key: cord-0719812-hww4rxkj authors: de Lasa, Cristina; Brown, Eric E.; Colman, Rebecca; Rajji, Tarek K.; Colman, Sarah title: Invited letter: Integrated palliative care in a geriatric mental health setting during the COVID‐19 pandemic date: 2021-11-18 journal: Int J Geriatr Psychiatry DOI: 10.1002/gps.5654 sha: 1049411f17897b57e337fb540438206c6e8828d6 doc_id: 719812 cord_uid: hww4rxkj nan Since December 2019, coronavirus disease 2019 (COVID-19) has spread worldwide, with over 230 million cases and 4.7 million deaths confirmed as of 28 September 2021. 1 The impact of the virus has been devastating internationally in long-term care (LTC), mental health hospitals and retirement homes, given an elevated risk of infection, morbidity and mortality. 2 Increased risk of infection arises in the congregate setting from overcrowding, 3 inadequate availability or use of personal protective equipment, and the inability of some residents to follow public health guidelines due to cognitive impairment. 4 The demographic and clinical characteristics of LTC residents, including advanced age, frailty and medical comorbidities, contribute to high morbidity and mortality. 5 In Canada, like other jurisdictions, the majority of residents in LTC have major neurocognitive disorder, or dementia, a progressive, disabling, irreversible and ultimately fatal disease. 6 Reported 6month mortality rate among people with advanced dementia is 25%. There have been longstanding calls to expand palliative care to include advanced dementia. 7 The culture in some Canadian LTC and inpatient geriatric psychiatric settings is to defer management of acute medical issues and palliation. [8] [9] [10] Patients with dementia may have challenges expressing their wishes. As a result, patients are often sent to medical hospitals, at times against their best interests, with increased risk of nosocomial infection and functional decline, and at a high cost to the medical system. 9 The COVID-19 pandemic has challenged healthcare systems internationally due to threatened and actual resource scarcity. Faced with the potential need to ration critical care resources, clear advance directives with respect to life-sustaining care are necessary. Defaulting to intensive life-sustaining therapy (e.g., CPR) to all patients without their truly informed consent may be harmful. The ethical principle of non-maleficence demands that we protect such vulnerable people from dying in this uncomfortable way. 5 Given these considerations, along with changes in the riskbenefit ratio during this pandemic, many institutions have had to pivot to be able to provide dignified death within their walls. Here we report our local experience in hopes that it will be useful for At the time, there were concerns about lack of medical hospital space. This led to a broader acceptance of the idea that patients may die at our facility, accelerating our efforts upskill capacity to integrate palliative care in our setting. We integrated a clinical frailty scale in goals of care discussions to assist families in deciding between lifeprolonging treatments and comfort-based approaches. 11, 12 Using elements of the palliative care pandemic framework set out by Arya et al. 13 we developed a plan to address 'stuff, staff, space and systems', the need for sedation and communication, with minimal additional expenses. We developed an electronic order set to standardize the provision of palliative care for those not frequently using those skills (Table 1) . We reviewed local hospital palliative order sets and elicited interdisciplinary feedback. We collaborated with our pharmacists to ensure an adequate supply of medications and obtained specialized equipment such as butterflies for subcutaneous medication administration. We developed a collaborative, working relationship with a local palliative care team for virtual support to our front-line physicians. A medical mobile team of two nurses with palliative care expertise provided nursing staff with bedside support. Palliative care staff training was provided by nurse educators. Discussions about goals of care were held with patients, family and SDMs following the principles of shared decision-making. We set up the conversation and shared information and prognosis. We explored goals, fears, and strengths and provided a summary. We documented the conversation and resuscitation status in the electronic medical record. We increased communication among the clinical team through daily 'huddles' to discuss concerns and ensure proper provision of palliation. During hospital-wide grand rounds, we shared our experiences to promote a more palliative-friendly culture. We realized that the risk of sending some patients to medical hospital may outweigh benefits. We acknowledged that death on the unit may be a preferred outcome by some patients and families. We adapted quickly to increase our comfort in managing end-of-life treatment. The issues facing our LTC homes and psychiatric hospitals in Canada were similar internationally. 2 As the COVID-19 pandemic continues to impact residents in our inpatient setting, as in LTC and other congregate settings in which people with dementia reside, integrated palliative care services will be needed. Failing to properly address patients' goals of care and to provide effective palliation will compound the tragedy of this pandemic. By upskilling and adapting, we will be better prepared for future pandemics or new cycles of the present one. Our experience attests to the feasibility of rising to this mission. advanced directives, code status, COVID-19, dementia, inpatient psychiatry, palliative care COVID-19 weekly epidemiological update Anticipating and mitigating the impact of the COVID-19 pandemic on Alzheimer's disease and related dementias Association between nursing home crowding and COVID-19 infection and mortality in Ontario, Canada Effectively caring for individuals with behavioral and psychological symptoms of dementia during the Covid-19 pandemic. Front Psychiatry Israel Ad Hoc COVID-19 Committee: guidelines for care of older persons during a pandemic Canadian Institute for Health Information Palliative care interventions in advanced dementia. Cochrane Database Syst Rev Are longterm care residents referred appropriately to hospital emergency departments? A systematic review of outcomes following emergency transfer to hospital for residents of aged care facilities Acute hospital service utilization by inpatients in psychiatric hospitals National Institute for Health and Care Excellence. COVID-19 rapid guideline: critical care in adults A global clinical measure of fitness and frailty in elderly people Pandemic palliative care: beyond ventilators and saving lives This research received no specific grant from any funding agency, commercial or not-for-profit sectors. The authors declare no conflict of interests.Cristina de Lasa 1,2 Eric E. Brown 3, 4 Rebecca Colman 5, 6 Tarek K. Rajji 3, 4, 7