key: cord-0954154-c9vvhe8t authors: Koh YH, Mervyn title: Palliative Care in the time of COVID-19: Reflections from the frontline date: 2020-04-08 journal: J Pain Symptom Manage DOI: 10.1016/j.jpainsymman.2020.03.023 sha: fb080cb06d4b58572f4b0d574641b7bf7debae55 doc_id: 954154 cord_uid: c9vvhe8t nan Palliative Care in the time of COVID-19: Reflections from the frontline When our palliative care unit was closed to make room for COVID-19 patients, we were prepared. The virus had made its way to our shores in Singapore by January 23, 2020 (1) . At the initial stages, Singapore, being the hyper-connected city that it is, was the country with the most confirmed COVID-19 cases outside of China (2) . We are part of a large general hospital of 1800 beds with a 13-Bed Acute Palliative Care Unit and a busy inpatient referral and outpatient service. We are also situated next to the National Centre of Infectious Diseases where the majority of COVID-19 positive or suspected patients were housed. Consequently, clinicians from our palliative care team were deployed to help 'fight' in this nation-wide healthcare crisis. Our Palliative Care Attending Physicians volunteered to go into the COVID-19 wards together with senior physicians from the rest of the hospital to help with the mounting patient numbers. Our Chief Advance Practice Nurse (APN) was sent to the 'frontline' Virus Screening Centre and we lost another APN to the ICU where she used to be from. We had to familiarize ourselves with the donning and removing of PPE (Personal Protective Equipment), gowns, goggles and gloves became the byword rather than morphine and fentanyl. We went back to being general internal medicine physicians, infectious disease and ICU nurses. Amongst other things, we lost our palliative care unit. Many of our palliative care nurses in the unit lamented a loss of their identity, their specialized roles and commented on how they 'missed taking care of palliative care patients', vacation leave was also sacrificed in the call for solidarity and to help 'man' the ever-expanding COVID-19 wards. Our art and music therapist could no longer come into hospital to work. There was also the fear of catching the virus while at work, and passing it to colleagues. Or worse, bringing it home to family. While there was strong government and public support for healthcare workers, the public were still afraid of coming too close to us. Some of us excused ourselves knowingly from family or social gatherings. Perhaps the isolation was the worst. We couldn't hold large group meetings anymore, and the usual staple of 'multi-disciplinary rounds' and 'journal clubs' which we took so much for granted had to be replaced by virtual meetings. Those who were in the 'dirty' wards usually isolated themselves from the rest of the team and often ate alone. So much of palliative care is about the camaraderie of being together as a team, these regular routines of team meeting provided the peer support which invariably strengthens us from burnout and builds resilience (3). However, it was the patients infected with the COVID-19 virus who suffered the most. They struggled with questions such as 'How did I get it?' and 'Is this going to get worse' or 'Am I going to the ICU like the other person' and even 'Will I die from this?'. These fears and questions are no different from our palliative care patients who suffer and experience these same feelings and emotions. The families suffered along with them. Often anxious, worried and burdened and because of the 'No visitor policy' in the hospital for this group of patients, they could only contact their loved ones online or on the phone. Many cried in the loneliness of their rooms. Many of the patients did recover, and this disease certainly does not qualify as a 'life-limiting illness' for many. But the principles of holistic care which palliative care embodies so well (4) still apply. For instance, empowering our clinicians to manage physical symptoms, spending time on the phone (through a stained glass window) to care for their psychological needs, and comforting and encouraging these patients. For those of us who had to move from our usual line of work in palliative care into the frontlines of fighting this epidemic, the echoes of the words of Sheila Cassidy (5) rings clear and true -that we in palliative care are here, walking 'through the darkness' with you. Coronavirus disease 2019: Cases in Singapore. A timeline of the confirmed cases in COVID-19 infections: Singapore emerges as most infected country outside of China Burnout and Resilience After a Decade in Palliative Care: What Survivors Have to Teach Us. A Qualitative Study of Palliative Care Clinicians With More Than 10 Years of Experience WHO Definition of Palliative Care Sharing the darkness. The spirituality of caring