Field Notes From the Frontline of a COVID-19 Outbreak

Dyspnea Management for Hospitalized Patients at End-of-life

Dawn Pavlu, MSN, APN, AGACNP-BC, ACHPN, CCRN; Katherine DeMarco, DNP, MSHS, APN, FNP-BC, ACHPN; Yusimi Sobrino-Bonilla, MSN, APN, ANP-BC, ACHPN, CCRN


Journal of Hospice and Palliative Nursing. 2021;23(2):128-134. 

In This Article

Abstract and Introduction


Northern New Jersey was inside one of the worst initial coronavirus disease 2019 pandemic epicenters in the United States. At the peak of the pandemic surge in mid-April 2020, New Jersey saw 8045 hospitalized patients with severe coronavirus disease 2019 symptoms, of which 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of critically ill patients, the national opioid shortage, and transmission prevention measures for standard palliative care treatment protocols in place for refractory and/or end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the following Notes From the Field is to provide concise, pragmatic, and experiential reflection by 3 palliative care advanced practice nurses from 3 different hospital systems within the pandemic epicenter. The novel methods and opioid strategies implemented by their respective palliative care teams to ensure continued effective and appropriate treatment for end-of-life dyspnea are described. These accounts include Lessons Learned in order to assist others who may need to quickly implement changes in the future due to pandemic resurgence or second-wave events.


In the early months of 2020, as the coronavirus disease 2019 (COVID-19) pandemic reached the shores of the United States, New Jersey became one of the worst epicenters in the nation. This pandemic surge threatened to overwhelm the existing health care systems. Initially, the northern counties of New Jersey were hit the hardest both in numbers of cases and deaths. The first laboratory-confirmed case was diagnosed on March 3, 2020. At the peak incidence of hospitalizations (April 4, 2020), the statewide hospital census was 8045, including 2002 patients in the intensive care unit (ICU) (representing 86.3% of statewide available capacity), with 1705 patients requiring mechanical ventilation (54.7% of statewide ventilator capacity). In the first 100 days of the pandemic, New Jersey saw a total of 165 816 confirmed positive COVID-19 cases: the most occurring in Bergen County (18 667), followed closely by Essex County (18 206). The statewide rate of laboratory confirmed COVID-19 mortality was 7.5% (12 443 deaths): the most occurring in Essex County (1723), followed closely by Bergen County (1635).[1,2] The unprecedented need for critical care services saw rapid expansion and conversion of existing regular medical floors into ICUs. Field hospitals were constructed by the Army Corp of Engineers at the Meadowlands Sports Arena (northern New Jersey), NJ Convention and Expo Center (central New Jersey), and at the Atlantic City Convention Center (southeast New Jersey). Draconian measures to "flatten the curve", such as social isolation and closure of nonessential businesses, were undertaken.

The goals of palliative care are to promote quality of life and relieve suffering due to the symptoms and stress related to serious or life-threatening illness. It is a widely accepted standard of care even on the global level.[3,4] High-quality palliative care includes expertise in symptom management and therefore remains an essential facet in the multidisciplinary care for patients who require hospitalization due to severe COVID-19 infection. In this brief "Notes From the Field", novel approaches for end-of-life dyspnea symptom management are described. The aim is to provide concise, pragmatic, and experiential reflection on methods used by 3 palliative care teams at differing hospital systems within the New Jersey COVID-19 pandemic epicenter to conserve scarce opioid resources during the surge while ensuring quality care.

The 3 hospital systems include Hackensack University Medical Center, the flagship hospital of the Hackensack Meridian Health System, a 770-bed nonprofit research and teaching hospital providing tertiary and health care needs to northern New Jersey and the New York metropolitan area; The Valley Hospital, part of Valley Health System, a 451-bed fully accredited acute care not-for-profit community hospital serving the 32 towns of Bergen County and adjoining communities; and East Orange VA Medical Center, part of the Veterans Administration New Jersey Health Care System, a 100+ acute care bed teaching hospital providing general medical, surgical, and psychiatric services, as well as a broad range of specialty programs for the greater New Jersey area veteran population.