Palliative Care in a Covid 19 ICU, an Integral Component for Families and Patient Care.

  Esther Segura, M.D.¹, Eduardo E. Chang, M.D., M.B.A.*

1. Senior Patient Liaison, Methodist Hospital, Houston Texas.

Corresponding Author: Eduardo E. Chang, M.D., M.B.A., Pulmonary, Sleep, Critical Care Specialist, Adjunct Clinical Assistant Professor of Medicine, Indiana University School of Medicine, Terre Haute, Indiana.

Copy Right: © 2022 Eduardo E. Chang. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received Date: January 17, 2022

Published Date: February 01, 2022

Objective: Letter to the editor

Conflict of Interest: None.

MeSH: Palliative care, COVID 19, Critical Care, Nursing, Intensivist, Intensive Care Medicine, Pandemic, Multidisciplinary rounds

As America surpasses eight hundred thousand deaths in this COVID Pandemic the number of infections keeps increasing. The United States has seen staggering numbers of new infections during the Omicron surge, up to one million new cases in a single day. It is important to recognize that most patients that have developed acute hypoxic respiratory failure, ARDS with multiorgan failure these patients have extremely high mortality. Before COVID, the mortality of ARDS was in the low forty percent and with COVID some ICUs have reported average deaths in the high seventy percent and more. These numbers increase disproportionately with each case, if you calculate SOFA scores, account for renal failure, morbid obesity which could be independent factors of ICU mortality.

In most ICUs in America, multidisciplinary rounds have been implemented to create a team approach in reviewing plan of care for each case. This ensures the needs of the COVID ICU patient are addressed by the entire care team.  We care for our patients from a pathophysiological approach, but at what point are we doing more than what the patient wanted? Palliative care can be incorporated to provide the patient and their family with counseling, prognostic awareness, and advanced care planning.

Addressing the family’s expectations, helping the patient and family cope with a life-threatening illness, and respecting the wishes of each patient should be important components in the treatment approach. In our facilities, we coordinate care with an Infectious Disease, Pulmonary, ICU and Critical Care specialist.

We believe a palliative care member should be incorporated as an integral and valued asset within the care team from the very beginning to help the family make any needed psychosocial changes and support them. Nevertheless, palliative care is seen as an end-of-life resource when there is no hope for the patient. We propose the integration of palliative specialty to empower the patient and their family during their struggles with COVID from the start, not at the end of a serious disease process.

ARDS induce by COVID 19 infection has a very high mortality, it is debilitating and, in some cases, has long-term repercussions. The patients that survive the inflammatory response will need long-term care, a nursing home, or a care home.

Some of these patients may never regain a normal meaningful quality of life.  Some may need a tracheostomy and feeding tube and may be dependent on others for basic needs.  Palliative care specialists can help the patient reach these difficult decisions about their care and definition of quality of life. They can support the family and prepare the patient with information to make the decision that is right for their care.

The many challenges for family, patients and providers is the lack of face-to-face interaction. We are all cloaked behind a mask or a respirator, many times you are not able to see emotion or feel empathy from behind a mask. The palliative team can provide the soft touch and understanding that is sometimes missed when we are intubating or resuscitating a patient. During this serious, life-altering and deadly pandemic, we need to have clarity on what the patient would want before they are unable to communicate with us. The patient’s decision is enormously valuable, which also must align with the family’s expectations. Care decisions, prognostic awareness, and understanding of outcomes should be assessed daily with the help of a palliative care specialist. This can be a challenge with the chimerical presentation and evolution of COVID throughout the pandemic.

Intensive care medicine promotes the management and support of the body through the disease process. Palliative care focuses on psychosocial, emotional support and decision making to integrate the wishes and values of the patient with the expectations of the family. Palliative care specialists can be an invaluable resource to aid with the patient’s wishes in the context of the therapies that the intensive care team is providing.  Bridging the patient’s physical care with the information and support required for decision making during a serious and many times deadly disease.

References

1.Fadul, N., Elsayem, A. F., & Bruera, E. (2021). Integration of palliative care into COVID-19 pandemic planning. BMJ supportive & palliative care, 11(1), 40-44.

2.Lancet, T. (2020). Palliative care and the COVID-19 pandemic. Lancet (London, England), 395(10231), 1168.

3.Radbruch, L., Knaul, F. M., de Lima, L., de Joncheere, C., & Bhadelia, A. (2020). The key role of palliative care in response to the COVID-19 tsunami of suffering. The Lancet, 395(10235), 1467-1469.

4.Thomas, J. D., Leiter, R. E., Abrahm, J. L., Shameklis, J. C., Kiser, S. B., Gelfand, S. L., ... & Lawton, A. J. (2020). Development of a palliative care toolkit for the COVID-19 pandemic. Journal of pain and symptom management, 60(2), e22-e25.

5.Wallace, C. L., Wladkowski, S. P., Gibson, A., & White, P. (2020). Grief during the COVID-19 pandemic: considerations for palliative care providers. Journal of pain and symptom management, 60(1), e70-e76.