End-of-life care for Serious COVID-19 Patients

“When medical prowess is finite, infinite compassion truly helps to heal”

Healthcare systems globally and in India have been struggling to cope with the COVID-19 pandemic. Kasturba Medical College and Hospital, Manipal, is a major teaching hospital in Udupi district, Karnataka and one of the main centres providing care for COVID-19 patients. The number of patients testing positive for COVID-19 has risen exponentially in our district, with a proportionate number of patients having critical illness.

The World Health Organization (WHO) has endorsed the need and urged countries to integrate palliative care and symptom control into their pandemic response strategies, while also reiterating that responses that do not include palliaitve care are “medically defecient and ethically indefensible.”

In our hospital palliative care consultants have been invovled in the care of patients in the Intensive Care Unit (ICU) as part of the subspecialty service that we offer. Our hospital also has an end-of-life-care (EOLC) policy, with processes and pathways in place for limiting life-sustaining treatments (LST). This integration has stood us in good stead in these trying times, enabling us to alleviate the suffering of our patients and their families.

Recently we had an 80-year-old gentleman from a neighoburing state refrred to us for EOLC which highlighted the challenges in today’s times. This gentleman with ischemic heart disease, chronic kidney disease stage 5, type 2 diabetes mellitus, and hypertension presented to the hospital with influenza-like-illness and altered sensorium. Diagnosed with COVID-19 pneumonia he was shifted into the COVID-19 ICU and started on appropriate treatment and high-flow oxygen therapy. Given their travel history, his wife, daughter, and son-in-law were in home quarantine. As his clinical condition was likely to worsen further he was triaged for palliative care (PC) by the ICU team, who initiated the discussion with the family and with their consent initiated the process of PC referral.

As we came in to provide care, we faced many challenges, logistic as well as emotional. Access to the ICU was restricted as part of the hospital infection-control strategy. By coordinating with the ICU team via videoconferencing we were able to overcome this, and we could assess the patient and manage his distressing symptoms. Our next challenge arose in scheduling the family meeting. Confined to their homes, the family members were distraught at not being able to see or be at the bedside of their loved one. The PC team contacted them via videoconferencing. Discussing death and dying via video call can be a daunting task. Eye contact between the clinician and the patient/caregiver is important in any communication task. The perception of eye contact in tele-consultation can be tricky and disconcerting. Silence and touch, two powerful conveyors of empathy, are lost in this modality of communication. When silence and touch becomes awkward, use of empathetic words become vital.

As physicians we have been fighting our own battles too – our anxiety, our helplessness, and our fears. Navigating these emotions along with the logistic constraints are some of the biggest challenges we face as clinicians. As the patient’s family concurred with limiting LST, our third challenge arose, the signing of the necessary documents to withhold LST, at the shortest time possible, given that the deterioration in COVID-19 is sudden. The concentrated efforts of the PC and the ICU team working in tandem ensured that the due processes were completed at the earliest, with the family e-mailing their consent.

The next challenge was to create a pathway for communication between the patient and the family. A designated healthcare provider updated the family at regular intervals and enabled video calling to help the family see their loved one daily. The PC team coordinated with the ICU team telephonically to provide optimal symptom control and end of life care. The gentleman passed away peacefully, his distressing symptoms well under control, not having to undergo the trauma and suffering that futile life prolonging treatments offer, a reflection of our commitment to uphold dignity of the patient and of the caregivers, in life and beyond death as well. After-death care, family preferences for cremation/burial was explored with the relatives and coordinated as part of the end-of-life care process.

Pandemics amplify suffering. It is up to us healthcare providers to tread those less trodden paths, and offer optimal compassionate care in these trying times, maintaining dignity of patient, family, and physician alike. In times when medical prowess is finite, when resources are finite, it is the infinite compassion in our hearts that truly heals, that empowers us to make the right choice, provides us with the wisdom of choosing ‘doing everything that can possibly help’ over ‘doing everything.’

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