Although this is often a difficult conversation to have, COVID-19 can and often does have a rapid onset and can advance quickly. COVID-19 is rapidly spreading across the world. Many patients will present with a high symptom burden, which specialists in palliative care can help manage. Increasing numbers of patients will not be suitable for mechanical ventilation but instead will require conservative approaches and palliative care management. In a report published by the Journal of Pain and Symptom Management, they describe the management plan for three types of patients who are not suitable for ventilation: stable, unstable, or at the end of life.
Assessment needs to be concise and quick as patients can deteriorate rapidly. A COVID-19 specific assessment tool was developed called the 3D-Ticino 2019-nCov Score (3D-TiCoS) which focused on key symptoms observed in this population, dyspnea, distress, and discomfort. This assessment tool is combined with the facial scale (similar to the Wong Baker Facial Pain Scale) often used in patients who are unable to respond verbally.
The study describes an assessment that determines the course of the disease, treatment and the ability to sustain life.
Stable Patients: May still recover even without intubation/ventilator support. They present with dyspnea, fever, anxiety, and shivering. Anxiety is high as they are being cared for in isolation and assume the diagnosis of COVID-19 is a death sentence.
Unstable patients: May present unstable or deteriorate and become unstable. Deterioration can be rapid, oxygen saturation levels below 88% even with oxygen. Some hydration is given to keep the patient comfortable however these patients are not going to recover and need their symptoms managed.
End of Life Patients: These patients have low saturation levels, they are dying, they are unable to communicate, and delirium is problematic. These patients need sedation and other treatments including oxygen, are discontinued as it is not helpful in treating palliative symptoms and does not improve comfort; opioids are more effective.
In conclusion, palliative care is recognized as offering symptom management, support to families, and providing spiritual support. Most patients with COVID-19 need a palliative care assessment due to the high symptom burden. Decisions need to be made quickly due to rapid deterioration that is often experienced. Treatment plans need to be clear and simple to follow and families need to be provided with care and support.
At the end of the day, caring for patients with COVID-19 can result in an ethical dilemma and can take a toll on the health care team caring for them. It is important to support the staff, provide counseling as needed, ensure appropriate breaks and days off are available, and provide reassurance that they are meeting the needs of the patients.
To read the report in its entirety please click the link below: