A COVID-19 Palliative Care Pandemic Plan: An Essential Tool

Palliative care physicians have created a coronavirus disease 2019 (COVID-19) palliative care plan as an essential tool to provide care and help manage scare resources during the pandemic. The plan, which focuses on 8 critical elements —"stuff," "staff," "space," "systems," "sedation," "separation," "communication," and "equity"— is published in CMAJ (Canadian Medical Association Journal).

Palliative care is a human right for patients. "The current COVID-19 pandemic will likely strain our palliative services beyond capacity," says Dr. James Downar, the head of the Division of Palliative Care at the University of Ottawa and a palliative care physician at The Ottawa Hospital and Bruyère Continuing Care. "We advise acting now to stockpile medications and supplies used in palliative care, train staff to meet palliative care needs, optimize our space, refine our systems, alleviate the effects of separation, have critical conversations, and focus on marginalized populations to ensure that all patients who require palliative care receive it."

"Many people already have advance care plans that stipulate that comfort measures are to be used if they become seriously ill," writes Dr. Downar with coauthors. "Other patients who are intubated and receiving mechanical ventilation but are not improving clinically will be extubated. A third group of patients may be denied ventilation because of resource scarcity."

The plan is an expansion of a framework developed by the US Task Force on Mass Casualty Critical Care for events with large numbers of injuries and casualties, with the addition of the last four elements, sedation, separation, communication, and equity.

• Stuff: medications should be stockpiled to provide comfort to patients on a larger scale, and for longer periods than usual. The authors suggest creating "palliative symptom management kits" for use by staff in long-term care facilities, paramedics and other health care professionals.
• Staff: regional pandemic planning should include all health care professionals with palliative care training and involve educating others to offer palliative care.
• Space: to accommodate large numbers of patients, it may be necessary to adapt specialized wards or nearby locations and ensure a quiet, peaceful environment for dying patients.
• Systems: new triage systems and virtual care models may be used to allocate physicians and increase efficiency while reducing risk of infection.
• Sedation: palliative sedation can provide comfort to people whose symptoms are unresponsive to standard comfort medications.
• Separation: to lessen the sense of separation because of isolation measures, use video calling, and technology to connect patient with family members.
• Communication: open communication and understanding of a patient's wishes is critical, as many may not want to receive life-sustaining measures.
• Equity: it is important to ensure marginalized groups, including people with disabilities or trauma and those living in poverty, have access to palliative care during a pandemic.

"Any triage system that does not integrate palliative care principles is unethical. Patients who are not expected to survive should not be abandoned but must receive palliative care as a human right," the authors conclude.

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