Experience of Palliative Care Services at Tertiary Comprehensive Cancer Center during COVID-19 Lockdown Phase: An Analytical Original Study

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has brought the world to the standstill with even developed countries finding it difficult to cope with the limited health resources. In India, the pandemic entered in January 2020. Little we knew that this unknown virus will lead to a total shutdown of the country with a population 1.3 billion, immensely affecting the whole community emotionally and financially.

During this lockdown, to manage health-care resources effectively, decisions to reschedule nonurgent outpatient visits, nonurgent elective surgeries, and elective procedures were taken globally.[12]

Our institute, despite being one of the biggest state cancer centers in Western India, also has to partially stop its elective treatment. Out of two hospital buildings, one is converted to a dedicated COVID-19 hospitals, and half of the workforce has been mobilized there. Due to this, collateral damage was done to oncology patients who were about to start their treatment or were undergoing some kind of treatment.

Lockdown, social distancing and need to manage symptoms of patients, and continuous supply of opioids in the current situation are some of the major issues we faced as pain and palliative care physicians.

Despite all these hurdles, we were able to provide symptom relief to our patients by various means such as teleconsultation and telephonic conversations with the patients along with hospital-based palliative care service.

In this analysis, we aim to analyze our data of outpatients, inpatients, emergency, and teleconsultations provided to palliative care patients. Apart from studying demographics, diagnosis, and opioid utilization, we also analyzed the precautions we took to prevent the transmission of COVID-19 and safeguard the health of our doctors, staff, and the patients.

There are lots of references[34] regarding palliative care to the COVID-19 patients, but we could find very few references[56] regarding essential palliative care services to oncology patients.

We intend to set certain guiding principles for the “Total Care” of palliative oncology patients in this era of pandemic, so that the dual purpose of alleviating sufferings, timely intervention along with the protection of our staff can be achieved maximally.

MATERIALS AND METHODS

This study was conducted in the department of pain and palliative medicine, tertiary comprehensive cancer center of Gujarat. All patients availing pain and palliative care service along with teleconsultation during the lockdown period from March 23, 2020, to May 3, 2020, were analyzed. After institutional review board permission, electronic medical records were used to retrieve data for demographic locations, extent of travel, types of cancer, and opioid utilization.

RESULTS

Total patients treated by pain and palliative care team were 1161 [Table 1]. Male and female distribution ratio was 780:381 [Table 1]. Of these 1161 patients, 36 patients were pediatric patients, and the youngest patient was 1-year-old. Ten patients were attended in the emergency room. Twelve patients required hospital admission for their symptoms control [Table 1].

Maximum patients were from Ahmadabad (50.0%) followed by who traveled from other cities of Gujarat (28.3%). During this lockdown period, 251 patients (21.6%) were from other states. Of these, patients or caregivers were mostly traveled from Rajasthan – 77 (6.60%) followed by Uttar Pradesh – 74 (6.30%) and Madhya Pradesh – 70 (6.02%) [Figure 1]. Few patients, who were present in the city for their oncology treatment, were stuck due to lockdown.

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Figure 1

Area-wise distribution of patients visiting palliative medicine outpatient department

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Number of patients suffering from head-and-neck cancer were maximum (48.7%) followed by gastrointestinal and hepatobiliary (13.0%), breast (8.1%), lung (7.7%), gynecological malignancy (6.4%), bone cancer (4.8%), hematological malignancy (4.4%), urology (3.7%), and brain tumor (2.9%) [Figure 2].

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Figure 2

Diagnosis-wise distribution of patients visiting palliative medicine outpatient department

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Out of 1161 patients, 398 (34.2%) patients were prescribed as essential narcotics. Of these 398, most of the patients were prescribed morphine (95%) and fentanyl patch (4.5%), and only two patients (0.5%) were prescribed methadone [Table 2].

DISCUSSION

India's first case was reported on January 30^th in Kerala.[7] On the 1^st day of lockdown 3.0, the figure increased enormously to ≥40,000.[8] During this lockdown, providing essential services to palliative oncology patients became exceedingly difficult. Despite these restrictions and with all the emphasis on COVID-19 patients, we were able to provide essential palliative care to 1161 patients through various means.

Many of these patients traveled far from other states. We found that people traveled to our center from as far as Karnataka and Odisha. Arranging the permission and vehicle to travel so far was a tedious, risky, and financially draining for the patient. These not only had increased risk to the patient owing to their immunocompromised state but also the accompanying person.

Most patients attending the outpatient department (OPD) were mostly suffering from head-and-neck cancer, as this is the most common malignancy we come across our state.[9]

The availability of opioids is not so widespread in India due to certain regulations.[10] Many patients traveled from far off distance due to the nonavailability of opioids in nearby centers.

However, still the fact is because of pandemic, we cannot overlook the need for oncology patients who are in severe distress. Hence, it becomes essential to prioritize the management of the patient as per the severity of the symptom.[6] As ESMO guideline,[6] priority of admission was given to patients suffering from severe distress such as intractable nausea/vomiting, refractory pain, or maggots infestation.

Patients were provided with an adequate supply of drugs, thus avoiding their need to travel frequently.[1] Telephonic consultation was provided for minor symptoms through our dedicated helpline number. Patients were also encouraged for telemedicine consultation.[111] We coordinated their regular supply of opioids from their nearby regional palliative care centers.[1213]

Due precautions were taken during OPD consultation, emergency consultation, and inpatient rounds to avoid virus transmission.[14] Training related to infection control, sanitization, Personal Protective Equipment (PPE) Kit, and the management of COVID-19 patients was made mandatory for all staff and doctors. This training was provided by the iGot.[15] Initial screening was done at the hospital building entrance. Patients were allowed inside the OPD with masks and were made to sit at a distance of 6 ft. Only one patient was allowed inside the room at a time to maintain the social distance. We could do this because of one-third workload of routine OPD. Washing of hands or the use of sanitizer was done every time after the consultation.[14]

Patients with severe symptoms who visited emergency were treated by taking proper universal precaution using PPE kit.[14]

We also emphasize on the “Total Care” of our staff by actively listening, supporting, and monitoring them.[1] By following the guidelines issued by the Government of India,[1415] we were not only able to treat the patients requiring palliative care services but also were successful in safeguarding our doctors and staff from unscrupulous exposure to the coronavirus.

CONCLUSION

By presenting this data, we want to emphasize that as this pandemic evolves over time, the need for continued palliative services for patients suffering from a life-limiting illness should not be under evaluated. Practical steps can be taken to ensure access to drugs (such as opioids) and protective equipment. We need to continue providing our services with proper precautions and consider greater use of telemedicine. We should collaborate with other regional centers across India so that the need for patients to travel for opioid prescriptions can be minimized. In this way, we can give requisite care to our patients and prevent cross infection by providing proper training and preparation across the health workforce.