key: cord-0948538-ima51d0x
authors: Thomas, Jane deLima; Leiter, Richard E.; Abrahm, Janet L.; Shameklis, Jaclyn C.; Kiser, Stephanie B.; Gelfand, Samantha L.; Sciacca, Kate R.; Reville, Barbara; Siegert, Callie A.; Zhang, Haipeng; Lai, Lucinda; Sato, Rintaro; Smith, Lorie N.; Kamdar, Mihir M.; Greco, Lauren; Lee, Kathleen A.; Tulsky, James A.; Lawton, Andrew J.
title: Development of a Palliative Care Toolkit for the COVID-19 Pandemic
date: 2020-05-23
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.05.021
sha: cd8575c01302e81ba8b9772b83436d7e1e4b8a39
doc_id: 948538
cord_uid: ima51d0x

The COVID-19 pandemic has led to high numbers of critically ill and dying patients in need of expert management of dyspnea, delirium, and serious illness communication. The rapid spread of SARS-CoV-2 creates surges of infected patients requiring hospitalization and puts palliative care programs at risk of being overwhelmed by patients, families, and clinicians seeking help. In response to this unprecedented need for palliative care, our program sought to create a collection of palliative care resources for non-palliative care clinicians. A workgroup of interdisciplinary palliative care clinicians developed the Palliative Care Toolkit, consisting of a detailed chapter in a COVID-19 online resource, a mobile and desktop web application, one-page guides, pocket cards, and communication skills training videos. The suite of resources provides expert and evidence-based guidance on symptom management including dyspnea, pain, and delirium, and also on serious illness communication, including conversations about goals of care, code status, and end-of-life. We also created a nurse resource hotline staffed by palliative care nurse practitioners and virtual office hours staffed by a palliative care attending physician. Since its development, the Toolkit has helped us disseminate best practices to non-palliative care clinicians delivering primary palliative care, allowing our team to focus on the highest-need consults, and increasing acceptance of palliative care across hospital settings.

First, we put together an interdisciplinary workgroup comprised of attendings, fellows, 80 nurse practitioners, educators, and informaticians to create the Toolkit. Team members were 81 assigned to work on particular sub-projects, with ongoing collaboration and exchange of 82 resources across the larger group. The workgroup met several times a week for several weeks 83 and then weekly thereafter to monitor the progress of projects and strategize about next steps.

We identified and followed several principles: 1) tools should focus on the care of patients with 85 COVID-19, although they may have wider applicability, 2) tools should be clear, concise, and 86 reflect palliative care best practices, 3) tools should be accessible to a wide variety of clinicians 87 in a wide variety of settings, and 4) although tools may take different forms and formats, they 88 should have internal consistency in content. As we created the Toolkit, we referenced materials 89 at our institutions 3-5 as well as outside institutions, including materials from Massachusetts 90 General Hospital and VitalTalk. 6,7 91

We started by writing a detailed palliative care chapter for covidprotocols.org, a 92 The Toolkit, available at pallicovid.app, includes a collection of resources described in 114 The combination of physical tools (pocket cards and one-page summaries), online tools 117 (the palliative care section of covidprotocols.org and communications skills videos), real-time 118 support tools (the 24/7 nurse resource line, daily palliative care office hours), and the Pallicovid 119 app has been well received by referring teams. We are able to direct clinicians to these 120 resources to answer straightforward questions and as a result we have been better able to 121 focus on more complex consultations that require higher-level palliative care expertise. 122

In response to the pandemic, we have also built new clinical programs aligned with the 123 Emergency Department, ICU, and Hospital Medicine teams. As we connected with attendings, 124 trainees, nursing leaders, and bedside nurses in those settings, we distributed information 125 about the Toolkit and made the resources available to all. Doing so has strengthened our 126 credibility as helpful partners in the crisis, even if we were not able to perform a consultation 127 for every patient we were called to see.

We plan to continue to enhance the Toolkit, including adding a coaching option for 129 referring teams needing more robust help with a particular case, but not a full consult. 130

Meanwhile, we are finding that the current resources are being met with great enthusiasm. 131

Covidprotocols.org had more than 660,000 page views between March 31, when the palliative 132 care chapter went live, and May 4. Similarly, the pockets cards have been positively received; 133 we ran out of the first order of 300 cards within two weeks. In addition, the Pallicovid app was 134 accessed by over 2000 users between April 7 (its launch date) and May 4th. 135

Discussion 137 138

The COVID-19 pandemic is providing surprising opportunities for creativity in the midst 139 of chaos and hardship. Our group's experience creating the Palliative Care Toolkit is one such 140 example, allowing us to pull our varied skills and interests together in order to rapidly create a 141 suite of helpful resources in anticipation of a surge of seriously ill patients at our hospital. We 142 will continue to track the use of the various resources over time and ask for feedback from 143 referring clinicians to determine which ones are proving especially useful. We will also adapt 144 different parts of the Toolkit for different clinical settings where appropriate; the 145 communication skills videos are one example of this kind of specialization. 146

We anticipate that many clinical and educational strategies developed during the 147 pandemic will continue to be useful long afterward. In creating the Toolkit, our group is 148 discovering new opportunities to expand our program's reach and help referring teams without 149 the need to perform a full consultation in response to every request. We are still experimenting 150 with which requests for consults can be adequately addressed by pointing to the resources in the Toolkit and which requests should result in full consults, and we are in the process of 152 creating algorithms to standardize our triage practice. But we are embracing the possibilities 153 afforded by having an array of specific, useful tools to put in the hands of our colleagues to help 154 them care for their patients, especially with real-time back up from the nursing resource line 155 and daily office hours. Our early experience demonstrates that we can provide a high level of 156 support and availability while using our human resources far more efficiently than we have in 157 the past. 158

A more ambitious hope is that the Toolkit will help strengthen the integration of our 159 palliative care program within our hospital. While our team is well supported by the hospital, in 160 the minds of some of our colleagues our specialty still remains inextricably linked to end of life 161 care. As we now help teams care for patients with COVID-19 who sometimes recover from 162 critical illness, it seems possible that the pandemic is creating an opening for real culture 163 change in how palliative care is viewed at our institution. The Palliative Care Toolkit is one 164 tangible demonstration of our intention to be available to teams caring for seriously ill patients 165 regardless of life expectancy or code status. 166

The resources included in the DFCI/BWH Palliative Care Toolkit can serve as a useful 167 example for other programs facing challenges similar to our own. These tools can be adapted 168 to a wide variety of clinical settings that are anticipating or experiencing higher than usual 169 palliative care needs during the pandemic. We hope other programs find -as we have found -170 that the Toolkit helps disseminate best practices in communication and symptom management, 171 allowing palliative care specialists to focus on the highest-need consults, and increasing 

The Role and Response of Palliative Care and Hospice 182 Services in Epidemics and Pandemics: A Rapid Review to Inform Practice During the 183 COVID-19 Pandemic

What Should Palliative Care's Response Be to the COVID-19 186 Pandemic?

A Physician's Guide to Pain and Symptom Management in Cancer Patients

Cancer Institute & Brigham and Women's Hospital

Adult Guidelines for Assessment and Management 194 of Nausea and Vomiting. Dana-Farber Cancer Institute & Brigham and Women's 195 Hospital

COVID-Ready Communication Skills: A Playbook of VitalTalk Tips

REMAP: A Framework for Goals of Care 200 Conversations