Dyspnea Most Important End-Of-Life Symptom In COVID-19 Patients

Dyspnea is the most significant end-of-life symptom in COVID-19 patients, and deaths are most commonly due to respiratory failure or heart failure, according to a new rapid systematic review and evidence summary.

The review, in BMJ Supportive and Palliative Care, looks at 12 papers from China, Italy and the U.K.

Dr. Paul Keeley of the Glasgow Royal Infirmary told Reuters Health he undertook the review after his wife developed COVID-19 symptoms in mid-March and he had to self-isolate.

"This is a new disease that we were going to be dealing with, we knew we were going to be dealing with a lot of people at the end of life," Dr. Keeley said by phone. Because China and Italy were further along in the course of the pandemic, he added, it was important to get as much information as possible to guide care in the U.K. and elsewhere.

He and his colleagues identified 12 studies of symptoms and modes of death in COVID-19 patients. "The caveat was that most of them were from acute physicians in China who were focused on presenting symptoms rather than symptom burden in those who were dying," Dr. Keeley noted.

The largest study from China included 1,099 patients. The review also included one study from Italy, of 6,801 patients, and a U.K. study of 101 patients.

Four of the studies included discrete data on symptoms of dying patients, although in three of these studies it was not clear whether symptoms occurred upon presentation or at the end of life. Dyspnea, cough and fatigue were frequent symptoms.

Two of the studies reported patients' cause or mode of death. In one study of 109 patients, 90% died due to acute respiratory distress syndrome (ARDS), 60% due to acute cardiac injury, 18% due to acute kidney injury, 12% shock and 6% disseminated vascular coagulation. The other study, in 68 patients, reported cause of death, which included respiratory failure in 53%, myocardial damage or failure in 33%, respiratory failure with myocardial damage or failure in 7%, and 7% unknown.

One of the studies included in the review, by Du et al, published in the American Journal of Respiratory and Critical Medicine on April 3, 2020, "disappeared from the original publication site, withdrawn by the authors," Dr. Keeley and his team note.

They conclude: "Rapid data gathering on the mode of death and the symptoms burden in dying patients (prevalence and where possible data refractions) in areas where COVID-19 is prevalent will provide important intelligence for clinicians. This should be undertaken urgently, within ethical norms, and the practicalities of dealing with a public health, clinical and logistical emergency."

Dr. Shunichi Nakagawa, director of Inpatient Palliative Care Services at Columbia University Medical Center in New York City, said more data is quickly becoming available on palliation in COVID-19 patients. He told Reuters Health by email that the review only included studies published through April 21, 2020.

"Probably the finding won't change much, but it would be important to collect more data," said Dr. Nakagawa, who was not involved in the review. "This paper doesn't contain the data from the U.S. (only from China, Italy, U.K.). We need data from the U.S. Additionally, it would be important to know how those symptoms were treated and if they were controlled well."

He concluded: "Unfortunately, many patients die of COVID and they have symptoms. Even if we cannot save them, we can still make sure they don't suffer and they remain comfortable."

—Anne Harding

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