An emergency department-based palliative-care program can help clarify treatment goals for COVID-19 patients and their families, according to new findings. "In a COVID-19 pandemic, the priority of having conversations with patients about their goals of treatment has never been more important," Dr. Marna Rayl Greenberg of Lehigh Valley Hospital and Health Network/University of South Florida Morsani College of Medicine, in Allentown, Pennsylvania, told Reuters Health by email. "And the best way we can serve our patients is to be comfortable in having these conversations while our patients are alert and capable; especially since, particularly in this disease, that ability can change very quickly," she said. Dr. Greenberg and her colleagues developed the program to serve the network's six hospitals, with a schematic for helping clinicians set up a palliative care consultation for COVID-19 patients. Clinicians were also provided with an abbreviated shared-decision tool from the National Hospice and Palliative Care Organization, a list of drugs appropriate for symptomatic treatment, a flow diagram for relief of dyspnea from the Center to Advance Palliative care, and a conversation guide from the American College of Emergency Physicians' COVID-19 Field Guide. Each site was provided with tablets and guidelines for clinicians and patients on how to use them, including instructions on disinfecting the devices after use, the authors explain in the American Journal of Emergency Medicine. A palliative-care nurse practitioner was available at the largest hospital from 11 a.m. to 9 p.m. every day, with other hospitals covered on an "on call" basis. Two emergency medicine physicians, one with fellowship training in palliative medicine, offered "at the elbow" support to clinicians at three of the sites. At the three hospitals in urban areas, COVID-19 patients were transferred to inpatient hospice when appropriate. In the three more-rural hospitals, hospitalists treated patients with comfort measures. Before the program was established, patients were commonly admitted as "Full Code by Default," Dr. Greenberg and her team note. This is less likely when the palliative-care team is on hand in the emergency department, the researcher said. "Of note, this does not mean patients are not still 'Full Code', it just means that we have had the discussion and that their wishes are not, by default, presumed to be Full Code," she added. "Instead it is representative that we have had a meaningful conversation that has resulted in their voice being heard for these important decisions." While the iPad technology used for palliative-care consultations has been "amazing," Dr. Greenberg said, providing these services 24-7 remains a challenge. "As the research evolves in this arena, it will be important to measure other important metrics like how treatment is changed based on these discussions, the economic and best logistic methods of staffing, and patient /family satisfaction with the process," she added. Physicians may be afraid to have discussions about goals of treatment with patients because they feel it means "giving up" on a patient, Dr. Greenberg added. "In reality, this is the best care that can ever be offered. We aim to help patients understand that we wish things will go well, but we worry they may not," she said. "And we wonder what their thoughts are about what options are available and what questions they may have about these interventions. There is no greater gift than for them to be able to participate in the decisions about their ultimate care." —Anne Harding Source
