Providing Palliative Home Care during COVID-19 Pandemic Lockdown in India

INTRODUCTION

The severe acute respiratory syndrome coronavirus 2 or coronavirus disease 2019 (COVID 2019)[1] was first reported from Wuhan, China, in late December 2019[2] and declared a pandemic by the World Health Organization on March 11, 2020. In India, the first patient was diagnosed on January 30, 2020, and with gradually increasing numbers in March, the Indian government imposed a strict countrywide lockdown on March 23, 2020, which continued till May 3, 2020. During this period, only essential services were allowed, and in hospitals, only emergency services were operating. There was no public transport, so for patients without their own vehicles, even reaching hospitals was difficult.

CanSupport, a nongovernmental organization providing palliative home care to more than 2500 cancer patients in the Delhi-NCR region through 27 palliative care teams, aimed to continue providing essential palliative home care services during the lockdown. For safety of patients as well as home care staff, majority of home visits were replaced with phone and video consultations. This had already been started in the 2^nd week of March after COVID-19 patients started increasing in India, and early research from China indicated that cancer patients were more likely to have poor outcomes if infected with COVID-19.[13] With the imposition of lockdown and spread of COVID-19 infection, home visits were further curtailed.

METHODS

Not all patients could be managed through teleconsultations, so some criteria or guidelines were needed in order to help decide which patients needed to be visited. Due to the absence of public transport and closure of hospital outpatient services, free medicines and minor procedures were unavailable to the majority of our patients who were from the low-income group. Many of these patients and their families also suffered loss of income due to the lockdown. In addition, strong opioids were not available at most pharmacies. Considering these issues, patient visits were decided according to the following criteria:

1. Need of morphine or other medicines for symptom control

2. Need of procedure, e.g., ascitic tap, catheter change, NG tube insertion, tracheostomy tube replacement, and large fungating wound dressing

3. New patient with multiple problems – severe pain, foul-smelling discharging wound, pressure sores, etc.

4. Patients in the last days of life with uncontrolled symptoms of pain, breathlessness, or delirium

5. Any patient with severe pain (Numeric Rating Scale >7 / 10) or other symptoms not managed through teleconsultation.

All patients registered with the organization were followed up by the home care teams through regular phone/video consultations and could call in for any problems, as was the practice earlier. However, they were visited only if their needs fulfilled the given criteria.

During home visits, safety of both staff and patients was a concern. Therefore, the day before a visit was planned, patients and caregivers were asked about a recent history of fever and respiratory symptoms in the family, any family member with a history of international travel, or any contact with a diagnosed patient of COVID-19.[4] Patients with a positive history were asked to contact the COVID helpline. All staff wore personal protective equipment, masks, gowns, and gloves during visits. When the purpose of the visit was to supply morphine or other medicines, these were handed over to the caregiver outside the patient's home, so there was no direct contact with the patient.

RESULTS

During the 6 weeks from March 23 to May 3, 2020, 845 home visits were done. Fifty-six percent (474) of visits were to done supply morphine and/or medicines. Supplies were given for 2–4 weeks to avoid frequent visits. One hundred and nine new patients were visited. All new patients were first interviewed through teleconsultation and were visited only if they had multiple complaints which could not be resolved through phone or video calls.

One hundred and seven procedures were done, the most frequent of which were fungating wound dressings (for fifty-three patients i.e. 50%) followed by urinary catheterizations (for twenty-eight patients i.e. 26%). Pain was the main symptom requiring a visit, and 121 patients were visited. Forty patients in the terminal phase of life were visited because of uncontrolled pain, delirium, or breathlessness.

Less than five patients had any positive history requiring referral to the COVID helpline, but in the later weeks of the lockdown, a number of patients were living in quarantined areas. There was no direct contact with these patients, but their morphine and medicine supplies were delivered to them through their caregivers.

DISCUSSION

The criteria made to decide on home visits were based on the immediate needs of patients created by the lockdown and helped concentrate limited services to those with the greatest need. As the lockdown is partially relaxed, hospital services resume, and home visits increase, the visit criteria will be revised again.

CONCLUSION

The extraordinary circumstances created by the pandemic and the lockdown have at present changed the way we provide palliative home care at CanSupport. Some changes such as improved teleconsultation techniques may be used in long run to help those in remote areas. However, it is possible to safely make home visits for those patients at the end of life who need the actual presence of a home care team for the best possible care.