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Analysis

Pandemic palliative care: beyond ventilators and saving lives

Amit Arya, Sandy Buchman, Bruno Gagnon and James Downar
CMAJ April 14, 2020 192 (15) E400-E404; DOI: https://doi.org/10.1503/cmaj.200465
Amit Arya
Division of Palliative Care (Arya, Buchman), Department of Family Medicine, McMaster University, Hamilton, Ont.; Division of Palliative Care (Arya, Buchman), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Departments of Family Medicine and Emergency Medicine (Gagnon), Cancer Research Centre, Université Laval, Québec, Que.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Palliative Care (Downar), Bruyère Continuing Care Ottawa, Ont.
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Sandy Buchman
Division of Palliative Care (Arya, Buchman), Department of Family Medicine, McMaster University, Hamilton, Ont.; Division of Palliative Care (Arya, Buchman), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Departments of Family Medicine and Emergency Medicine (Gagnon), Cancer Research Centre, Université Laval, Québec, Que.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Palliative Care (Downar), Bruyère Continuing Care Ottawa, Ont.
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Bruno Gagnon
Division of Palliative Care (Arya, Buchman), Department of Family Medicine, McMaster University, Hamilton, Ont.; Division of Palliative Care (Arya, Buchman), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Departments of Family Medicine and Emergency Medicine (Gagnon), Cancer Research Centre, Université Laval, Québec, Que.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Palliative Care (Downar), Bruyère Continuing Care Ottawa, Ont.
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James Downar
Division of Palliative Care (Arya, Buchman), Department of Family Medicine, McMaster University, Hamilton, Ont.; Division of Palliative Care (Arya, Buchman), Department of Family and Community Medicine, University of Toronto, Toronto, Ont.; Departments of Family Medicine and Emergency Medicine (Gagnon), Cancer Research Centre, Université Laval, Québec, Que.; Division of Palliative Care (Downar), Department of Medicine, University of Ottawa; Department of Palliative Care (Downar), Bruyère Continuing Care Ottawa, Ont.
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  • Equity and pandemic palliative care
    Ryan Tonkens [PhD]
    Posted on: 02 August 2020
  • Palliative care as a priority for integration into pandemic responses
    Shyh Poh Teo [MBChB, FRACP]
    Posted on: 18 April 2020
  • RE: Making treatment recommendations during the COVID-19 pandemic
    Warren Lewin [MD]
    Posted on: 18 April 2020
  • RE: Choice and scarce resources
    Dhastagir Sheriff [PhD]
    Posted on: 15 April 2020
  • COVID Towers: low and medium intensity care for non ICU patients
    Renzo Rozzini and Angelo Bianchetti
    Posted on: 06 April 2020
  • Posted on: (2 August 2020)
    Page navigation anchor for Equity and pandemic palliative care
    Equity and pandemic palliative care
    • Ryan Tonkens [PhD], Bioethicist and Associate Professor, Lakehead University Centre for Health Care Ethics, and Northern Ontario School of Medicine

    It is laudable that Arya, Buchman, Gagnon & Downar (1) include equity considerations as part of their framework for determining how palliative care ought to be provided during a pandemic. I encourage the further development of these considerations.

    These authors write that “Palliative care providers should pay greater attention to patients who are marginalized” (E401). I interpret them to mean that such patients should receive greater attention than those patients that are not marginalized. However, this claim begs the question: If, in the context of the provision of palliative care during a pandemic, marginalized patients ought to receive more attention than patients who are not marginalized (but who would also benefit from palliative care), then why not also receive greater attention in the prior context of decision making about access to scarce resources available during a pandemic (and thus perhaps avoid the need for palliative care for some of those patients)?

    A plausible interpretation of the Canadian Medical Association’s Framework for Ethical Decision Making During the Coronavirus Pandemic (2) (and Emmanuel et al.’s (3) recommendations that they mimic) is that ‘patients living with deficits in the social determinants of health’ will likely not receive access to e.g. ventilators or ICU beds during a pandemic, for reasons rooted in those determinants, e.g. because marginalized people are less likely to be medical professionals (4), and are more like...

    Show More

    It is laudable that Arya, Buchman, Gagnon & Downar (1) include equity considerations as part of their framework for determining how palliative care ought to be provided during a pandemic. I encourage the further development of these considerations.

    These authors write that “Palliative care providers should pay greater attention to patients who are marginalized” (E401). I interpret them to mean that such patients should receive greater attention than those patients that are not marginalized. However, this claim begs the question: If, in the context of the provision of palliative care during a pandemic, marginalized patients ought to receive more attention than patients who are not marginalized (but who would also benefit from palliative care), then why not also receive greater attention in the prior context of decision making about access to scarce resources available during a pandemic (and thus perhaps avoid the need for palliative care for some of those patients)?

    A plausible interpretation of the Canadian Medical Association’s Framework for Ethical Decision Making During the Coronavirus Pandemic (2) (and Emmanuel et al.’s (3) recommendations that they mimic) is that ‘patients living with deficits in the social determinants of health’ will likely not receive access to e.g. ventilators or ICU beds during a pandemic, for reasons rooted in those determinants, e.g. because marginalized people are less likely to be medical professionals (4), and are more likely to have lower health status and the presence of disqualifying comorbidities.

    Arya et al. also suggest that, because of the inequalities in the distribution of the social determinants of health, it is imperative that marginalized “patients who are denied critical care should be the top priority for palliative care” (E401) and that “palliative care thus becomes the compassionate option to counterbalance this inequity” (E404).

    I agree that denying such people access to palliative care would be worse than providing access. However, labeling this as a “compassionate” response is unsettling. It is indicative of a system that is thoroughly uncompassionate towards such people during their life, and then purports to provide relief for that pain during the final weeks or days of their lives. Insofar as the root cause of their pain is the same system that is now offering pain relief, then this response is hardly a “compassionate” one. A true ‘counterbalancing of this inequity’ would come much sooner than at the end of life.

    The point here is not to place the burden on these authors to remedy the inequalities in the distribution of the social determinants of health in Canada. Rather, it is to challenge us all to explore ways in which healthcare could be delivered in a manner such that no one would be put in a position where they should receive higher priority in access to pain relief at the end of their life because of systematic marginalization they have endured during their life.

    Show Less
    Competing Interests: None declared.

    References

    • Amit Arya, Sandy Buchman, Bruno Gagnon, et al. Pandemic palliative care: beyond ventilators and saving lives. CMAJ 2020;192:E400-E404.
    • Canadian Medical Association (2020). Framework for Ethical Decision Making During the Coronavirus Pandemic.
    • Emanuel, Ezekiel J., Govind Persad, Ross Upshur, Beatriz Thome, Michael Parker, Aaron Glickman, Cathy Zhang, Connor Boyle, Maxwell Smith, and James P. Phillips. "Fair allocation of scarce medical resources in the time of Covid-19." (2020): 2049-2055.
    • Khan, R., Apramian, T., Kang, J.H. et al. Demographic and socioeconomic characteristics of Canadian medical students: a cross-sectional study. BMC Med Educ 20, 151 (2020).
  • Posted on: (18 April 2020)
    Page navigation anchor for Palliative care as a priority for integration into pandemic responses
    Palliative care as a priority for integration into pandemic responses
    • Shyh Poh Teo [MBChB, FRACP], Consultant Geriatrician and Physician, Geriatrics and Palliative Unit, Department of Internal Medicine, Raja Isteri Pengiran Anak Saleha Hospital

    I read with interest the paper by Arya et al (1), providing a framework for a palliative care pandemic plan. A palliative approach and compassionate care is required more than ever before during this global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

    Patient autonomy and rights to decide what treatment people want diminishes in resource-limited settings, where the emphasis is utilitarianism to offer the greatest good for the greatest number (2). Providing optimal end-of-life care for SARS-CoV-2 patients is difficult, as rapid deterioration in patients limit the time to prepare and communicate bad news. Implemented visitor restrictions also preclude families from spending time with unwell loved ones. This results in complicated grief, with an increased need for psychosocial and bereavement support for families. Complicated grief is associated with the inability to say ‘goodbye’, pre-loss grief symptoms, limited preparation for death and guilt (3), which is highly likely during the pandemic. Disenfranchisement from families may also occur when unable to grieve ‘normally’ with rituals, funerals and availability of social support.

    It is crucial to address distressing physical and psychological symptoms, lack of understanding of the disease process and initiate end-of-life discussions. For conditions with an unpredictable course and prognosticating difficulties, palliative care referrals based on complexity of symptoms and patient conce...

    Show More

    I read with interest the paper by Arya et al (1), providing a framework for a palliative care pandemic plan. A palliative approach and compassionate care is required more than ever before during this global severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic.

    Patient autonomy and rights to decide what treatment people want diminishes in resource-limited settings, where the emphasis is utilitarianism to offer the greatest good for the greatest number (2). Providing optimal end-of-life care for SARS-CoV-2 patients is difficult, as rapid deterioration in patients limit the time to prepare and communicate bad news. Implemented visitor restrictions also preclude families from spending time with unwell loved ones. This results in complicated grief, with an increased need for psychosocial and bereavement support for families. Complicated grief is associated with the inability to say ‘goodbye’, pre-loss grief symptoms, limited preparation for death and guilt (3), which is highly likely during the pandemic. Disenfranchisement from families may also occur when unable to grieve ‘normally’ with rituals, funerals and availability of social support.

    It is crucial to address distressing physical and psychological symptoms, lack of understanding of the disease process and initiate end-of-life discussions. For conditions with an unpredictable course and prognosticating difficulties, palliative care referrals based on complexity of symptoms and patient concerns was shown to improve patient and caregiver outcomes (4). Symptomatic management and empathic communication should be adjunctive treatment, rather than a primary focus on oxygenation or escalating care to ventilator support. There is a need to mitigate grief and allow patients and families to cope through these stressful times (3). Symptom management, psychosocial support and bereavement support are necessary components to provide holistic care to patients (5).

    In conclusion, palliative care should be prioritised and integrated as part of the international pandemic response.

    Show Less
    Competing Interests: None declared.

    References

    • Arya A, Buchman S, Gagnon B, Downar J. Pandemic palliative care: beyond ventilators and saving lives. CMAJ 2020;192:E400-4.
    • Pattison N. End-of-life decisions and care in the midst of a global coronavirus (COVID-19) pandemic. Intensive Crit Care Nurs 2020. doi: 10.1016/j.iccn.2020.102862
    • Wallace CL, Wladkowski SP, Gibson A, White P. Grief during the COVID-19 pandemic: considerations for palliative care providers, J Pain Symptom Manage 2020. doi:10.1016/j.jpainsymman.2020.04.012
    • Maddocks M, Lovell N, Booth S, Man WD, Higginson IJ. Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease. Lancet 2017;390(10098):988-1002.
    • Etkind SN, Bone AE, Lovell N, et al. The role and response of palliative care and hospice services in epidemics and pandemics: a rapid review to inform practice during the COVID-19 pandemic.J Pain Symptom Manage 2020. doi:10.1016/j.jpainsymman.2020.03.029
  • Posted on: (18 April 2020)
    Page navigation anchor for RE: Making treatment recommendations during the COVID-19 pandemic
    RE: Making treatment recommendations during the COVID-19 pandemic
    • Warren Lewin [MD], Palliative Care Physician, University Health Network - Toronto Western Hospital

    In their article on pandemic palliative care, Arya and colleagues offer suggested language for discussing a treatment plan for patients unlikely to survive a critical illness, but whose current treatment plan would include life-sustaining therapies, if indicated (1). I would like to highlight the important skill of making treatment recommendations. Patients and families facing serious illness often feel anxiety in the face of uncertainty. During a pandemic, this anxiety is amplified as patients and families may be physically separated and guidance from government and institutions may change rapidly. Our ability as clinicians to respond empathically, share prognostic concerns, listen to what matters most, and use this information to make treatment recommendations aligned to their goals can garner trust and alleviate distress.

    Communication skills training programs are available to assist clinicians to navigate goals-of-care discussions and make treatment recommendations. These programs, which utilize structured guides and teach empathic communication skills, are associated with favorable patient outcomes (2, 3). Importantly, these guides move clinicians away from asking patients what they want (e.g., “Would you want treatment [x] if you got sicker?”), to recommending treatments aligned to patient and family values (e.g., “Based on what I hear you saying, I’d like to make a recommendation that would support you to achieve your goals of [a] and [b]. Is that okay?”). I...

    Show More

    In their article on pandemic palliative care, Arya and colleagues offer suggested language for discussing a treatment plan for patients unlikely to survive a critical illness, but whose current treatment plan would include life-sustaining therapies, if indicated (1). I would like to highlight the important skill of making treatment recommendations. Patients and families facing serious illness often feel anxiety in the face of uncertainty. During a pandemic, this anxiety is amplified as patients and families may be physically separated and guidance from government and institutions may change rapidly. Our ability as clinicians to respond empathically, share prognostic concerns, listen to what matters most, and use this information to make treatment recommendations aligned to their goals can garner trust and alleviate distress.

    Communication skills training programs are available to assist clinicians to navigate goals-of-care discussions and make treatment recommendations. These programs, which utilize structured guides and teach empathic communication skills, are associated with favorable patient outcomes (2, 3). Importantly, these guides move clinicians away from asking patients what they want (e.g., “Would you want treatment [x] if you got sicker?”), to recommending treatments aligned to patient and family values (e.g., “Based on what I hear you saying, I’d like to make a recommendation that would support you to achieve your goals of [a] and [b]. Is that okay?”). In my experience as a palliative care physician, patients and families expect clinicians to make values-based recommendations and are comforted by not feeling burdened to make “the right decision” themselves.

    Show Less
    Competing Interests: None declared.

    References

    • Amit Arya, Sandy Buchman, Bruno Gagnon, et al. Pandemic palliative care: beyond ventilators and saving lives. CMAJ 2020;192:E400-E404.
    • Childers JW, Back AL, Tulsky JA and Arnold RM. REMAP: A framework for goals of care conversations. Journal of Oncology Practice. 2017; 13(10):e844- e850.
    • Bernacki R, Hutchings M, Vick J, et al. Development of the Serious Illness Care Program: a randomised controlled trial of a palliative care communication intervention. BMJ Open 2015;5:e009032. doi:10.1136/bmjopen-2015- 009032
  • Posted on: (15 April 2020)
    Page navigation anchor for RE: Choice and scarce resources
    RE: Choice and scarce resources
    • Dhastagir Sheriff [PhD], Professor, Faculty of Medicine, Benghazi University, Benghazi,Libya

    We are in the midst of a pandemic which has taken every nation with a shocking surprise. When leaders were discussing to fight climate change, global warming and space living life on earth has become a challenge for ordinary citizens to live. Warnings and a clarion call for community health were on the back seat of healthcare system including primary care. Tertiary care hospitals with specialized gadgets abound in the most advanced hospitals. Primary care had a disconnect with many countries and there was a divide between these two. Primary care physician had become a family physician. Medical expenses for every citizen in some countries are linked to medical insurance and social security. The under privileged and sheltered citizens or those living in poor economic conditions are at the mercy of governments to take care of them. Social determinants of health economic status, life style including alcohol, drug and smoking habits and fast food have made people immune compromised. The expansion of geriatric population with good health or with co-morbidities suddenly face a choice of being saved or left on the corridor to die. Death in isolation in intensive care unit leave the patients to die with human indignity. Above all those health care personnel who stand between the virus and victim left with no choice to treat the patient with no mechanical devise to oxygenate or without protective gear to die in the service of patient care. WHO with its guidelines on facing such vira...

    Show More

    We are in the midst of a pandemic which has taken every nation with a shocking surprise. When leaders were discussing to fight climate change, global warming and space living life on earth has become a challenge for ordinary citizens to live. Warnings and a clarion call for community health were on the back seat of healthcare system including primary care. Tertiary care hospitals with specialized gadgets abound in the most advanced hospitals. Primary care had a disconnect with many countries and there was a divide between these two. Primary care physician had become a family physician. Medical expenses for every citizen in some countries are linked to medical insurance and social security. The under privileged and sheltered citizens or those living in poor economic conditions are at the mercy of governments to take care of them. Social determinants of health economic status, life style including alcohol, drug and smoking habits and fast food have made people immune compromised. The expansion of geriatric population with good health or with co-morbidities suddenly face a choice of being saved or left on the corridor to die. Death in isolation in intensive care unit leave the patients to die with human indignity. Above all those health care personnel who stand between the virus and victim left with no choice to treat the patient with no mechanical devise to oxygenate or without protective gear to die in the service of patient care. WHO with its guidelines on facing such viral pandemics is still at the mercy of the signatory nations or funding countries. When we man on the moon or possibly on the mars with hightech world Corona Virus with a RNA genome has taught us to live on earth with lock down, social distancing and ill-prepared health care system. Ordinary citizens in such dilemma of scarce resources stands staring at the preamble that Right to Life is Right to Health. Where such a citizen can appeal or ask why nations and WHO have failed to protect him or her exposing them to COVID-19. Justice denied is justice violated.

    Show Less
    Competing Interests: None declared.

    References

    • Amit Arya, Sandy Buchman, Bruno Gagnon, et al. Pandemic palliative care: beyond ventilators and saving lives. CMAJ 2020;192:E400-E404.
  • Posted on: (6 April 2020)
    Page navigation anchor for COVID Towers: low and medium intensity care for non ICU patients
    COVID Towers: low and medium intensity care for non ICU patients
    • Renzo Rozzini, Fondazione Poliambulanza Istituto Ospedaliero, Brescia (Italy)
    • Other Contributors:
      • Angelo Bianchetti, Istituto Clinico Sant’Anna – Gruppo San Donato

    In their paper Arya and colleagues mention the ways in which Italy has dealt with the COVID-19 epidemic; the authors state that “many older patients with comorbidities being denied access to critical care resources”.(1) This assertion does not correspond to reality. Indeed, next to the great effort to increase ICUs for the most critical patients, often younger, many hospital beds have been converted to offer a low-medium intensity of care to the great majority of patients, even older and frail, and we can affirm that no one was denied a cure because of age and comorbidity.(2) In Lombardy, a region of northern Italy, the COVID-19 outbreak has been catastrophic. In four weeks, the virus has overcrowded all hospitals and most wards have had to be converted into COVID-19 wards. Brescia, a city east of Milan and the capital of a Province with 1.2 million inhabitants, has had 6300 cases of COVID-19 between Feb 22 and Mar 26 and, of these, 1000 died. About 53% (2265 out of 4200) of hospital beds have been converted to the treatment of patients with Covid-19 related pneumonia, mainly in acute medical units and in ICUs (8.5% of dedicated beds). In the face of this challenge we radically reorganized traditional hospital departments (actually in our hospitals we manage 430 beds for COVID-19 patients): involving in the care doctors of various specialties, defining clear and shared guidelines, organize training program, daily meeting with team members and constant psycholog...

    Show More

    In their paper Arya and colleagues mention the ways in which Italy has dealt with the COVID-19 epidemic; the authors state that “many older patients with comorbidities being denied access to critical care resources”.(1) This assertion does not correspond to reality. Indeed, next to the great effort to increase ICUs for the most critical patients, often younger, many hospital beds have been converted to offer a low-medium intensity of care to the great majority of patients, even older and frail, and we can affirm that no one was denied a cure because of age and comorbidity.(2) In Lombardy, a region of northern Italy, the COVID-19 outbreak has been catastrophic. In four weeks, the virus has overcrowded all hospitals and most wards have had to be converted into COVID-19 wards. Brescia, a city east of Milan and the capital of a Province with 1.2 million inhabitants, has had 6300 cases of COVID-19 between Feb 22 and Mar 26 and, of these, 1000 died. About 53% (2265 out of 4200) of hospital beds have been converted to the treatment of patients with Covid-19 related pneumonia, mainly in acute medical units and in ICUs (8.5% of dedicated beds). In the face of this challenge we radically reorganized traditional hospital departments (actually in our hospitals we manage 430 beds for COVID-19 patients): involving in the care doctors of various specialties, defining clear and shared guidelines, organize training program, daily meeting with team members and constant psychological support. In this way we faced an emergency of absolutely unexpected proportions, maintaining a high level of care and avoiding burnout of staff, offering to all patients, regardless of age and  economic level, the comfort of a hospital bed. It is our hope that our experience will be of help to other hospitalist colleagues.

    References

    1. Arya A et al. Pandemic palliative care... CMAJ;2020:doi:10.1503/cmaj.200465.

    2. Grasselli G et al. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy... JAMA;2020:doi:10.1001/jama.2020.4031.

    Show Less
    Competing Interests: None declared.

    References

    • 1. Amit Arya, Sandy Buchman, Bruno Gagnon, et al. Pandemic palliative care: beyond ventilators and saving lives. CMAJ 2020;10.1503/cmaj.200465.
    • 2. Grasselli G, Pesenti A, Cecconi M. Critical Care Utilization for the COVID-19 Outbreak in Lombardy, Italy: Early Experience and Forecast During an Emergency Response. JAMA. 2020 Mar 13. doi: 10.1001/jama.2020.4031.
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Canadian Medical Association Journal: 192 (15)
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Pandemic palliative care: beyond ventilators and saving lives
Amit Arya, Sandy Buchman, Bruno Gagnon, James Downar
CMAJ Apr 2020, 192 (15) E400-E404; DOI: 10.1503/cmaj.200465

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Pandemic palliative care: beyond ventilators and saving lives
Amit Arya, Sandy Buchman, Bruno Gagnon, James Downar
CMAJ Apr 2020, 192 (15) E400-E404; DOI: 10.1503/cmaj.200465
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