By JULIE MINDA
Palliative care experts have an important role to play as their health systems and facilities hone — and then implement — policies and protocols around COVID-19. The pandemic raises critical questions for health care facilities about the allocation of scarce resources, the protection of patients and staff and numerous other concerns — and palliative care leadership should have a role in discussions of how to address such concerns. And, these specialists should be among those who serve as an anchor to Catholic social teaching as policies and protocols are implemented.
Those were key themes that surfaced during a March 26 webinar, "Palliative Care and COVID-19: Implications for Clinical Practice." The presentation was the first in a series of three panel discussions from CHA and the Supportive Care Coalition. The next webinar in the series is at 10 a.m. eastern, on Thursday, April 2. To register, visit supportivecarecoalition.org/, and click on the COVID-19 resource section at the very top of the page.
Because epidemiological models predict that the number of patients with severe cases of COVID-19 hold the potential to overwhelm hospitals and the health care system, facilities nationwide are grappling with questions around how to decide which patients will receive limited resources including intensive care unit beds, ventilators and clinician time in the event of a surge of critically ill patients. The panelists said the ministry's current work in this area is based on a foundation of preparation over nearly a decade.
Stuff, staff, space and systems
Panelist Dr. Gregg VandeKieft, medical director for palliative care for Providence St. Joseph Health's Southwest Region, said what systems and facilities currently are deliberating is the allocation of four items he referred to as stuff, staff, space and systems. They're determining how to deal with finite resources in a fair, equitable manner, he said.
He cited an article published in February 2010 in the Journal of Pain and Symptom Management that said that in the event of an overwhelming influenza pandemic, seriously ill patients who are denied critical care must have access to palliative care. The authors of "Palliating a pandemic, 'All patients must be cared for' presented a mathematical and ethical justification for having a palliative care surge plan in place.
Panelist Dr. Olumuyiwa Adeboye, medical director of palliative care for Ascension Wisconsin, said palliative care leaders in ministry systems and hospitals are helping refine long-standing policies and protocols related to resource allocation for the evolving situation. He said it is essential that palliative care leaders collaborate closely with colleagues, keep all departments aware of what resources palliative care teams can offer and how they can be reached, use technology innovatively and be careful not to overwhelm colleagues with information.
The panel, which included Nathaniel Blanton Hibner, CHA director of ethics; and MC Sullivan, chief healthcare ethicist for the Initiative on Palliative Care and Advance Care Planning for the Archdiocese of Boston, agreed that palliative care providers whose facilities are not yet in the midst of the COVID-19 patient surge should be grounding themselves in the details of COVID-19 policies and protocols once they have been honed.
Panelists said palliative care specialists should be educating their clinical colleagues so these clinicians can also administer palliative care to the sick and the dying because there are too few palliative care specialists to respond to a patient surge.
It also is important to raise public awareness about the importance of advance directives for health care, especially for people who are at higher risk of having serious or life-threatening complications from COVID-19. Panelists said clinicians should be preparing for difficult discussions that may need to have with patients and family members if resource allocation does become necessary. Palliative care experts expect that many of these heartbreaking conversations will take place over the phone with families because of hospital prohibitions against visitors.
Several panelists referenced a webinar from the Center to Advance Palliative Care, recorded March 18. "Palliative Care and the Impact of COVID-19" featured New York-based palliative care experts, Dr. Diane E. Meier and Dr. R. Sean Morrison, sharing practical advice and resources from one of the epicenters of the crisis. Meier directs the Center to Advance Palliative Care and Morrison co-directs the Patty and Jay Baker National Palliative Care Center and directs the National Palliative Care Research Center. Both hold endowed professorships at the Icahn School of Medicine at Mount Sinai. Their webinar is available at capc.org/events/recorded-webinars/palliative-care-and-impact-covid-19/. An open access resource toolkit on the center's website include symptom management protocols for patients with COVID-19.
Resource allocation
The panelists in the CHA/ Supportive Care webinar said data is emerging that suggests that patients with certain serious preexisting health concerns who are critically ill with COVID-19 may not benefit from therapeutic intervention. The panelists said if resources are scarce, comfort care rather than therapeutic intervention may be warranted for patients who are highly unlikely to benefit from extraordinary medical interventions.
These life-or-death decisions should be made on a case by case basis, relying on the structure of protocols and policies and input of treating physicians, said panelists.
Do not resuscitate orders
On March 27, CHA released a statement related to this issue. Sr. Mary Haddad, RSM, president and chief executive of CHA, said in the statement that, "COVID-19 is often deadly for patients with comorbid illnesses, and that even with supportive care that may include ventilators, many critically ill patients with COVID-19 will die due to conditions such as multiorgan failure, sepsis, and/or cardiomyopathy. As a result, cardiopulmonary resuscitation may be medically inappropriate for a significant portion of critically ill patients with COVID-19 and underlying comorbidities."
She said that while it is morally permissible under the Ethical and Religious Directives for Catholic Health Care Services to withhold CPR if the burdens outweigh the benefits, such decisions should be made on a case by case basis, in the context of a clinical decision-making model.
Referencing current public debate around the potentiality that hospitals may create universal do not resuscitate policies for COVID-19 patients, Sr. Mary said: "It is not morally appropriate to propose a universal, unilateral DNR on patients who have tested positive for COVID-19. This eliminates clinical decision making and erodes the patient-professional relationship."
In the webinar, Hibner said triage protocols used by ministry members in the pandemic will be based in long-standing protocols that incorporate principles of Catholic social teaching related to care of the vulnerable. Brian Kane, CHA senior director of ethics, told Catholic Health World that in this context, this means that protocols used in Catholic health care facilities can't disadvantage the disabled or the aged, or the poor who may have poorer health to begin with when it comes to allocating ventilators. Decisions must instead revolve around survivability.
Care in the time of scarcity
Sullivan said Catholic social teaching principles that are top of mind amid the pandemic include the dignity of the human person; the call to participate in family and community; the dignity of work; solidarity; and care of God's creation. She said throughout its history, Catholic health care has grounded its work in these principles, even in the midst of crisis.
Sullivan said that while the individual patient must always be at the center of each care decision, there is the added complexity now of weighing to perhaps a greater degree than in the past the other patients in the queue for care behind that person.
CHA and Supportive Care Coalition have resources on their websites related to the topics covered in the webinar. These include links to past webinars, sample policies and guidelines, and articles.
View the webinar