COVID

Question 1

Challenges to providing palliative care during a pandemic

Answer 1

1. Increased demand due to triage criteria and higher risk of death
2. Limited prognostication information
3. Limited support by the full interprofessional team for psych/social/spiritual needs due to isolation requirements
4. More limited health human resources due to care demands

Question 2

Framework for palliative care pandemic plan

Answer 2

1. Stuff
   - Stockpile comfort meds or symptom management kits, especially in LTCcommunity
   - Stockpile PPE for palliative care providers
   - Stockpile equipment (CADDs, syringe drivers, subcut lines)
2. Staff
   - Identify and mobilize all staff with palliative care experience
   - Brief education for front-line providers (emphasise safety of symptom targeted opioids)
   - Allied health for emotional/grief/bereavement support
3. Space
   - Optimise use of beds in hospice and PCUs, particularly via direct admits from ER or community
   - Separate wards, areas that could be used for palliative care for covid patients
4. Systems
   - Triage system to determine which patients need SPC and which can be seen virtually
   - Maximise virtual care (infection control and efficiency)
   - PPOs for acute, LTC, community settings
   - PC provider groups for coverage and support
5. Sedation
   - Palliative sedation for symptoms refractory to common comfort meds
6. Separation
   - Video calling to connect patients with family members in cases of travel/visitor restrictions
7. Communication
   - Ensure ACPs updated in patients with frailty or comorbidities
   - Before surge in patients, providers should have triage and treatment plans in place for patients with significant comorbidities request CPR/ICU/etc.
8. Equity
   - Be mindful of how a pandemic will exacerbate existing systemic inequity
   - If protocols for critical care triage are implemented, patients denied critical care should be top priority for palliative care.

Question 3

Contents of a symptom management it

Answer 3

1. HM 2mg/ml (pain or dyspnea)
2. Haldol 5mg/ml (nausea or agitation)
3. Midaz 5mg/ml (sedation)
4. Scopolamine 0.4mg/ml (secretions)
5. Tylenol Supps 650mg (fever)
6. Foley 16 French (urinary retention)
7. Mouth swabs (dry mouth)

Question 4

What non-specialist PC clinicians can support in a pandemic

Answer 4

1. Identification and management of pain, dyspnea, agitated delirium, respiratory congestion
2. Management of caregiver grief
3. Discussions about prognosis, goals of care, suffering, and resuscitation status

Question 5

What special PCs can support in a pandemic

Answer 5

1. Patients with refractory/complex symptoms
2. Patients denied access to critical care due to triage protocol, despite wanting access
3. management of complex depression, anxiety, grief, and existential distress
4. Requirement for palliative sedation therapy
5. Pre-existing opioid use disorder
6. Parents with young children
7. Patients belonging to marginalized populations (homeless, incarcerated, indigenous) at risk of being underserved