Palliative Care in a Pandemic

A Retrospective Review of the Impact of Early Palliative Care Consultation During the Coronavirus Disease 2019 Pandemic

Rachel M. Sabolish, MSN; Jennifer M. Wilson, MS; Hollie K. Caldwell, PhD

Disclosures

Journal of Hospice and Palliative Nursing. 2022;24(1):50-56. 

In This Article

Discussion

The population seen for an early PC consult demonstrated a higher percentage of positive COVID-19 test results, increased age, and incidence of ICU admissions. Age is the primary risk factor for developing COVID-19–related complications,[9] and the higher age and likelihood of requiring ICU admission found in the group seen by PC were expected.[2,3] Advanced practice registered nurses prioritized by acuity in collaboration with the interdisciplinary team, which may have resulted in de-prioritizing patients with lower acuity or lower suspicion of a positive COVID-19 test result. Patients seen by PC were more likely to require aggressive care in the ICU indicating increased severity of illness; thus, the finding that they were more likely to require additional resources at discharge including home health services or transfer to a facility setting is unsurprising.[10] The average length of stay was higher in the group seen by PC, which may indicate early PC involvement did not reduce length of stay, which has been a key success in other studies showing the value of an early PC consult;[11] however, this cannot be concluded based on 2 groups that were not case matched or randomly assigned. Patients who transitioned to comfort care or hospice experienced novel obstacles in discharge planning because of fear of transmission; therefore, patients with COVID-19 during the initial surge who died were more frequently inpatient at the time of death.

Because of the chaos of the pandemic, there were times patients did not receive consult orders on admission. Implementing a PC consult order prompt into the EHR admissions order set when a COVID-19 test is ordered would be beneficial to streamline the process. The initial workflow to obtain PC consult order when not placed on admission included having a PC APRN round with the critical care physician in the COVID-19 ICU and with the internal medicine attending in the COVID-19 medical unit. As the pandemic worsened, it became clear that rounding with the physicians was not the best use of the APRNs' limited time because of patient volume and rapid nature of decline. A new process was established by which the APRNs reviewed charts in the morning and assigned priority based on vital signs, oxygen requirements, medical complexity, and code status. When comparing the 2 groups, younger patients, or those screened for COVID-19 before being admitted to an inpatient psychiatric unit, were less likely to receive a PC consult. These findings may reflect provider awareness that younger patients are less likely to decompensate, and asymptomatic patients who are emergently admitted for psychiatric care are less likely to be positive for COVID-19. The PC team was exposed to an unusual patient demographic during the COVID-19 pandemic, which required counseling patients who were otherwise healthy.

It would be interesting to explore feedback from the referring physicians regarding the impact of a PC consult on the patient's plan of care. Closer examination of the patient and family experience comparing those who received PC versus those who did not would help elicit the perceived value of PC for patients and families during a pandemic. In addition, learning more about the experience of the PC team members to better understand resiliency and stress during the pandemic surge would be beneficial. Any team operating under this level of stress and volume during a pandemic lacks long-term sustainability without appropriate surge planning and staffing support.[12]

If an acute care hospital is unable to support the employment of PC providers, it would likely lead to more stress on the health care team, patients, and families, which may result in prolonged ICU admissions and care that could exceed patient care preferences. However, it is not always possible for some hospitals in rural areas to provide access to PC services. Whenever possible, PC providers are crucial members of a patient's interdisciplinary acute care team.

More research on the role of PC during a pandemic would be valuable to identify appropriate utilization of PC services, cost savings, and the impact on resource allocation. The referring providers at this hospital are well informed about the benefits of PC due to the strong relationships built in the hospital before the pandemic. It is not clear whether this study could be replicated in a different hospital culture. Specialized training in PC was essential and impacted the APRNs' ability to effectively complete timely values-based goals-of-care discussions in a high-stress environment. Providers who have not received specialty training, or do not routinely practice these conversations, may be at a disadvantage to effectively complete goals-of-care conversations. By moving between ICU and internal medicine floors, APRNs were knowledgeable on current COVID-19 treatment modalities, complications, prognosis, and the impact of interventions on an individual patient's quality of life. Advanced practice registered nurses have a unique scope of practice allowing them to provide medical updates, extensive counseling on ICU interventions, prognosis, and options for care. Therefore, PC teams with strong clinical backgrounds and provider relationships are most likely to be successful in implementing this workflow.

Limitations

The patient sample included all patients tested for COVID-19 and was not limited to only patients who tested positive. The intervention was completed with all PUIs because of delay in test results and rapid decompensation for those with COVID-19 necessitating conversations before receiving COVID-19 results. Patients who had no symptoms of COVID-19 but tested positive incidentally were included, such as during routine screening for psychiatric admission, elective surgeries, procedures, and transfer to outpatient facilities. Patients were not randomly assigned to the intervention and control groups, and the sample was not large enough to match the intervention and control groups by characteristics, which would have created a more rigorous study.

This study did not compare the comorbidity index or prognosis of the 2 groups. Data suggest that patients with higher comorbidity indices and worse prognoses were more likely to be referred to PC, but this cannot be confirmed. Palliative care APRNs triaged patients deemed to be at a lower risk, which may introduce study bias because it would indicate that more severely ill patients were in the intervention group seen by PC. Future studies could include randomized controlled trials and case matching with patient characteristics to strengthen the validity and generalizability of the results.

A challenge of this study was demonstrating the value of PC clinicians in eliciting values-based goals of care when choosing quantifiable outcome measures. It is certainly not the goal of PC to counsel families into electing for DNR or end-of-life/hospice care. A diverse patient population was not present, with more than three-quarters of the COVID-19 PUIs (75.6%) identifying as White or Caucasian. This is consistent with the all-cause hospital admission demographic data for the hospital service area (77.5% White) and the local city (80.9% White).[13] The retrospective chart review used for data extraction is limited by the quality of the patient information available in the EHR, and the accuracy of the data extraction process was limited because it did not include a second review of the data.

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