Palliative Care in a Pandemic

A Retrospective Review of the Impact of Early Palliative Care Consultation During the Coronavirus Disease 2019 Pandemic

Rachel M. Sabolish, MSN; Jennifer M. Wilson, MS; Hollie K. Caldwell, PhD

Disclosures

Journal of Hospice and Palliative Nursing. 2022;24(1):50-56. 

In This Article

Methods

Study Design, Setting, and Study Population

This was a retrospective exploratory study using a 2-group nonrandomized design with descriptive and inferential statistics that compared patient care preference elicitation between patients who received an early PC consult and patients who did not receive PC during a pandemic. Institutional review board approval was received for this research study. Data on all COVID-19 PUIs were obtained from the Patient Safety Manager based on initial tracking through the hospital incident command center. This de-identified patient data set is not publicly available and may be available to researchers who provide a methodologically sound proposal to the Common Spirit Health Research Institute Institutional Review Board for the period immediately after publication until November 2023.

The population included all patients who were tested for COVID-19, referred to in this article as PUI. This means that both patients who tested positive and negative were included in the 2 comparison groups because of the often several days of delay in receiving COVID-19 test results during this time. Inclusion criteria for an early PC consultation included COVID-19 PUIs 18 years or older seen within 72 hours of admission. The intervention period was the initial COVID-19 surge from March 1 to May 31, 2020. Duplicate patients or patients whose attending physician requested that goals of care not be addressed with the patient were excluded. The comparison group included patients who did not receive PC consultation during the admission.

To determine the impact of early PC on a patient's hospital course, the following patient outcome data were compared for the 2 nonrandomized groups, including identification of a medical decision-maker, change in code status, change in goals of care, transition to comfort care, demographics, and discharge disposition. For this study, a change in goals of care was defined as an election by the patient or family that the plan of care would not include a transfer to a higher level of care in the ICU.

The hospital is a 368-bed acute care, not-for-profit hospital in an urban city and employs approximately 500 professional nurses. Two units were designated for COVID-19 patients, one in the ICU and one on the medical floor. The number of beds fluctuated depending on the COVID-19 PUI census with a maximum of 36 ICU beds and 24 medical beds.

The Intervention

On March 31, 2020, less than a month after the first COVID-19 patient was admitted, multiple patients decompensated on the COVID-19 medical unit requiring a rapid response to be called. The critical care and internal medicine physicians, along with the PC APRNs, met briefly to discuss the gap in early identification of patient wishes for care in COVID-19 PUIs. A collective decision was reached that every patient tested for COVID-19 would receive an automatic PC consult order upon admission to address goals of care.

To facilitate this new process, PC APRNs requested that the physicians initiate the PC consult order at the time of admission. Advanced practice registered nurses prioritized patients based on medical acuity and collaborated with internal medicine and ICU physicians to further delineate patient priority. This daily conversation facilitated obtaining a PC consult order on patients who did not receive an order on admission. See Figure for the comparison of PC workflow pre and post COVID-19.

Figure.

Palliative care (PC) workflow comparison pre to post coronavirus disease 2019 (COVID-19).

The early PC workflow was implemented on March 31, 2020. Consults were completed by phone, via Zoom, or in person depending on patient needs. Families were included in conversations when possible, and interpreters were used when applicable. Palliative care APRNs assisted patients and families with the following elements of care: determining a decision-maker, discussing individually defined quality of life, and identifying values-based goals of care. Advanced practice registered nurses provided a medical update on the patient's current condition, discussed concerns for worsening condition and prognosis, and counseled patients and families on COVID-19 and ICU interventions including cardiopulmonary resuscitation, noninvasive positive pressure ventilation, mechanical ventilator, and tracheostomy. Advanced practice registered nurses discussed the option of comfort care when appropriate for patients with a worsening condition, for those who did not wish to escalate their care to the ICU, or for those who elected a DNR.

During the initial pandemic surge, PC APRNs continued to manage end-of-life symptoms for all patients dying in the hospital. Patients dying from COVID-19 presented unique challenges related to the pandemic including isolation, inability to have loved ones by their bedside, and lack of hospice discharge options. The hospital, like many throughout the nation, enacted a visitation ban to decrease the potential spread of the COVID-19 virus. The PC team noted this visitor ban resulted in a great deal of emotional, social, and spiritual distress. Advanced practice registered nurses supported family interaction with patients via video technology and provided much needed emotional support to frightened patients. In addition, the PC team initiated spiritual care referrals for hospital chaplains to provide support and facilitation of patient contact with their spiritual care advisors. The COVID-19 medical unit was staffed primarily by orthopedic nurses who found assessment and interventions for rapid respiratory decompensation initially challenging. Their experience caring for patients at the end of life before COVID-19 was also limited. As a result, APRNs advocated for an oncology nurse trained in end-of-life assessment and management be assigned to every shift on the COVID-19 unit.

Statistical Analysis

Elicitation of patient care preferences for the early PC group and the non-PC group was derived and recorded from the patient's electronic health record (EHR). Care preferences for patients seen for an early PC consult were compared with those for patients who did not receive PC. Descriptive statistics and an independent t test assuming unequal variance (2-tailed, significance of .05) were used to analyze the data.

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