Palliative care may require caution, creativity during COVID-19

NEW YORK (Reuters Health) - Although palliative care may be tough to provide during the pandemic, specialists are finding new ways to help their patients, according to a new report.

Patients with advanced cancer, in particular, may be more vulnerable to potential COVID-19 exposure, which requires a creative approach to palliative care, the authors write in JAMA Oncology.

“We care for patients’ minds, bodies and spirits. COVID-19, like other serious illnesses, impacts all of these,” said lead author Dr. Ambereen Mehta of UCLA Health in Los Angeles.

“However, our traditional ways of providing excellent palliative care weren’t possible with physical distancing,” she told Reuters Health by email. “At the same time, more people were asking for palliative-care services.”

Instead of spending time at the bedside and holding long in-person meetings with families, they needed a new option. Palliative-care doctors held national video calls to discuss their concerns. Initial studies showed that cancer patients had higher death rates from COVID-19, and they were unsure how often immunocompromised patients should continue chemotherapy and radiation treatments.

“We were all feeling stuck between having to choose between two possible deaths - the cancer or COVID-19,” Dr. Mehta said, adding that the new challenge made it “even more important to proactively discuss patients’ wishes about the risks and benefits of cancer-directed therapies and hospital admissions.”

In the article, Dr. Mehta and co-author Dr. Thomas Smith of Johns Hopkins Medicine’s Sidney Kimmel Comprehensive Cancer Center in Baltimore, Maryland, write about the three different types of patients who could be affected: cancer patients outside of hospitals, those inside hospitals who test positive for COVID-19 and those inside hospitals who test negative for COVID-19.

Telemedicine has become a main strategy for providing palliative care, they note, and new federal guidelines allow palliative-care professionals to write new and refill prescriptions for opioids through the telemedicine process. Video appointments also allow specialists to observe patients’ homes, which is typically unavailable in traditional in-office visits.

“Being present, validating emotions, responding to questions, and using communication tools should continue to be implemented for virtual visits,” they write.

Palliative-care professionals are also using telemedicine for hospitalized patients, including those who test positive and those who test negative for COVID-19, since personal protective equipment is limited and caregiver visits are restricted. Patients with COVID-19, in particular, may decline quickly, which gives little time for families to prepare and make decisions. At the same time, video allows them to have face-to-face communication and talk to several healthcare professionals in one call

“Patients with critical illness are dying alone, and families/caregivers are distressed as they grieve for their loved ones from a distance,” the authors write.

Another issue is physical presence. Palliative care specialists often provide emotional support through presence and touch, and although some of this can still be provided during telemedicine appointments, it can be difficult, the authors write.

“It can also worsen the digital divide when computer-savvy families can participate in telehealth while others can only manage a phone visit,” they say.

Ultimately, palliative-care professionals can reduce the healthcare burden on hospitals and hospices by providing support to patients, the authors write. They can also offer emotional support to frontline medical workers who are “equally afraid and overworked,” Drs. Mehta and Smith add. Nurses, chaplains, social workers and pharmacists need help and extra care, and palliative care specialists can step in to divide patient lists and assist where needed.

“All cancer patients, especially head- and neck-cancer patients, are particularly vulnerable during this time because they are at an increased risk of complications from COVID-19,” said Dr. Arun Sharma of the Southern Illinois University of School and Medicine in Springfield, Illinois. Sharma, who wasn’t involved with this paper, has written about the concerns that patients with head and neck cancers have during the COVID-19 pandemic.

“Palliative-care services are critical for cancer patients as they help balance patient and family wishes with symptom management and coordination of care,” he told Reuters Health by email.

SOURCE: JAMA Oncology, online May 7, 2020.