key: cord-1018414-v2cmwtfd
authors: Kudo, Hiroshi; Miyata, Chieko; Kawaguchi, Yoshiki; Yachi, Yutaka; Shinfuku, Masaki; Kinoshita, Takayuki; Kurihara, Tomohiro; Momiyama, Yukihiko; Chong, Tonghyo; Kobayashi, Yoshiro; Takazawa, Mihiro; Itoh, Kenji; Tsunoda, Koichi
title: Do hospital visit restrictions cause increase in the doses of morphine in terminal care?-Spiritual pain and palliative care in the COVID-19 pandemic-
date: 2022-04-25
journal: Am J Med
DOI: 10.1016/j.amjmed.2022.04.011
sha: a2626ca7772b39ad24aa86ad3377d1c797d812c0
doc_id: 1018414
cord_uid: v2cmwtfd

nan

The Centers for Disease Control and Prevention (CDC) has alerted public health departments, health care professionals, and first responders of "a concerning acceleration of the increase in drug overdose deaths" coinciding with the emergence of the coronavirus disease 2019 (COVID-19) pandemic and has said that the surge in deaths was driven primarily by a rapid rise in overdose deaths caused by synthetic opioids. 1 Palliative care is one of the most important factors for pain control in terminal cases of cancer patients. Lack of visitation by loved family may strongly affect pain control in terminal care. 2 Visitation seems important as a spiritual component of palliative care, although there is not enough evidence for this yet. In a study of 937 cases of patients receiving dialysis an association between the importance of religious or spiritual beliefs with care preferences and palliative care needs was found for most study participants. 3

The COVID-19 pandemic has resulted in hospitals across world, including Japan, restricting visitation to their patients. Families of terminal stage patients were 3 also prohibited from visiting. We speculated that these restrictions of visitation would increase the physiological and psychological distress of patients and increase their total dose of opioids (morphine milligram equivalents). In this study, we objectively compared the total dose of patients in terminal stage before death, between the periods before the COVID-19 pandemic (hospital visits allowed for patients' families) and during the COVID-19 pandemic (visiting prohibited).

We investigated all clinical records of the patient with cancer pain on opioid analgesics who received palliative care from our palliative care team and who died in Table- 1.

The mean intervention duration per patient was approximately constant at 15.5days (p=0.9603, d=0.01) and the mean age of patients also showed almost no difference in each year over the 3-year period. The mean size of every applied dose in 2020 exceeded that of the previous two years (p<0.0001, d=0.25) by 39%, as shown in Figure 1 , and the mean full dose per patient increased by 24% in 2020 as shown in Table- 1.

Before the increases of morphine dose, all members of the clinical team are called to utilize compassionate listening and communication skills to address the pervasive isolation and grief of those in their care 4 . With the firm care of our palliative care team, we were able to see a decreasing trend in total opioid doses in the two years 5 prior to restricting visits. However, after the restricted visitation, total doses for pain relief increased significantly. In other words, the study found that the restricted visitation increased the spiritual pain factor and could cause significant stress to patients in terminal stage.

To decrease spiritual or physiological pain, solutions were suggested to provide spiritual and psychological palliative care to hospitalized patients and their families through interdisciplinary telehealth delivery 5 . Phone and video calls can be effective and may significantly reduce the dosage of morphine needed. The results of this study provide objective evidence that it is very important for patients to meet and talk with someone close to them in person, and that there is a causal relation between this invisible power and spiritual pain. 

CDC Warns of Surge in Drug Overdose Deaths During COVID-19

Change in Per Capita Opioid Prescriptions Filled at Retail Pharmacies

Association Between Self-reported Importance of Religious or Spiritual Beliefs and End-of-Life Care Preferences Among People Receiving Dialysis

The Still, Small Voice of Grief

Implementation of a Palliative Hospital-Centered Spiritual and Psychological Telehealth System During COVID-19 Pandemic

Welch's t-test p< 0.0001 Effect size * d=0

The mean size of applied doses in 2020 exceeded that of the previous two years