The world is experiencing insurmountable illness related to COVID-19. The virus originated in Asia and spread through surrounding countries and eventually presented here in the United States. This illness has taken the lives of so many of our frail/elderly and those with underlying health conditions (cardiac conditions, COPD, cancer, etc.). As the virus continues to spread, hospitals are beginning to feel the pressure of surge, with an overflow of patients. In most states, hospitals are preparing for this overflow by setting up field hospitals, however, at the end of the day, it has been determined that physicians, nurses and other healthcare professionals are having to choose who has the best chance of recovery if provided with life-saving procedures. In Italy, for example, patients presenting with more than five co-morbidities are provided with comfort care and healthcare workers are being forced to make life-sustaining decisions with little or no experience working through the process with the patients and/or family.  

Many facilities in self-quarantine are being told that if the virus does enter the facility local hospitals do not have the capacity to take on their residents. This leaves the staff feeling uneasy and may create a little panic at the facility level. Most centers have implemented a screening process for those entering the center and this has assisted in decreasing the risk of spreading the virus. Utilizing PPE equipment is another option however availability of these supplies may be limited and there is still a chance the virus will spread. Are you prepared to handle these situations? Is your staff ready to take on caring for those individuals that may not survive the virus?

Palliative care is a sensitive topic especially when a few weeks ago our residents hadn’t considered it as a needed service. However it is important to remember, Palliative Care is a recommended care process designed to assist residents and families during the dying process. Residents may be denied access to critical care however still deserve high-quality care. Our responsibility is to ensure caregivers trained to provide support, comfort, and resources are available to assist these residents.

So how do we prepare for a surge? Consider stocking up on comfort packs and other medications that are administered at end-of-life. This will ensure that you have appropriate supplies on hand for residents if needed. It is also strongly recommended that residents’ advanced care plan be in place and reviewed/updated as needed. Consider utilizing Telehealth in lieu of transporting residents out into the community for appointments. Virtual visits are being implemented for Palliative Care as well in an effort to decrease the spread of the virus. If palliative care staff/hospice are providing services onsite, require that facility screening protocols are followed, provide them with appropriate PPE equipment and limit the staff from leaving the room except to obtain essential care items.

What happens when that trained Palliative Care worker becomes ill? Is your team equipped and ready to provide care to the resident in their absence? They should be, remember end of life care is designed to be an interdisciplinary process where several different disciplines are involved; physicians, nurses, social worker, and spiritual care worker. Your staff should be prepared to step in and assist in these areas and even though they may not have the experience of the trained Palliative Care team, they can communicate via video chat and be guided on alleviating pain/discomfort, etc. They can also be a support system for residents; maintaining family communication, providing care and support when family is not able to be with them and assisting residents in feeling less isolated. If a resident is positive with the virus, they are isolated, confined to their room/apartment. Having a care team member available to stay with the resident until family arrives is part of Palliative Care. The resident may not be able to voice their fears, pain, etc., so staff need to be alert to unspoken communication/signs of pain. Medications should be available to assist staff in following physician orders and guidance from the Palliative Care team.

When a resident is in the dying process, we should validate their feelings as they relive regrets they have from their lives, confess their faults, express their fears, etc. The interdisciplinary care team should be there with open arms and a loving touch to ease the resident’s transition. Remember, the resident may have had a plan in place, the people they wanted to have close to them, things they wanted around them, music played in the background, scriptures read, etc. and now they are facing the end-of-life alone. Prepare your team so that they assist the resident with comfort needs and working with families during these challenging and emotional times.

Lastly, we need to be sure we are aware of the needs care teams may have as they provide Palliative Care. We need to be sure we are supporting team members as death is not easy to prepare for and caregivers may experience emotions they have not faced before. Be sure to offer EAP, access to counselors and/or support groups before, during and after.

Be safe, stay well and thank you for all you are doing during this difficult time!

CMAJ 2020. doi: 10.1503/cmaj.200465; early-released March 31, 2020