COVID 19: The New Normal in the Clinic: Overcoming Challenges in Palliative Care

INTRODUCTION

Cancer patients are the most vulnerable group to COVID-19 infection.[1] Since the outbreak of novel coronavirus, the world has come to a standstill. The lockdown which was implemented from March 22, 2020, brought enormous changes not only in the way of life but also in treatment preferences in hospitals in India. This led to a setback to the treatment plans for cancer patients.[2] The cessation of chemotherapy sessions, radiotherapy sessions, cancellation of surgical plans, and limited access to pain management and palliative care, all were jeopardizing. The World Health Organisation (WHO) had issued guidelines on how to maintain essential health services during the pandemic, highlighting maternal care, emergency care, immunization, and chronic diseases among others, but there was no mention of palliative care.[3]

Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, is one of the biggest central government-run tertiary care hospitals. With the COVID-19 outbreak, all elective surgical cases and outpatient clinics were curtailed to divert the workforce toward the newly opened COVID intensive care unit and wards, with only functional emergency services.

After taking hospital administration into an agreement regarding palliative care as essential services, we continued to provide outpatient as well as inpatient services for the maximum benefit of patients.

With the expectation of COVID19 staying for long and suggestion of opening restrictions by govt authorities,[4] it is high time that we need to find solutions to live with the pandemic. This article describes our experiences and challenges regarding providing hospital-based palliative care with suggestions for the vision of future palliative pain clinic.

MATERIALS AND METHODS

An observational study was conducted in the pain and palliative care unit under the umbrella of the Department of Anesthesia and Intensive Care at VMMC and Safdarjung Hospital, New Delhi. The data was collected from March 23, 2020, to May 22, 2020, of all patients coming to pain and palliative care clinic and bedside pain management referrals. The WHO step ladder is being used in cancer pain management.[5] We have been following the Ministry of Health and Family Welfare, WHO, and Indian Society of Anesthesiologist[6] guidelines for running OPD, written for pain and palliative care clinic.

RESULTS

The data was analyzed using Microsoft Excel. The total number of patients who visited the pain and palliative clinic was 108. The observed male:female ratio was 65:43 [Figure 1]. The median age was 43.94 years with a range of 6 years to 76 years. Eighty-four patients belonged to Delhi, and the others were from Uttar Pradesh, Haryana, and Bihar [Figure 2].

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Figure 1

Sex distribution among all patients

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Figure 2

Statewise demographic distribution

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There were 33 new cases and 75 old registered cases [Figure 3]. They were mainly referred from the medical oncology, Radiation oncology, and the ear, nose, and throat department. Some cases were referred from other departments such as cancer surgery, hematology, plastic surgery, orthopedics, respiratory medicine, and casualty.

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Figure 3

Total registrated cases

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About 37% of the patients with head-and-neck diagnosis made the major load coming to the clinic with chief complaints of pain, oral thrush, wounds, and maggots [Figure 4].

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Figure 4

Distribution of patients according to the diagnosis

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Seventeen patients came to the clinic with a visual analog scale of >8. The reasons for acute pain include new-onset pain, noncompliance of drugs, the opioid stock finished with the patient.

We saw a very high number of patients requiring strong and weak opioids [Figure 5]. Fifty-four patients were requiring Morphine with 30 mg and 60 mg as maximum daily morphine requirement [Figure 6]. Some of the patients were put on morphine by the primary team and were referred to us for dose escalation and optimization.

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Figure 5

Patient distribution by the World Health Organization step ladder for cancer pain management

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Figure 6

Distribution as per the daily morphine requirement

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DISCUSSION

During COVID-19 pandemic, there are many reasons for psychological burdens not only for the patient but also for the physician. There are multiple reasons including uncertainty of future, anticipation of infection, social distancing leading to social isolation and loss of mental support. Also financial problems and difficulty in commuting due to lockdown add to their burden.

However, in spite of the total lockdown, we saw a footfall of 108 patients which was one-fourth of the census of the previous 2 months but still significant. The number of male patients was more as compared to females. The difference in the age of patients coming to the pain clinic was wide, i.e., 6 years to 76 years with a median age of 43.94 years. Although the recommendation in COVID 19 times suggests avoiding travel of children below 10 years and adults above 65 years, still, we saw their attendance in our clinic. The main reason for their visits includes new-onset pain, need for change in the treatment plan and finished opioid stock.

The movement in Delhi was difficult and it was even more difficult to cross state borders which were under heavy security with restrictions. We saw 84 patients belonging to Delhi, and the rest were from other states like Uttar Pradesh, Haryana, and Bihar. The patients from outside Delhi were staying with their relatives or staying in hospital premises. The cost of traveling intrastate becomes very high. We offered financial help to the patients, kits for personal hygiene, and dressing material.

The challenge was to run clinic simultaneously protecting patients as well as staff during this time.

Personal protective equipment (PPE) comprising N95 mask, glasses/face shield, and gloves was worn by staff sitting in the OPD [Figure 7], and PPE kit was worn when visiting a patient in the ward [Figure 8].

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Figure 7

Palliative clinic use of personal protective equipment

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Figure 8

Use of personal protective equipment kit

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Personal and environmental sanitization was done regularly. Patients were checked for temperature by a noncontact thermometer, and hands were sanitized before entering the clinic; the mask was mandatory for patients and accompanying person. Social distancing was ascertained by limiting the staff by posting one doctor and nurse for a day. The patient was made to sit on a stool 1 m away with an artificial barrier placed in between patient stool and doctor table [Figure 9]. The patient stool was tied to the nearby furniture to maintain the gap. None of the patients and staff visiting the clinic during these times fell sick.

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Figure 9

Social distancing

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Lessons learned:

• This new way of patient management is now a part of the new curriculum, i.e., to live with the virus

• The agony of pain and suffering of these patients brought them to the hospitals, which is very much evident by the requirement of opioids

• We had made a provisional change regarding dispensing drugs for a longer duration with vigilance

• Proper personal protection and social distancing can prevent coronavirus infection

• Learning proper donning and doffing with a buddy

• Rational use of PPE kit

• Medical staff were compliant in following protection and social distancing

• Patients and their relatives initially found wearing the mask difficult, although a constant reminder in the form of posters, instructions, and providing them with face mask and small hand sanitizer helped us in enforcing these manners

• Implementation of government policy regarding providing palliative care at primary health care is still deficient. This leads to a need for traveling across states just for pain management. Creating a telephonic network among the palliative care physicians helps in referring patient and information exchange

• Communication skill is an art behind those mask and glasses. The use of eye contact, expressions, pitch of voice and hand gestures should be emphasized.

CONCLUSION

We share our experience and challenges of providing palliative care in our clinic which can be modified as per the individual requirements in other setups. Our articles also emphasize the future vision for palliative care clinics in this COVID-19 pandemic with the need for more further studies and widespread implementation.