COVID-19 Pandemic Prompts Changes to Pain and Palliative Care at Home

Sir,

In the coronavirus infectious disease (COVID-19) pandemic, palliative care is a great challenge for the elderly and terminally ill patients in hospital settings. As we all are aware that at the present scenario, the entire population is at risk from infection with SARS-CoV-2, older people suffering from multiple diseases – are always at high risk. Experience from Italy shows that the average age of death is 79 years for men and 82 years for women.[1] The Association for Geriatric Palliative Medicine (FGPG) promotes the integration of palliative care approach and skills into the care of elderly and very elderly people – both in the inpatient setting and at home. The current pandemic and the publication of the SAMS guidelines “COVID-19 pandemic: triage for intensive-care treatment under resource scarcity”[2] have prompted the FGPG to prepare these recommendations for practice. In view of the current COVID-19 pandemic in India, it will be more fruitful if the care of palliative patient is done under the following three categories.

CATEGORY 1 ADVANCE CARE PLANNING IN THE ELDERLY AND TERMINALLY Ill PATIENTS

The basic purpose of advance care planning (ACP) in the COVID-19 setting is to escape undesirable hospitalizations and intensive care treatment. There are high chances of infections of COVID-19 for the elderly and terminally ill patients because they are immunocompromised. If we avoid unwanted hospital treatment, there is less burden on health-care workers. The experience of intensive care specialists also says that mortality is very high in this group of patients in spite of hospitalization and intensive care treatment, and there are rare chances of survival in mechanically ventilated patients with acute respiratory distress syndrome.

Considering this reason, the hospital admission of the elderly and terminally ill patients needs utmost precautions. Most people would prefer to die in their familiar atmosphere rather not to die in the intensive care unit. Therefore, ACP plays an important role, before or at the latest stage when the infection is diagnosed.

An open and proper communication to the patient and his/her relatives should be made about the important aspects of palliative treatment and care and the corresponding monetary burden. A comprehensible, repeated, and step-wise explanation enables the patient to develop realistic expectations, to express his/her own wishes, and to make decisions.[3] After evaluation if palliative care is required, then it has to be decided whether this should take place in a hospital, nursing home or home care setting. This will not only depend upon patients' symptoms, their additional care needs but also on their and family's wishes. According to their decision, plan of treatment shall be prepared.

CATEGORY 2 PAIN MANAGEMENT VIA E-HEALTH

Pain is among the frequently occurring and most feared symptoms in patients with advanced cancer. E-health communication technologies are very useful in the current situation (COVID-19). It is advantageous of E-health system for physicians to talk to their patients about health information. By this method doctor and patient can communicate properly. The application of online palliative care training systems is very much helpful to health-care providers and patients to develop communication for effective pain management. Whatever information the patients have gathered from Internet can be discussed with the healthcare providers and can be implemented accordingly.[4]

CATEGORY 3 HOME CARE AND SUPPORT

If the patients and their relatives wish to take care at home, then patients are cared for at home and the necessary support should be provided by nursing professionals and, if feasible, by mobile palliative care (MPC) teams. In addition, advice for care may be given telephonically and videoconferencing, if possible. If required, MPC teams should also be called into residential and nursing homes to ensure optimal treatment based on the geographical location. In spite of any ban on visits to care homes, relatives must be offered the chance to be with the patient and say good- bye, while complying with protective measures. They should also receive appropriate support.