CARE: A Holistic Approach Toward Patients During Pandemic: Through the Eyes of a Palliative Physician

INTRODUCTION

All doctors are palliative care doctors now rightly quoted by the Washington Post.[1]

The world has seen many pandemics such as Spanish flu (1918–1919), Asian flu (1957–1958), Hong Kong flu (1968–1969), many influenza epidemics, and now, the coronavirus disease (COVID-19) pandemic which have caused severe health crisis leading to great amount of morbidity and morbidity worldwide. The role of palliative care is very crucial due to the uncertain nature of the disease and its devastating effects on health. The role of palliative care will be very crucial in providing symptomatic management and relieving the sufferings of the patients and their caregivers in maintaining their quality of life in the time of pandemic.[2]

THE CURRENT COVID-19 PANDEMIC

The world is in the grip of COVID-19, an infectious disease caused by the novel severe acute respiratory syndrome coronavirus 2 isolated from the respiratory tract of patients from Wuhan, China, and spreading to almost all the countries globally causing high morbidity and mortality.[3] The WHO identified it as a Public Health Emergency of International Concern on January 31, 2020, due to its ability of human-to-human transmission. Later on March 11, 2020, COVID-19 was declared a pandemic by the WHO. COVID-19 started in China has reached and spreading to almost all the countries globally causing high morbidity and mortality with a global mortality at 3.4% by the WHO.[4]

WHY DO WE NEED A HOLISTIC CARE PLAN?

For ages, medical profession has largely been relying on objective management of disease, which only includes care of the disease only. The same has been followed for pandemics also. In recent times, it has been evident that treating just the disease does not cure the patient in a whole.[5] Treating the disease provides relief just to the physical illness and leaves behind the more complex psychological, social, and spiritual concerns.[6] Quality of life of a patient depends on relief from physical symptoms as well as on his sound psychosocial and spiritual well-being. Therefore, a holistic treatment approach is the need of the hour for the complete care of patient.

Pandemics are state of uncertainty which, in turn, creates panic to the society. A sudden surge of cases during acute pandemics puts a huge onus to health-care system for smooth delivery of services. Strong apprehension about the disease makes people think about their illness as a causal link to the pandemic itself. In recent COVID pandemic it is observed that along with symptomatic cases, there are equal or even more number of asymptomatic cases.[7] Therefore, both symptomatic and asymptomatic cases need a comprehensive care plan to be managed, and this is the time we can introduce a holistic care approach.

MANAGING CONCERNS

CONTROL OF SYMPTOMS

Patients present with wide range of symptoms ranging from asymptomatic to critically ill and life-threatening symptoms. Management should begin with preventive measures, control of physical symptoms, and finally taking care of the psychological issues faced by these patients at the time of crisis.

Basic preventive measures as suggested by the WHO include: staying up with latest updates on pandemic, performing hand hygiene frequently with soap- or alcohol-based hand rubs, avoiding touching eyes, nose, and mouth, maintaining social distancing from individuals, and seeking medical care if symptoms arise.[9] This is very important to stop the transmission. By strictly following these principles, asymptomatic carriers may also limit the transmission.

ANTICIPATORY MEASURES

Due to the unpredictable and uncertain nature of the outcome of the disease, anticipatory measures are very critical. Proper counseling, communication, and prognostication are very much required. To involve in patients' future health-care decisions, patients' perspectives should also be well kept in mind.

Anticipating the outcomes in terms of disease trajectory, symptoms, and in patients with advanced chronic disease with comorbidities is useful for triage and proper allocation of resources available. For prevention and mild symptoms, home-based isolation remains the key. For a good and adequate home care facility, integration of home care plan into pandemic care plans is necessary. Anticipatory prescription for mild symptoms can be given such as acetaminophen for fever, cough syrup for cough, lots of fluids along with nonpharmacological home remedies, and breathing exercises. If symptoms persist or aggravates, patient can contact the physician on telephone (telemedicine) or can visit the nearest hospital.

Palliative care is required in terms of controlling symptoms and providing comfort in chronic illness and terminally ill patients who have been denied ICU based aggressive life saving therapies. This should justify the judicial use of resources and should be planned for those who benefit from intensive care and can be saved based on triage.

Prognostication through proper communication remains the key. Correct, honest, and empathetic communication facilitates realistic expectations about the treatment goals and allows the patient and family to express their care choices.[12] In these patients, advance directives and advance care planning are important as it documents the treatment preference according to his goal of care. These patients would not feel abandoned if palliative care is given when life-saving treatment is denied. Proper home-based care educating the caregivers in the care will remain the goal.

Anticipatory prescription in terms of pharmacological drugs for end of life and comfort must be given according to the symptoms expected. Psychological and spiritual care should also be given as to provide a complete holistic care to the critically ill. This, in turn, will relieve the stress and burnout of the health-care workers.[13]

REASSURANCE

Health-care professionals have little awareness of the important impact that their presence has in a reassuring patient and family and improving their confidence in caring.[14] Reassurance begins with correct knowledge of the disease, prognostication, and finally communicating the true goals of care plans. Reassurance whether by phone (telemedicine) or in person created a sense of caring by experts among the caregivers in early asymptomatic situation as well as end-of-life care situation. Reassurance results in greater confidence and better mindset to fight the infection which further decreases the psychological stress among the patients.

EMOTIONAL AND SPIRITUAL CARE

Emotional well-being is essential for physical well-being.[15] Pandemic, particularly a newly emerged disease, has always been a state of confusion to health-care system and to the society. Since there has been no established and formulated protocol for a new disease, it becomes a source of misconception and misinformation. These misconceptions and misinformation lead to the development of fear for the disease. Excessive fear can cause anxiety. Severe anxiety will hamper a person's day-to-day activities leading to the development of stress and, in worst cases, depression also. Thus, emotional well-being should be an essential aspect of treatment plan. Addressing emotional issues of patients helps a quicker recovery, longer survival, and better quality of life.[16] This will also decrease the stress and burnout among the caregivers and the treating health-care workers.

Spiritual care involves the care of a patient as a whole and not just treating the disease. Holistic care of physical, emotional, and social concerns makes a healthy spiritual impact on patient's lives.[6] Studies suggest that there is a complex and nonlinear relationship between spiritual health and quality of life, and this relationship is potentially influenced by emotional well-being of patient.[17] Therefore, emotional and spiritual care should be an essential part of treatment plan.

CONCLUSION

The uncertain and unpredictable nature of any pandemic makes the health-care system in a state of confusion regarding tackling and management of symptoms. A drift in the management perspective of health-care profession from objective toward subjective approach is essential and is the need of the hour for comprehensive well-being of patient as a whole. The CARE approach is an effort in guiding health-care workers for the complete care of the person.