key: cord-010658-67k8pthy
authors: Bernard, Andie
title: PC-FACS May 2020 for July 2020 Issue
date: 2020-05-07
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.05.001
sha: 
doc_id: 10658
cord_uid: 67k8pthy

nan

(48%). Symptom onset was mean 3.5 days prehospitalization (81% ICU-admitted <24 hours postadmission). At admission: 95% had an abnormal chest radiograph (bilateral reticular nodular opacities [52%; 86% by 72 hours] and ground-glass opacities [48%; 67%]), WBC count was mean 9365 µL (67% were normal), 67% had an absolute lymphocyte count <1000 cells/µL, and 38% had abnormal liver function. Fifteen patients out of 15 requiring mechanical ventilation had ARDS (8/15 severe by 72 hours). Although most did not present with shock, 67% received vasopressors. Cardiomyopathy developed in 33%. As of March 17, mortality was 67%, 24% of patients have remained critically ill, and 9.5% have been discharged from the ICU.

The COVID-19 pandemic has caused unprecedented stresses on healthcare workers and systems, including palliative care teams. Palliative care teams, as the experts in conducting goals of care discussions with patients and families who are informed by prognostic information, are now faced with the difficult task of trying to help patients and families navigate a disease in which short-term prognostic data are limited and long-term prognostic data are nonexistent. These two cohort studies examined the factors associated with risk of ARDS and death in patients with COVID-19-associated pneumonia. Although their findings are valuable for palliative care teams to be aware of, they are preliminary. Because a significant minority of patients remained hospitalized on ventilators at the time of publication, the reported mortality rates may be even higher (or lower, although that is less likely) when longer-term data are available. In addition, these early reports are unable to provide insight into longer-term outcomes that are important to many of our patients, such as function and ability to live independently. To expertly guide patients through this often devastating illness, palliative care professionals will need to keep abreast of the COVID-19 literature as the pandemic evolves and the longer-term outcomes come into sharper focus.

Bottom Line: Early reports of COVID-19-associated pneumonia and ARDS provide insights into risk factors, short-term prognosis, and mortality that are important for palliative care professionals to be aware of when counselling patients and families. To access this article, link to PubMed.

Keywords: Noncancer Disease Categories, Health Service Delivery, Nonpain Symptoms/Disorders/Syndromes

Background: Emerging viral pandemics can place extraordinary demands on public health systems. 1 How can medical resources be allocated fairly during the COVID-19 pandemic?

Design and Participants: This article discussed how hospitals and states might establish and implement policies for fairly allocating scarce resources.

Results: Categorically excluding patients with certain comorbid conditions is too rigid for a dynamic crisis (ventilator shortages will surge and decline episodically during the pandemic); less restrictive approaches like allowing all patients to be eligible and giving priority to those most likely to benefit are feasible. Prioritizing critically ill patients most likely to survive to hospital discharge is inadequate because it ignores other considerations such as number of years of life saved and whether people have essential responsibilities in saving lives (reciprocity for putting themselves at risk). Ventilation should be presented to patients/families as a time-limited therapy (not an unlimited promise), but ventilation duration must not be too brief to avoid discontinuing ventilators from patients who (if treated longer) would have survived. A triage officer/team, not the treating physician, should make allocation/discontinuation decisions (to enhance objectivity, avoid commitment conflicts, and minimize treatment clinicians' moral distress). After discontinuing ventilation, comprehensive palliative care is imperative (families should be granted personal protective equipment so they can be with the dying patient, or hospitals should help families use videoconferencing technology). Pennsylvania and Minnesota have endorsed the following strategy: patients meeting usual medical indications for intensive care unit beds/ventilators are assigned a priority score (lower scores indicate greater likelihood of benefit) based on the patient's likelihood of surviving to discharge and achieving longer-term survival (comorbid conditions), and individuals performing vital public health tasks are given heightened priority by subtracting points from their score. Younger patients are prioritized in the event of tying scores.

Design and Participants: This article recommended guidelines to ensure individual doctors are never tasked with deciding unaided which patients receive lifesaving care. Critical COVID-19 interventions should go first to healthcare workers and others who keep critical infrastructure operating, particularly workers facing high infection risk and with difficult-to-replace training. (3) For patients with similar prognoses, equality should be operationalized through random allocation rather than as first-come, first-served. (4) Prioritization guidelines should differ by intervention and should respond to changing scientific evidence (eg, the value of maximizing saving lives justifies giving older people priority for vaccines immediately after healthcare workers and first responders). (5) Vaccine/therapeutic research participants should receive some priority for COVID-19 interventions. (6) There should be no difference in allocating scarce resources between patients with COVID-19 and those with other conditions.

is what to do if resources like mechanical ventilators become scarce. These helpful articles summarize ethical criteria and provide guidelines for the allocation of such scarce, potentially life-sustaining resources. The first article briefly focuses on ethical principles and suggests steps to help with decision making. The second relates scientific evidence and experience from past pandemics to the current situation. Its recommendations are articulated with examples applicable to clinical practice. A key message in both articles is that treating clinicians should not make these decisions for their own patients; fair allocation of resources must be made by third, unbiased parties. In both articles, authors recognize the challenges inherent in these decisions, including that there may be no clear answer, different institutions will proceed differently, and these cases take an emotional toll on all involved.

Bottom Line: Ethical guidelines for the allocation of scarce life-sustaining resources may help institutions faced with seemingly impossible decisions. Regardless of which patients receive which resources, palliative care teams will be needed to support patients, families, and professional colleagues.

These papers describe the limited published experience in Wuhan, the pandemic's origin. The number of babies described is small; they were all in good condition at the time of elective caesarean delivery and remained clinically well the remainder of their inhospital isolation. This is reassuring, with the caveat that these highly orchestrated deliveries occurred in a well-resourced setting. Progression of the pandemic in Africa, and in other resource-poor settings, may dramatically increase the already high maternal and infant mortality rates.

Finally, vertical transmission of COVID-19 has many implications from the palliative care standpoint: fetal loss, embryotoxicity, and infant health sequelae are all possible. Further, the experience of isolation for exposed neonates will add to the complexity of both maternal and child perinatal experiences, especially if one or both become seriously ill or die from this infection. Limited bereavement and funeral support may exacerbate the difficulties of grief and loss. Long-term repercussions, including bereavement in the setting of restricted access, are unknown, adding to the worries new families may experience.

Bottom Line: Although infants born to COVID-19-infected mothers have appeared well, longitudinal research is needed, particularly in resource-limited environments. Palliative care clinicians can help families navigate the uncertainty. Results: Healthcare workers (N=1,257; 34 hospitals) were 65% age 26-40 years, 77% female, 61% nurses, and 39% physicians; 61% worked in Wuhan, and 42% were frontline workers. Participants reported symptoms of depression (50%), anxiety (45%), insomnia (34%), and distress (72%). Nurses, women, frontline workers, and those working in Wuhan reported more severe MHOs than other healthcare workers (median [IQR] scores among physicians vs. nurses: PHQ=4 [1] [2] [3] [4] [5] [6] [7] 

Stress and psychological distress among SARS survivors 1 year after the outbreak

Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019

Understanding the treatment preferences of seriously ill patients

Risk factors associated with acute respiratory distress syndrome and death in patients with coronavirus disease 2019 pneumonia in Wuhan, China

Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State

Defining advance care planning for adults: a consensus definition from a multidisciplinary delphi panel

Ethical considerations: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

Point: the ethics of unilateral "do not resuscitate" orders: the role of "informed assent

Clinician statements and family satisfaction with family conferences in the intensive care unit

The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19)

The importance of addressing advance care planning and decisions about do-not-resuscitate orders during novel coronavirus 2019 (COVID-19)

Keywords: Advance Care Planning, Communication, Informed Consent, End-of-Life Decisions

To access this article, link to PubMed.Keywords: Practitioner Self-Care, Well Being

Background: Patients most likely to develop severe COVID-19-related illness will be older and have greater chronic illness burden-exactly those who may wish to forgo prolonged life support. [1] [2] [3] How is the importance of providing goal-concordant care heightened during this pandemic?

This article discussed a component of an appropriate response to the COVID-19 pandemic: ensuring that clinicians have discussions about advance care planning (especially with older patients with chronic illness) and goals of care with patients/families.

Clinicians always should strive to avoid intensive life-sustaining treatments when unwanted by patients. Avoiding nonbeneficial/unwanted care becomes especially important in times of stress on healthcare capacity. Furthermore, nonbeneficial/unwanted care puts other patients, family, and healthcare workers at greater transmission risk. For patients in a community setting or nursing home, clinicians should engage in goals-of-care discussions now. Patients with chronic life-limiting illnesses should be offered the option to complete a physician order for life-sustaining treatments form, especially if they would not want cardiopulmonary resuscitation (CPR) or mechanical ventilation. This pandemic heightens the importance of implementing do-not-resuscitate (DNR) orders for appropriate patients: although unwanted/nonbeneficial CPR always risks increasing psychological distress for patients' families, inappropriate CPR now is especially stressful and potentially dangerous for healthcare workers. Nonbeneficial/unwanted advanced cardiac life support will strain available personal protective equipment. During this pandemic, in extreme situations, there may be a role for clinicians unilaterally deciding to write DNR orders to reduce the risk of medically futile CPR. Lastly, informed assent (vs. informed consent) provides family members a way to agree with the clinician's determination without assuming decision-making responsibility.Commentary: Traditionally, the approach to advance care planning is informed consent relying on the central tenants of patient autonomy and shared decision making, with the goal of ensuring medical care is consistent with patients' values, goals, and preferences. 4 In extreme circumstances, like pandemics, informed assent has been suggested as permissible. 5 The intent of unilateral decision making has been attributed to removing undue burden from patients/families. 6, 7 However, it is controversial because it suggests patients' values can be bypassed. 6 Although the current proposed model addresses patients' values as the starting point, it could more clearly note that informed assent must be grounded in patient values. 8Bottom Line: The COVID-19 pandemic has created unusual, resource-scarce circumstances in which informed assent of DNR orders may be justified. However, its use should be limited by using informed consent for as long as possible, using informed assent only as necessary, and identifying patients' values to inform every decision.Reviewer: Ambereen K. Mehta, MD MPH, University of California, Los Angeles, Los Angeles, CA