Palliative Care Consult for COVID-19 Patients May Reduce Unwanted Treatment

By Anne Harding

June 15, 2020

NEW YORK (Reuters Health) - An emergency department-based palliative-care intervention focused on clarifying COVID-19 patients' goals of care (GOC) may help reduce unwanted use of life-sustaining treatment, according to new findings.

After palliative-care consultation, most patients and family members decided against mechanical ventilation and/or cardiopulmonary resuscitation (CPR), and more opted for comfort-directed care, Dr. Shunichi Nakagawa, director of inpatient palliative services at Columbia University Medical Center (CUMC) in New York City, and colleagues found.

"For serious illness conversations, clinicians really need good communication skills, regardless of their specialty. It is a procedure, same as surgery," Dr. Nakagawa told Reuters Health by email. "I cannot emphasize more that you have to practice continuously and diligently, in order to get better. By having quality communication in a timely fashion, we were able to avoid lots of unnecessary suffering."

It's "extremely challenging" for ED doctors to discuss palliative-care related issues with COVID-19 patients, given the sheer number of these patients and their often acute illness, Dr. Nakagawa and his colleagues note in JAMA Internal Medicine.

To assist them, "we implemented an ED-based COVID-19 palliative care response team focused on providing high-quality GOC conversations in time-critical situations," the team writes. Team members were available for in-person consultation 12 hours every weekday, and by phone overnight and on the weekend.

In their research letter, Dr. Nakagawa and his team review clinical characteristics and outcomes for 110 patients for whom ED doctors requested a palliative-care consult between March 27 and April 10. Follow-up continued through May 9, when six patients were stlll hospitalized.

Patients' GOC were categorized as full code (including those with no recorded advance directives or medical orders for life-sustaining treatment); do not resuscitate (DNR) only; DNR/do not intubate (DNI), with continued medical treatment; or comfort-directed care.

Before the palliative-care consult, 82.7% were full code, 0.9% were DNR only, 13.6% were DNR/DNI with medical treatment and 2.7% comfort-directed care.

After consultation, 18.2% of patients were full code, 10% DNR only, 42.7% were DNR/DNI with medical treatment, and 29% comfort-directed care. At death or discharge, 8.7% were full code, 13.5% were DNR only, 26% were DNR/DNI with medical treatment, and 51.9% comfort-directed care.

Because patients were too sick to have conversations, and the hospital had a no-visitor policy, Dr. Nakagawa and his team spoke with patients' family members over the phone.

"We tried to convey the condition in a clear and simple way, focused on exploring their goals and values, and made a recommendation to achieve that goal. There are COVID specific conversation phrases, we also used our recently published 'three-stage protocol' (", Dr. Nakagawa said.

"Starting the conversation in the emergency department is sort of too late," he added. "Ideally, while they are healthy or before coming to the hospital, people in general should talk more openly about what is important, what makes their life meaningful, what is the condition unacceptable, etc. I saw many families who said 'we had never talked about it'."

SOURCE: JAMA Internal Medicine, online June 5, 2020.