key: cord-0970471-zawfotcx
authors: Fausto, James; Hirano, Lianne; Lam, Daniel; Mehta, Amisha; Mills, Blair; Owens, Darrell; Perry, Elizabeth; Curtis, J. Randall
title: Creating a Palliative Care Inpatient Response Plan for COVID-19—The UW Medicine Experience
date: 2020-03-31
journal: J Pain Symptom Manage
DOI: 10.1016/j.jpainsymman.2020.03.025
sha: 0a67144ee20745181efe19f9e3b9ac0929b578d4
doc_id: 970471
cord_uid: zawfotcx

Abstract Context The coronavirus disease 2019 (COVID-19) pandemic is stressing health care systems throughout the world. Significant numbers of patients are being admitted to the hospital with severe illness, often in the setting of advanced age and underlying comorbidities. Therefore, palliative care is an important part of the response to this pandemic. The Seattle area and UW Medicine have been on the forefront of the pandemic in the U.S. Methods UW Medicine developed a strategy to implement a palliative care response for a multihospital health care system that incorporates conventional capacity, contingency capacity, and crisis capacity. The strategy was developed by our palliative care programs with input from the health care system leadership. Results In this publication, we share our multifaceted strategy to implement high-quality palliative care in the context of the COVID-19 pandemic that incorporates conventional, contingency, and crisis capacity and focuses on the areas of the hospital caring for the most patients: the emergency department, intensive care units, and acute care services. The strategy focuses on key content areas, including identifying and addressing goals of care, addressing moderate and severe symptoms, and supporting family members. Conclusion Strategy planning for delivery of high-quality palliative care in the context of the COVID-19 pandemic represents an important area of need for our health care systems. We share our experiences of developing such a strategy to help other institutions conduct and adapt such strategies more quickly.

The novel coronavirus, severe acute respiratory syndrome coronavirus 2, emerged in Wuhan, China, in late November 2019. Reports of case-fatality rates varied dramatically across regions of China, but it was clear that this virus resulted in severe and lifethreatening illness for some patients, particularly patients who are older and have comorbid chronic illness. 1e3 During the few months that followed, new cases were being reported outside China at a rapid rate. The first confirmed case in the U.S. was a travel-associated case screened on January 19, 2020, in Snohomish County, Washington. Six weeks later, a second presumptive case was identified roughly 10 miles from where the first case was treated. 4 As of March 22, 2020, Washington state has confirmed 1793 cases and reported the known recovery of 124 people and 96 deaths. In this context, our regional health care systems are challenged to develop strategies to provide high-quality care to patients with coronavirus disease 2019 . Given the number of patients with severe illness and the number of deaths, our UW Medicine palliative care program has been centrally involved in developing a systemlevel palliative care response to the COVID-19 pandemic.

As part of our UW Medicine palliative care response, we have developed a system-wide strategy for implementation of palliative care across our health care system that includes four acute care hospitals, an extensive neighborhood clinic network, and a comprehensive cancer center. This strategy focused on care of hospitalized patients, as this represents the area of greatest immediate need. This inpatient palliative care response plan was rapidly developed and continues to be modified and updated at UW Medicine. This plan was developed in coordination with the health system leadership along with clinical leads from key services within UW Medicine, including the palliative, emergency, intensive, and acute care services at each hospital.

Numerous authors have described approaches to disaster preparedness and responses for events such as natural disasters and pandemics to guide decision making about use of resources to allow the greatest good for the greatest number. Many of these approaches use a continuum of medical care scenarios, including conventional care, contingency care, and crisis care. 5e7 These proposals highlight that the primary objective in a disaster is to remain in conventional and contingency care to avoid crisis care, which will compromise patient outcomes. In conventional care, usual resources and level of care are provided. 5 In contingency care, the goal is to provide functionally equivalent care adapted from usual practices with approaches such as boarding critical care patients in postanesthesia care areas. In crisis care, there are inadequate resources available to provide equivalent care, and care is provided to the highest level possible, acknowledging that there will likely be increased mortality and morbidity as a result of scarce resources but striving to provide this care in the highest quality and most ethical way possible. We used this framework to guide the development of a palliative care strategy in response to the COVID-19 pandemic.

The initial approach at UW Medicine involved discerning what areas in our hospitals would be most greatly impacted early in the COVID-19 pandemic and focusing on those areas most impacted by a surge of acutely and critically ill patients with COVID-19. A document was drafted that identified the areas where palliative care would likely be needed most, which led to a focus on the emergency department (ED), intensive care units, and key acute care medical services where most patients with COVID-19 would be seen. The next part of the plan detailed the form and function of the palliative care team in the context of the current capacity, a contingency capacity, and a crisis capacity. We identified the form of support as including coaching for the delivery of primary palliative care, brief and targeted palliative care consultations to address key issues, and full palliative care consultations. We focused on the primary areas of need identified as we began to see patients with COVID-19 in our health care system, including identifying and addressing goals of care, addressing code status to reduce the risk of unwanted or nonbeneficial cardiopulmonary resuscitation in the context of COVID-19, identifying and addressing moderate or severe symptoms not adequately addressed through primary palliative care, and supporting family members in the difficult context of restricted visitation and possible self-quarantine.

This strategy was reviewed and updated by the leadership of the palliative care services at each of the hospitals and also by UW Medicine leadership. Changes were made to ensure that the strategy covered the areas of most need being seen by each of the palliative care services as the pandemic unfolded, as well as the EDs, intensive care units, and acute care services.

We produced a document that described our strategy for supporting high-quality palliative care under conventional capacity, contingency capacity, and crisis capacity. Table 1 depicts the strategy for the ED; Table 2 for the intensive care units; and Table 3 for acute care services. For the intensive care units and acute care services, we highlighted specific strategies for general units as well as those units solely dedicated to the care of patients with COVID-19. In these tables, the components relevant to conventional care, contingency care, and crisis care are identified.

During the drafting of this content, other topics that needed consideration were identified, including the fact that palliative care specialty staffing is often limited in conventional capacity situations and would certainly be challenged in contingency and crisis capacity situations. However, we noted that other specialty palliative care workforce exists but are assigned to other clinical or nonclinical duties, such as nonpalliative care services, teaching, or research. During contingency and crisis capacity, our strategy includes the reallocation of these staff to support the palliative care response to create the greatest good for the greatest number of patients. This approach would increase the size and reach of a palliative care team. In additionally, given that we have a multihospital system, we also developed plans for redeploying specialty palliative care workforce across sites to levelload palliative care resources.

A second consideration was the implementation of personal protective equipment (PPE) preservation, which has been a core strategy to maintain health care worker safety. Given this priority, we decided that the palliative care consult service should only use PPE when absolutely necessary for the delivery of care, and the goal should be to try remote approaches through digital health and telephonic options when possible. In addition, our palliative care consult service is interdisciplinary, including physicians, nurse practitioners, nurses, social workers, and spiritual care providers, and our usual operating procedure often entails more than one palliative care clinician visiting a patient or family at the same time. During the COVID-19 pandemic, we decided that if an in-person encounter is necessary, generally only one palliative care provider would see the patient in person regardless of whether the patient has COVID-19 to conserve palliative care specialists to see more patients and, for patients with COVID-19 or other PPE-using infections, to preserve PPE.

A third consideration was the provision of palliative care service support after routine working hours. Our primary approach is to have an on-call palliative care attending physician provide coaching to primary team as well as telephonic support to patients and families. The palliative care attending physician would be available for in-person visits, but these would be limited when possible to preserve our palliative care workforce.

A fourth consideration was the decision that routine palliative care consultation during this time will be triaged and postponed where possible. If an urgent consult is not needed, these would be deferred to the outpatient program or later consultation. However, urgent consultations would be prioritized similarly for patients with COVID-19 and patients with other illnesses.

A fifth consideration is the importance of early goals-of-care discussions and addressing code status, especially for older patients and those with chronic life-limiting illness. Decisions to forego cardiopulmonary resuscitation and mechanical ventilation that is unwanted or nonbeneficial take on additional importance in the context of constrained resources given the potential risk to health care workers and subsequent increased strain on our health care capacity. Our palliative care specialists are charged with providing guidance for primary teams conducting these goals-of-care and code status discussions to preserve resources by avoiding unwanted or nonbeneficial use. We also strived to provide all teams with clinician discussion tools as well as consultation to assist with complex communication. These resources include an informed assent strategy for discussing do-not-resuscitate orders 8 and resources for COVIDready communication skills. 9 Our strategy specifies that in a crisis capacity setting, we would consider the creation of an end-of-life care unit specifically for patients dying with COVID-19, which would be staffed by palliative care physicians and advanced practice provider specialists trained in use of PPE. We also specify that in a crisis capacity setting, telephonic support at all hours may provide additional palliative care capacity to provide coaching and symptom guidance to primary teams.

The COVID-19 pandemic has driven rapid change management for many health care settings nationally. These rapid changes have caused many health care systems, including our own, to move from conventional capacity to contingency capacity delivery in a matter of weeks. It is hoped that contingency capacity in addition to federal, state, and local government recommendations for social distancing and other measures to reduce transmission will help avoid a This strategy has several important limitations. First, we describe the strategy for a single health care system with a relatively mature palliative care program. Certain aspects of this strategy may not generalize to other locations. Second, this strategy is undergoing constant modifications and is a work in progress. However, we thought that it would be useful to share it with others early given the rapid expansion of this pandemic. Finally, it is important to acknowledge that this strategy is a plan that has not been fully implemented. We are actively using the conventional and some of the contingency capacity approaches, but some contingency and all crisis capacity strategies have not been tested.

As we strive to support and provide high-quality primary and specialty palliative care during the COVID-19 pandemic, it is important that we share planning and experiences with each other to minimize the amount of unnecessary work in developing, adapting, and implementing strategies. This report strives to share our early experience developing and implementing such a strategy.

This study was supported by a grant from the Cambia Health Foundation. The authors declare no conflicts of interest.

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ICUdnon-COVID-19 units 1. ICU can access onsite specialty palliative care seven days/week from 9 AM to 6 PM, by consult request. In addition, palliative care telephonic coaching available 24 hours a day, seven days/week 2. Daily huddle with key ICUs to assess confirmed