Palliative Care During the COVID-19 Surge

Jennifer Reidy, MD, MS, FAAHPM

The global pandemic has been described as a “powerful amplifier of suffering,”(1) and the field of palliative care has mobilized onto the frontlines in emergency rooms, hospital wards, and intensive care units during the COVID-19 crisis.

In general, palliative care is focused on providing patients with relief from the symptoms, pain, and stress of a serious illness – whatever the diagnosis. The goal is to improve quality of life for both the patient and the family. Palliative care is appropriate at any age and at any stage in a serious, life-threatening illness and can be provided together with curative treatment.

During the pandemic, palliative care providers have faced multiple barriers to their usual hightouch, relationship-based care, including PPE shortages limiting direct patient contact; a no-visitors policy for hospitalized patients which separates loved ones and prevents in-person family meetings; and the moral distress of redeployed clinicians without training in serious illness communication and symptom management.

Based on reports from the epicenter in New York City, our palliative care team at UMass Memorial Medical Center quickly developed strategies to plan for the patient surge in central Massachusetts last spring, including:

• Expand in-person consults from 5 to 7 days per week at University and Memorial campuses as well as telephone support for outpatient clinicians and the DCU Field Hospital;

• Partner with outpatient providers to proactively reach out to their highest-risk patients about their goals and medical wishes if they contracted COVID-19;

• Collaborate with local hospices and skilled nursing facilities to anticipate barriers to providing end-of-life care in the community for people dying of COVID-19; and

• Promote the use of video technology to connect isolated patients with their loved ones.

We codified these strategies as a best-practice guideline and distributed it throughout the health system via virtual town halls, department meetings, grand rounds and the intranet. We provided at-theelbow coaching for providers in the hospital and quick, focused trainings on serious illness conversations for critical care and ED physicians. Our team distributed 200 laminated pocket cards to hospitalists, nurses, and trainees on symptom management, communication tips and how to reach us. Already a scarce resource before the pandemic, palliative care also closely involved in “crisis standards of care” preparations of local health care systems – including hospice agencies – were overwhelmed.(2)

When the COVID-19 surge hit, our inpatient team saw its daily consult volume nearly double and an unprecedented number of patient deaths from April through May 2020. Across the hospital, providers experienced severe levels of stress related to deployment in areas outside their discipline with unfamiliar colleagues, caring for very sick and dying patients, and long hours of donning/doffing PPE, with fears of contracting COVID-19 and/or transmitting the virus to loved ones.

In response, our team developed creative strategies to maintain humanism in a frightening, hectic health care environment. First, we implemented an art intervention, “PPE Portraits” or postcard-sized face portraits printed on stickers and affixed to PPE. Artist Mary Beth Heffernan, a professor at Occidental College, had created and piloted PPE Portraits during the Ebola epidemic in 2015.

During the COVID-19 surge, PPE Portraits helped reassure scared patients and enhanced patient and team interactions, according to a recent survey of 170 UMMMC providers.(3)

Simultaneously, we expanded our music therapy program to help with direct patient care and staff support. For example, we used music therapy to engage a patient recovering from COVID-19, which improved his alertness and ability to wean from a ventilator. For patients dying from COVID-19, we instituted a ritual of pausing at the bedside to reflect after a patient’s death, which was widely embraced throughout the medical center. Our music therapist created “heartsongs,” or heartbeat recordings fused with a person’s favorite music as legacy gifts for families. For hospital staff, our palliative care team members reached out to individuals and COVID-19 units needing emotional support, and our music therapist developed a popular “music for resilience” session available via Zoom for all health care providers once a week.

Meanwhile in clinic, the outpatient palliative care team conducted video telehealth visits side-by-side with primary care providers and their patients at home, assisted living, and skilled nursing facilities to navigate COVID-19 and non-COVID-19 related serious illness. We found these planning conversations were met with relief and gratitude, and ensured people received care tailored to their own values and goals.(4) Many frail patients, who have trouble getting to the clinic and/or a multitude of appointments, appreciated the new telehealth capability, which will improve access to palliative care both now and in the future.

Personally, the experience of the pandemic so far has helped me appreciate the existential stress and anxiety of patients living every day with serious illness and their families. Like a life-threatening diagnosis, the pandemic clarifies what is most important in life. For my team and I, this experience only fuels our efforts and passion to grow “palliative care everywhere,” both during the pandemic and beyond. +

references:

1. The Lancet. Palliative care and the COVID-19 pandemic. The Lancet. 2020;395(10231):1168. doi:10.1016/S0140- 6736(20)30822-9

2. 2. Abbott J, Johnson D, Wynia M. Ensuring Adequate Palliative and Hospice Care During COVID-19 Surges. JAMA Published online - September 21, 2020. doi:10.1001/jama.2020.16843

3. Reidy J, Brown-Johnson C, McCool N, Steadman S, Heffernan MB, Nagpal V, Provider perceptions of a humanizing intervention for healthcare workers – a survey study of PPE Portraits, Journal of Pain and Symptom Management (2020), doi: https://doi. org/10.1016/ j.jpainsymman.2020.08.038.

4. Gracey K, Martin S, Reidy J. Palliative Care During Public Health Emergencies: Examples from the COVID-19 Pandemic. American Family Physician (September 1, 2020) Vol 102(5):312-315

Jennifer Reidy, MD, MS, FAAHPM, is chief of the Division of Palliative Care at UMass Memorial Medical Center and associate professor at UMass Medical School. Email: Jennifer.reidy@umassmemorial.org