Curbside Consultation

Palliative Care During Public Health Emergencies: Examples from the COVID-19 Pandemic

 

Am Fam Physician. 2020 Sep 1;102(5):312-315.

Case Scenarios

SCENARIO #1

In March 2020, my area became a hot spot for coronavirus disease 2019 (COVID-19). One of my regular patients, a 72-year-old with chronic obstructive pulmonary disease, called my office stating that he had severe shortness of breath. The patient had tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) two days earlier, but initially he had only mild symptoms. After receiving the diagnosis, the patient expressed fear of being alone in the hospital and wanted to stay at home no matter what. I confirmed the patient's preference for his do-not-resuscitate/do-not-intubate status and completed the Physician Orders for Life-Sustaining Treatment form. His spouse, designated as the health care agent, supports the patient's wishes. The patient declined home-based services, including hospice. During today's telemedicine visit, the patient is gasping, fatigued, and reports using 4 L of oxygen instead of the usual 2 L. He states, “Doc, I think I am dying. I don't want to go to the hospital, but I'm not sure my spouse can manage my care. What should I do?” When time is of the essence during public health emergencies, how can physicians implement a crisis care plan that meets patients' needs while honoring their values and preferences?

SCENARIO #2

The COVID-19 pandemic has unexpectedly expanded in my area, and a 58-year-old patient called my team, requesting a telemedicine visit for mild shortness of breath. The patient reported no chest pain or other symptoms. During the visit, I reviewed her recent oncology consultation detailing remission following lobectomy and radiation therapy for stage 2 lung cancer. Her preference is listed as full code, but she has never discussed the benefits and risks of cardiopulmonary resuscitation and mechanical ventilation with her physicians. She hopes to live as long as possible, provided that her quality of life is good, and wants to see her children graduate from school. The patient is worried that she has COVID-19 and is scared. With time to plan ahead and with lessons learned from the COVID-19 pandemic, what approaches can help vulnerable patients anticipate and appropriately plan for the possibility of decompensation?

Commentary

In public health emergencies such as the COVID-19 pandemic, some patients—especially older patients or those who have chronic health conditions—are confronted with treatment choices as they face life-threatening illness. Drawing on longitudinal relationships, primary care physicians can help patients and their families reach decisions that best align with patient goals. These crucial conversations may take place under intense pressure. COVID-19, for example, can cause sudden decompensation, leading to abrupt respiratory failure and death. Other factors, including unpredictable clinical courses and resource limitations, may further complicate guiding patients through goal-aligned decision-making.

Patients' expressed wishes (e.g., to stay at home no matter what) can conflict with their goals (e.g., to die with minimal discomfort). Dying with severe dyspnea from COVID-19 pneumonia is traumatic and may contribute to complicated grieving and lifelong regret and guilt for caregivers. In addition to relationship-based advance care planning, physicians can use palliative care and ethical principles to develop high-quality crisis care plans that best meet patient needs, even during emergencies.

Emergent and Nonemergent Crisis Planning During Public Health Emergencies

When a patient who prefers comfort-focused care decompensates quickly at home, a physician needs a viable crisis plan (developed in advance or in real time) that balances the ethical principles of autonomy and duty to provide care.1 An appropriate plan could be based on the following steps.

  • Review written advance directives and/or a patient's previously stated wishes with the health care agent (or

Address correspondence to Kristina Gracey, MD, MPH, at kristina.gracey@umassmemorial.org. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

References

show all references

1. DePergola PA. Ethical guidelines for the treatment of patients with suspected or confirmed novel coronavirus disease (COVID-19). Online J Heal Ethics. 2020;16(1)....

2. Shah S, Majmudar K, Stein A, et al. Novel use of home pulse oximetry monitoring in COVID-19 patients discharged from the emergency department identifies need for hospitalization [published online June 17, 2020]. Acad Emerg Med. Accessed August 3, 2020. https://onlinelibrary.wiley.com/doi/full/10.1111/acem.14053

3. Greenhalgh T, Koh GCH, Car J. Covid-19: a remote assessment in primary care. BMJ. 2020;368:m1182.

4. Bernacki RE, Block SD; American College of Physicians High Value Care Task Force. Communication about serious illness care goals: a review and synthesis of best practices. JAMA Intern Med. 2014;174(12):1994–2003.

5. Smith AK, Lo B, Sudore R. When previously expressed wishes conflict with best interests. JAMA Intern Med. 2013;173(13):1241–1245.

6. Talebreza S, Widera E. Advance directives: navigating conflicts between expressed wishes and best interests [Curbside Consultation]. Am Fam Physician. 2015;91(7):480–484. Accessed July 14, 2020. https://www.aafp.org/afp/2015/0401/p480.html

7. Respecting Choices®, a division of C-TAC Innovations. (2020). Priorities for medical care and treatment option for serious illness. Accessed August 3, 2020. https://respectingchoices.org/wp-content/uploads/2020/06/Medical-Priorities_Treatment-Options_For-Use-in-Conversation-Only_06.20.pdf

8. Center to Advance Palliative Care. Symptom management. Accessed June 29, 2020. https://www.capc.org/covid-19/symptom-management/

9. Lee J, Abrukin L, Flores S, et al. Early intervention of palliative care in the emergency department during the COVID-19 pandemic [published online June 5, 2020]. JAMA Intern Med. Accessed August 3, 2020. https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2767018

10. Respecting Choices: Person-Centered Care. COVID-19 resources. Accessed June 2020. https://respectingchoices.org/covid-19-resources/#planning-conversations

11. VITALtalk. COVID ready communication playbook. Accessed June 15, 2020. https://www.vitaltalk.org/guides/covid-19-communication-skills/

12. Ariadne Labs. Serious illness care program COVID-19 response toolkit. Accessed August 6, 2020. https://covid19.ariadnelabs.org/serious-illness-care-program-covid-19-response-toolkit/

13. Rosenberg LB, Greenwald JL, Jacobsen JC. To prepare patients better: reimagining advance care planning [editorial]. Am Fam Physician. 2019;99(5):278–280. Accessed July 14, 2020. https://www.aafp.org/afp/2019/0301/p278.html

14. Paladino J, Fromme EK. Preparing for serious illness: a model for better conversations over the continuum of care [editorial]. Am Fam Physician. 2019;99(5):281–284. Accessed July 14, 2020. https://www.aafp.org/afp/2019/0301/p281.html

15. Sirianni G. Addressing serious illness conversastions during COVID-19. Can Fam Physician. 2020;66(7):533–536.

16. Center to Advance Palliative Care. COVID-19 response resources hub. Accessed June 15, 2020. https://www.capc.org/toolkits/covid-19-response-resources/

17. U.S. Department of Health and Human Services. OCR announces notification of enforcement discretion for telehealth remote communications during the COVID-19 nationwide public health emergency. March 17, 2020. Accessed June 15, 2020. https://www.hhs.gov/about/news/2020/03/17/ocr-announces-notification-of-enforcement-discretion-for-telehealth-remote-communications-during-the-covid-19.html

Case scenarios are written to express typical situations that family physicians may encounter; authors remain anonymous. Send scenarios to afpjournal@aafp.org. Materials are edited to retain confidentiality.

This series is coordinated by Caroline Wellbery, MD, associate deputy editor.

A collection of Curbside Consultation published in AFP is available at https://www.aafp.org/afp/curbside

Please send scenarios to Caroline Wellbery, MD, at afpjournal@aafp.org. Materials are edited to retain confidentiality.

 

 

Copyright © 2020 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP


Editor's Collections


Related Content


More in Pubmed

MOST RECENT ISSUE


Sep 15, 2020

Access the latest issue of American Family Physician

Read the Issue


Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article