As we all are dealing with the unprecedented COVID-19 pandemic health crisis, it has raised an alarm: can we meet the demands of patient care in a way that we have never had to before at scale? This stems from the increasing number of individuals testing positive and rising mortality due to the same. (1) In this unique time, it continues to be vital to guarantee a clear plan of engagement by ensuring the care that is received by patients is in line with their values and achievable from a medical standpoint – ultimately consistent with the notion of “what matters” to them. Particular focus needs to be paid to the elderly and susceptible.
Challenge convention:
Often in medical crises with patients, the default setting is to treat the given episode, stabilizing the patient and reassessing the situation and prognosis once the patient is “out of danger”. This often arises due to lack of previous conversations around patient preferences of medical interventions and an acceptable quality of life as an outcome of these measures. In respecting patient autonomy, it is imperative to explore the maximum burden of medical intervention a patient is willing to go through along with an acceptable outcome. This is a dialogue wherein the clinical team’s role is to guide the patient, make recommendations to ensure the outcomes are achievable, and ensure the patients are informed of the risks and benefits. Ideally, these conversations should occur with the involvement with the identified surrogate decision maker(s). This is the shared decision making model that allows for informed decisions to be made. After these conversations, a document called an advance directive needs to be completed. It also identifies the patient’s surrogate healthcare decision maker(s) to ensure the patient’s wishes are followed in the event the patient cannot communicate the same. The decision and the contents of the document can be revisited at any given time. Currently, approximately a third of the American population is known to have an advance directive. (2)
In patients with advanced illnesses, a physician’s order relaying the intensity and preferences of care by a patient in a document such as the physicians order for life sustaining treatments (POLST) in California is ideal since it is valid across various points of care. This document may have various names in different states.
During situations such as the current pandemic, it may not be possible to have any of the above documents to be physically filled out. Conversations can occur virtually or via telephone. If filling out any of the documents are not feasible, documentation of the same in the patient’s medical record and availability of the same across different settings to clinicians in the easiest possible way needs to be ensured. When possible, patients and their surrogates should carry the same with them across different settings. Clinicians should constantly confirm and reevaluate what matters if the patient’s condition changes or is moved between facilities. A point to be noted is that if any cognitive changes are observed in the patient, it might be an early sign of COVID.
In addition, here are five key actions to take so that we consider the best approach of caring for patients who are highly susceptible, serious and advanced illness in time of this pandemic:
• Move triage to the curb so older adults who are not acutely ill can be scheduled on the spot for appropriate testing and care.
• Create capacity for telemedicine for routine care and non-urgent visits. This may be very new for most clinicians and patients. Clinicians may require support in the form a brief training to identify simple and effective tips to make these virtual visits more effective eg looking at the patient in the eye.
• Social Distancing doesn’t mean social isolation. Social and physical distancing has become the norm. This can have challenges for older adults given the impact that social isolation can have. Clinicians should encourage their patients to use technology, consider engaging their family and friends via phone video.
• Continue to focus on the 4M’s. (3)
-What Matters: Include the ACP completed by the provider after discussion and send to patient.
-Medication: Hold up each bottle and ask them to tell you about it and how they take it.
-Mentation: Evaluate cognition and depression.
-Mobility: Ask them to stand up and observe a TUG. This is essential to do as there might be
seniors living in isolation and are self depended on their mobility to care for themselves.
• Have a post acute care plan. (4)
-patients moving older adults home who are recovering from moderate symptomatic COVID.
-increase capacity and capability to move frequently assess, and move, older adults home.
-reassess treatment plans and goals.
-adjust rooming to meet physical needs of older adults and address what matters.
Consider bi-directional safety as virus doesn’t have boundaries. Given the COVID pandemic, it is important to ensure these patients are not unnecessarily exposed to environments and situations that may expose them to the virus. Contact between patients with advance illnesses and clinicians should be minimized when possible to avoid transmission. Use of creative ways such as the use of technology needs to be optimized. This will minimize the risk of exposure and transmission along, judicious use of the personal protective equipment, save travel time and contact. It is least desirable for a patient to go through interventions that are not in line with their goals of care. Not only will it put these patients at risk but also those who come in contact with them. In addition, resources will be unnecessarily drained to provide care that is out of the predetermined “goals of care.”
In terms of the safety of patients as well as clinicians, the following populations need to have these conversations, and these should be viewed with the same importance as a critical medical intervention:
• Patients who have tested positive and have been admitted with symptoms of the infection.
• Those who have tested positive and do not have symptoms.
• Individuals exposed to those who have tested positive.
• Healthcare workers.
• Other individuals who work in high risk environments.
In addition, the elderly and patients with chronic medical conditions should have their goals of treatments documented. While the above populations are identified based on priority, in any ideal situation, all individuals should have their desires for any medical intervention and outcomes identified. That should be the current pursuit as resources permit.
Depending on the availability of resources and the strain on organizations a multipronged and tiered approach needs to be developed in order of the priority of the focus populations and aligning the right resources to meet the needs. It might be worth mobilizing resources that may not have the skillset to be trained quickly. Tapping on palliative care and hospice resources to assist with the same is highly recommended. In crises situations, such as the one we are dealing with, current palliative care resources might not be able to meet current or future demands and need to be utilized as a resource to help mobilize other skilled clinicians who can share the burden of volume. Part of the strategy should ideally involve support for the clinical teams as well. Every organization needs to look into its capacity and ability to deal with a potential volume surge. A contingency plan needs to be in place. (5)
The adage often used in palliative care is to hope for the best and prepare for the worst. While this statement might not hold as much weight in more normal times, situations such as the current experience need to be engrained into our minds to remind us of the critical nature of these conversations. This is to ensure that all patients receive the best care possible and at the same time protecting those delivering care when possible. During trying times, being prepared for the worst by having had these conversations will pay dividends for the patients and clinicians alike.
References:
1. Coronavirus COVID-19 Global Cases by the Center for Systems Science and Engineering (CSSE) at Johns Hopkins University (JHU). https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 . (last accessed March 25, 2020).
2. Yadav KN, Gabler NB, Cooney E, Kent S, Kim J, Herbst N, Mante A, Halpern SD, Courtright KR. Approximately One In Three US Adults Completes Any Type Of Advance Directive For End-Of-Life Care. Health Affairs. 2017 Jul 1;36(7):1244-1251.
3. Age-Friendly Health Systems: Guide to Using the 4Ms in the Care of Older Adults. http://www.ihi.org/Engage/Initiative s/Age-Friendly-Health-Systems/Documents/IHIAgeFriendlyHealthSystems_GuidetoUsing4MsCare.pdf . (last accessed March 25, 2020).
4. Grabowski DC, Joynt Maddox KE. Postacute Care Preparedness for COVID-19: Thinking Ahead. JAMA. 2020 Mar 25.
5. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, Zhang C, Boyle C, Smith M, Phillips JP. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med. 2020 Mar 23.