Palliative care and COVID-19 in the Australian context: a review of patients with COVID-19 referred to palliative care
Ruwani Mendis A B F , Anita Haines A , Loretta Williams A , Kirsten Mitchener A , Fiona Grimaldi A , Marianne Phillips A , Margaret Shaw A C , Thy Pham Hoai Nguyen A D , Adrian Dabscheck A , Odette Spruijt A E and Maria Coperchini AA Western Health, 176 Furlong Road, St Albans, Melbourne, Vic. 3021, Australia.
B Department of Medicine, Western Health, The University of Melbourne, 176 Furlong Road, St. Albans, Vic. 3021, Australia.
C Mercy Palliative Care, 3 Devonshire Road, Sunshine, Vic. 3020, Australia.
D School of BioSciences, The University of Melbourne, Melbourne, Vic., Australia.
E Faculty of Medicine, Dentistry and Health, The University of Melbourne, Melbourne, Vic., Australia.
F Corresponding author. Email: ruwani.mendis@wh.org.au
Australian Health Review 45(6) 667-674 https://doi.org/10.1071/AH21157
Submitted: 3 May 2021 Accepted: 7 June 2021 Published: 27 August 2021
Journal Compilation © AHHA 2021 Open Access CC BY
Abstract
Objective Palliative care has played a key role in the response to the coronavirus disease 2019 (COVID-19) pandemic in Australia. This review of consecutive patients with COVID-19 referred to the palliative care consultancy service of a tertiary health service in Melbourne describes the palliative care experience with COVID-19 in Australia.
Methods The experiences of 55 patients (median age 86 years; interquartile range (IQR) 81–90 years; 55% male; median Charlson comorbidity score 6 (IQR 5–8); 85% with Australia-modified Karnofsky Performance Status ≤50; 67% from residential aged care facilities) were reviewed to collect relevant data points.
Results Most patients were referred for end-of-life care with symptoms including dyspnoea (80%) and agitation/delirium (60%). Continuous subcutaneous infusions were commenced in 71% of patients, with the most frequent medications being opioids and benzodiazepines in relatively small doses; 81% required ≤20 mg subcutaneous morphine equivalent and 64% required ≤10 mg subcutaneous midazolam over 24 h. Fifty patients (91%) died in hospital and the median time from palliative care referral to death was 3 days (IQR 1–5 days). Five patients were discharged back to residential aged care facilities. Overall, 80% of referrals were from the aged care team.
Conclusion Our patients had similar demographics, symptoms, medication needs and outcomes to patients in similar settings overseas. We found the symptom management of patients with COVID-19 to be generally straightforward. However, the psychosocial needs of patients were predominant and contributed to complexity. This study highlights the need for well-integrated relationships between the palliative care consultancy service and the diverse range of key treating teams involved in the delivery of pandemic health care.
What is known about the topic? Palliative care has played a key role in the response to the COVID-19 pandemic in Australia. There is limited research describing the Australian palliative care experience with the COVID-19 pandemic.
What does this paper add? Patients with COVID-19 referred to a hospital-based palliative care consultancy service in Australia had similar demographic characteristics, symptoms, medication needs and outcomes to patients with COVID-19 referred to other palliative care services in the UK and the US. There were significant psychosocial issues affecting patients, families and staff in the context of the pandemic.
What are the implications for practitioners? This study highlights the need for well-functioning working relationships between the palliative care consultancy service and other hospital teams that can be leveraged at a time of crisis, such as a pandemic, to provide optimal palliative care to patients.
Keywords: COVID-19, Australia, palliative care services, end-of-life, health systems, psychosocial support, pandemic, health funding and financing.
References
[1] Department of Health and Human Services, Victoria State Government. Coronavirus update for Victoria – 30 November 2020 [media release]. Available at https://www.dhhs.vic.gov.au/coronavirus-update-victoria-30-november-2020[2] Butt C. Ten graphs that show the rise and fall of Victoria’s COVID-19 second wave. The Age, 27 October 2020. Available at https://www.theage.com.au/national/victoria/ten-graphs-that-show-the-rise-and-fall-of-victoria-s-covid-19-second-wave-20201027-p5694b.html
[3] Lovell N, Maddocks M, Etkind SN, Taylor K, Carey I, Vora V, et al Characteristics, symptom management, and outcomes of 101 patients with COVID-19 referred for hospital palliative care. J Pain Symptom Manage 2020; 60 e77–81.
| Characteristics, symptom management, and outcomes of 101 patients with COVID-19 referred for hospital palliative care.Crossref | GoogleScholarGoogle Scholar | 32325167PubMed |
[4] Heath L, Yates S, Carey M, Miller M. Palliative care during COVID-19: data and visits from loved ones. Am J Hosp Palliat Care 2020; 37 988–91.
| Palliative care during COVID-19: data and visits from loved ones.Crossref | GoogleScholarGoogle Scholar | 32705889PubMed |
[5] Jackson T, Hobson K, Clare H, Weegmann D, Moloughney C, McManus S. End-of-life care in COVID-19: an audit of pharmacological management in hospital inpatients. Palliat Med 2020; 34 1235–40.
| End-of-life care in COVID-19: an audit of pharmacological management in hospital inpatients.Crossref | GoogleScholarGoogle Scholar | 32588748PubMed |
[6] Obata R, Maeda T, Rizk D, Kuno T. Palliative care team involvement in patients with COVID-19 in New York City. Am J Hosp Palliat Care 2020; 37 869–72.
| Palliative care team involvement in patients with COVID-19 in New York City.Crossref | GoogleScholarGoogle Scholar | 32638632PubMed |
[7] Hetherington L, Johnston B, Kotronoulas G, Finlay F, Keeley P, McKeown A. COVID-19 and hospital palliative care – a service evaluation exploring the symptoms and outcomes of 186 patients and the impact of the pandemic on specialist hospital palliative care. Palliat Med 2020; 34 1256–62.
| COVID-19 and hospital palliative care – a service evaluation exploring the symptoms and outcomes of 186 patients and the impact of the pandemic on specialist hospital palliative care.Crossref | GoogleScholarGoogle Scholar | 32794435PubMed |
[8] Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42 377–81.
| Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support.Crossref | GoogleScholarGoogle Scholar | 18929686PubMed |
[9] Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 373–83.
| A new method of classifying prognostic comorbidity in longitudinal studies: development and validation.Crossref | GoogleScholarGoogle Scholar | 3558716PubMed |
[10] Abernethy AP, Shelby-James T, Fazekas BS, Woods D, Currow DC. The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481]. BMC Palliat Care 2005; 4 7
| The Australia-modified Karnofsky Performance Status (AKPS) scale: a revised scale for contemporary palliative care clinical practice [ISRCTN81117481].Crossref | GoogleScholarGoogle Scholar | 16283937PubMed |
[11] Australian Institute of Health and Welfare. Palliative care services in Australia. 2021. Available at https://www.aihw.gov.au/reports/palliative-care-services/palliative-care-services-in-australia/contents/palliative-care-outcomes/palliative-care-phases
[12] Turner J, Eliot Hodgson L, Leckie T, Eade L, Ford-Dunn S. A dual-center observational review of hospital-based palliative care in patients dying with COVID-19. J Pain Symptom Manage 2020; 60 e75–8.
| A dual-center observational review of hospital-based palliative care in patients dying with COVID-19.Crossref | GoogleScholarGoogle Scholar | 32387139PubMed |
[13] Healthcare Improvement Scotland, National Health Service Scotland. End of life care guidance when a person is imminently dying from COVID-19 lung disease. 2020. Available at https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/end-of-life-care-guidance-when-a-person-is-imminently-dying-from-covid-19-lung-disease.aspx
[14] Association for Palliative Medicine of Great Britain and Ireland. COVID-19 and palliative, end of life and bereavement care in secondary care: role of the specialty and guidance to aid care – version 4, 20 April 2020. Available at https://apmonline.org/wp-content/uploads/2020/04/COVID-19-and-Palliative-End-of-Life-and-Bereavement-Care-20-April-2020-2.pdf
[15] Alderman B, Webber K, Davies A. An audit of end-of-life symptom control in patients with corona virus disease 2019 (COVID-19) dying in a hospital in the United Kingdom. Palliat Med 2020; 34 1249–55.
| An audit of end-of-life symptom control in patients with corona virus disease 2019 (COVID-19) dying in a hospital in the United Kingdom.Crossref | GoogleScholarGoogle Scholar | 32736493PubMed |
[16] Dubey S, Biswas P, Ghosh R, Chatterjee S, Dubey MJ, Chatterjee S, et al Psychosocial impact of COVID-19. Diabetes Metab Syndr 2020; 14 779–88.
| Psychosocial impact of COVID-19.Crossref | GoogleScholarGoogle Scholar | 32526627PubMed |
[17] Mheidly N, Fares MY, Zalzale H, Fares J. Effect of face masks on interpersonal communication during the COVID-19 pandemic. Front Public Health 2020; 8 582191
| Effect of face masks on interpersonal communication during the COVID-19 pandemic.Crossref | GoogleScholarGoogle Scholar | 33363081PubMed |
[18] Mayland CR, Harding AJE, Preston N, Payne S. Supporting adults bereaved through COVID-19: a rapid review of the impact of previous pandemics on grief and bereavement. J Pain Symptom Manage 2020; 60 e33–9.
| Supporting adults bereaved through COVID-19: a rapid review of the impact of previous pandemics on grief and bereavement.Crossref | GoogleScholarGoogle Scholar | 32416233PubMed |
[19] Hwang TJ, Rabheru K, Peisah C, Reichman W, Ikeda M. Loneliness and social isolation during the COVID-19 pandemic. Int Psychogeriatr 2020; 32 1217–20.
| Loneliness and social isolation during the COVID-19 pandemic.Crossref | GoogleScholarGoogle Scholar | 32450943PubMed |
[20] Smith BJ, Lim MH. How the COVID-19 pandemic is focusing attention on loneliness and social isolation. Public Health Res Pract 2020; 30 3022008
| How the COVID-19 pandemic is focusing attention on loneliness and social isolation.Crossref | GoogleScholarGoogle Scholar | 32601651PubMed |
[21] Australian Centre for Grief and Bereavement. Australian Government appoints Australian Centre for Grief and Bereavement to deliver COVID-19 bereavement support services [media release]. 2020. Available at https://www.grief.org.au/ACGB/ACGB/About_ACGB/News/News/Media_Release_-_Australian_Government_appoints_Australian_Centre_for_Grief_and_Bereavement_to_delive.aspx
[22] Marie Curie. Grief during coronavirus. 2021. Available at https://www.mariecurie.org.uk/help/support/coronavirus/grief-coronavirus
