 2020, and another 60 inpatients, referred to the hospital palliative care service between 11 March 2019 and 23 April 2019, were included from a district general hospital in East London, UK.
RESULTS: Patients with COVID-19 have lower comorbidity scores, poorer performance status, and a shorter time from referral to death compared to patients without COVID-19. Breathlessness, drowsiness, agitation, and fever are the most prevalent symptoms during COVID-19 compared to pain and drowsiness pre-COVID-19. Time from admission to referral to palliative care is longer for Black, Asian and minority ethnic patients, especially during COVID-19.
CONCLUSION: Early referral to palliative care is essential in COVID-19, especially for Black, Asian and minority ethnic groups. There is urgent need to research why Black, Asian and minority ethnic patients are referred late; how palliative care services have changed; and possible solutions to setting up responsive, flexible, and integrated services.
BACKGROUND: The increased number of deaths in the community happening as a result of COVID-19 has caused primary healthcare services to change their traditional service delivery in a short timeframe. Services are quickly adapting to new challenges in the practical delivery of end-of-life care to patients in the community including through virtual consultations and in the provision of timely symptom control.
AIM: To synthesise existing evidence related to the delivery of palliative and end-of-life care by primary healthcare professionals in epidemics and pandemics.
DESIGN: Rapid systematic review using modified systematic review methods, with narrative synthesis of the evidence.
DATA SOURCES: Searches were carried out in Medline, Embase, PsychINFO, CINAHL and Web of Science on 7th March 2020.
RESULTS: Only five studies met the inclusion criteria, highlighting a striking lack of evidence base for the response of primary healthcare services in palliative care during epidemics and pandemics. All were observational studies. Findings were synthesised using a pandemic response framework according to 'systems' (community providers feeling disadvantaged in terms of receiving timely information and protocols), 'space' (recognised need for more care in the community), 'staff' (training needs and resilience) and 'stuff' (other aspects of managing care in pandemics including personal protective equipment, cleaning care settings and access to investigations).
CONCLUSIONS: As the COVID-19 pandemic progresses, there is an urgent need for research to provide increased understanding of the role of primary care and community nursing services in palliative care, alongside hospices and community specialist palliative care providers.
Background: Increasing numbers of people dying from COVID-19 are reported, but data are lacking on the way they die.
Objective: To study symptoms and symptom relief during the last week of life, comparing nursing homes with hospitals.
Design: The Swedish Register of Palliative Care with national coverage was used. Breakthrough symptoms were registered as Yes/No. Symptom relief was recorded on a 3-grade scale as complete—partial—no relief.
All deaths in COVID-19 were contrasted to deaths in a reference population (deaths 2019). Deaths at nursing homes were compared with deaths in hospitals.
Setting and Subjects: All deaths in hospitals or nursing homes (n = 490) were analyzed. Deaths in other settings (specialized palliative care wards [n = 11], in palliative home care [n = 2], or in their own homes [n = 8]) were excluded (n = 21). Only patients with expected deaths (n = 390) were entered in the final analysis.
Results: Breathlessness as a breakthrough symptom was more common in COVID-19 patients than in the 2019 reference population (p < 0.001) and relief of breathlessness, as well as anxiety, delirium, and death rattles was less successful in COVID-19 patients (p < 0.05 to p < 0.01 in different comparisons). Patients were older in nursing homes than in hospitals (86.6 years vs. 80.9 years, p < 0.001) and more often female (48% vs. 34%, p < 0.001). Breakthrough of breathlessness was much more frequently reported in hospital settings than in nursing homes, 73% versus 35% (p < 0.0001), and complete relief was more rarely possible in hospitals, 20% versus 42% (p < 0.01). The proportion of partial relief+complete relief was comparable, 92% versus 95% (ns). Also, anxiety and pain were more often completely relieved in nursing homes (p < 0.01 in both comparisons).
Conclusion: The lower symptom prevalence in nursing homes may be explained by elderly frail residents dying already in the first phase of the COVID-19 disease, before acute respiratory distress syndrome develops.
BACKGROUND: Nursing homes are highly vulnerable to the occurrence of COVID-19 outbreaks, which result in high lethality rates. Most of them are not prepared to SARS-CoV-2 pandemic.
METHODS: A coordinated on-site medicalization program (MP) in response to a sizeable COVID-19 outbreak in four nursing homes was organized, with the objectives of improving survival, offering humanistic palliative care to residents in their natural environment, and reducing hospital referrals. Ten key processes and interventions were established (provision of informatics infrastructure, medical equipment, and human resources, universal testing, separation of 'clean' and 'contaminated' areas, epidemiological surveys, and unified protocols stratifying for active or palliative care approach, among others). Main outcomes were a composite endpoint of survival or optimal palliative care (SOPC), survival, and referral to hospital.
RESULTS: 272 out of 457 (59.5%) residents and 85 out of 320 (26.5%) staff members were affected. The SOPC, survival, and referrals to hospital, occurred in 77%, 72.5%, and 29% of patients diagnosed before MP start, with respect to 97%, 83.7% and 17% of those diagnosed during the program, respectively. The SOPC was independently associated to MP (OR=15 [3-81]); and survival in patients stratified to active approach, to the use of any antiviral treatment (OR=28 [5-160]). All outbreaks were controlled in 39 [37-42] days.
CONCLUSIONS: A coordinated on-site medicalization program of nursing homes with COVID-19 outbreaks achieved a higher survival or optimal palliative care rate, and a reduction in referrals to hospital, thus ensuring rigorous but also humanistic and gentle care to residents.
As the world has rightfully focused on COVID-19 people have continued to die of other things, and their needs and the needs of their loved ones have been overshadowed by the pandemic. My mother died of stage IV pancreatic cancer on April 25, 2020 in New York City (NYC).
[Début de l'article]