Thread by @AmitAryaMD

What is the importance of #palliativecare during a viral epidemic such as #COVID19? Surprised to see this critical need is not being openly addressed. Thread to follow about how we should prepare, and some of the expected challenges.

#publichealth #cdnhealth #medtwitter

1/ As the #COVID19 epidemic continues, ICU services could go from limited to unavailable. It is expected that the need for critical care could be 200% of capacity, or even much higher. More patients may be denied ICU than those who will receive it.

2/ Pts who are not going to survive #COVID19 still have an equal right to care. We can’t abandon them or their families. Hence, all pts who are denied ICU should be receiving #palliativecare- not optional but a basic human right, which should be included in all contingency plans.

3/ We need to prepare “symptom management kits" on mass for use in hospital or hospice, and in preparation for delivery to patient homes or LTCs. This could include opioids for pain & dyspnea, scopolamine for secretions, as well as subcut butterflies & PCA pumps.

4/ #Palliativecare teams need to start preparing for how they would provide care to a large number of pts. Do these teams start training others on basic symptom management at EOL? Do we need to train first responders and ER staff? Having a readily available order set could help.

5/ Where would patients who are dying from #COVID19 go? Is there a quiet & peaceful location where they could still receive O2 & symptom management, in addition to close monitoring for signs of discomfort? As hospices & PCUs are often very close to full, new space may be needed.

6/ Who would be seen by #palliativecare specialists? Could palliative care consults be provided via #telemedicine in order to support the greatest number of pts? If survival is unlikely, could pts be triaged to receive palliation in the community if hospital resources are scarce?

7/ Important for all of us working with elderly, frail or terminally ill pts to proactively include #COVID19 in #goalsofcare discussions. Not all pts want to be intubated, so this needs to be documented. We have to deal with prognostic uncertainty as COVID-19 is a new illness.

8/ Human connectedness is vital to relief of suffering. Yet pts dying with #COVID19 will be in isolation, receiving care from HCPs with PPE. There may be visiting restrictions as well as stigma from being in an isolation room. Family from out of town may not be able to fly in.

9/ Usually, when we provide EOL care, we have a very remote chance of developing the same condition as our pt. #COVID19 could change that. Would nurses & doctors avoid examining pts to "stay safe?” This would increase the feeling of isolation at EOL & would be highly unethical.

10/ Bereavement rituals at EOL could be affected by #COVID19. In an isolation room, you may not be able to call a priest & everyone may not be allowed to come & say goodbye. This could lead to complicated grief and we would need expert support from social work & spiritual care.

11/ Let’s remember that #palliativecare teams have much to contribute, and would be essential to include in any #COVID19 contingency plan. We have a fundamental duty to relieve suffering & provide the best care with the available resources, regardless of the chances of survival.

12/ Would highly encourage everyone to read this excellent article by @jamesdownar & Dori Seccareccia

jpsmjournal.com/article/S0885-…

as well as this article about palliative care during the SARS epidemic by Ian Leong et. al.

journals.sagepub.com/doi/abs/10.119…