Palliative Care during the Pandemic
Experience of Team TMC, Mumbai
Dr. Jayita Deodhar, Ad Hoc Officer in Charge, Dept of Palliative Medicine, TATA Memorial Hospital, Mumbai, shares the experience of Palliative Care Team.
The nationwide 21-day lockdown has widely impacted the routine healthcare services and so has it impacted provision of optimal Palliative Care services. Till date, Mumbai has reported highest number of COVID-19 positive cases in the country, which makes the situation even more difficult here.
The Department of Palliative Medicine in Tata Memorial Hospital, Mumbai has kept its services functional and working according to the TMC guidelines for Infection Prevention and Control.
The patients catered to by Palliative Care services are those who are with advanced metastatic disease, immune-compromised, with comorbidities, and this makes them more at-risk to develop infections. Hence, certain restrictions are being followed by the department. We have cut down our staff to half of its usual strength to reduce over-crowding and keep backup staff available.
The number of referrals in OPD has reduced by 30% due to various reasons like postponement of routine follow-up, patients are unable to travel due to restriction of transportation across the country. Doctors, social workers and nurses in the Department make regular phone calls to the patients to make ensure that their symptoms are taken care off. In cases where the patients are symptomatic, liaison with the nearest physician is made to provide care.
Follow up visits are allowed for those patients who come with emergencies like pain, delirium, intractable dyspnea which is not of infective cause, intractable nausea/vomiting, or patients with uncontrolled symptoms which need specialist palliative medicine referral. Early palliative care referrals for those patients who are asymptomatic and do not need urgent specialist palliative care attention are suspended for now. Simplified pain assessment and management guidelines for generalists have been circulated to all the doctors working across hospital, to be adopted for practice.
Screening for Fever and Flu
Strict screening for fever and flu like symptoms is carried out at the hospital entrance for all including patients as well as their caregivers. Febrile patients with chest infection or other symptoms are directed to the fever OPD for further assessment. For those who attend Palliative Medicine OPD, further triaging and screening is done by the Palliative Care nurse. Only one person is allowed to accompany a patient to prevent over-crowding. The procedure of patient registration has been modified to minimize the waiting period of patients in OPD.
The number of patients and doctors inside op has been restricted to maintain social distancing. The seating in the waiting area for the patients is also arranged so as to maintain social distancing protocols. Administrative and health care staff follow strict hand hygiene measures. Cleaning of the OPD is done at frequent intervals.
Referral letters to the local physicians (for further symptom management) and police (for allowing transport) are issued for those patients who need to travel back by ambulance and stock of medicines is issued for at least a month according to the symptoms.
Accommodation has been arranged by the hospital for those patients who are stuck in Mumbai because of lack of transportation to their hometown.
For in-patients, consultation liaison services are ongoing every day. The referral criteria for in-patient consultation liaison services are similar to those for out-patient services. Only those patients who have intractable symptoms are seen in wards..
Emergency palliative medicine services continue to operate for patients who come to emergency department with acute symptoms. For those who come with fever or respiratory distress are screened by fever clinic for COVID-19 screening. Hospital protocol for COVID-19 is followed for these patients.
Hospital has made provision for isolation ward and testing for those who are COVID-19 suspects according to the protocol. For other patients who are not at risk of COVID-19, are attended in emergency room as per usual emergency protocol. Those patients who are imminently dying are assessed thoroughly and managed according to end of life care protocol of palliative medicine department.
Respite care facility has been temporarily closed due to high risk of infection transmission.
Homecare services have been discontinued and the team makes regular phone calls to all the patients. Contact with the family physicians, where ever possible, is made if patient needs urgent medical attention or assessment.
For the patients who need a refill in stock of opioid medicines, relatives are asked to collect one-month stock from the hospital. For those patients who need medicines that are available near the residence of the patient or can be prescribed by the family physician, are encouraged not to travel to the hospital and collect medicines from the nearest possible place.
These phone calls are also utilized as an opportunity to educate the patients and their families and creating awareness about the current COVID-19 situation, guiding them about the precautionary measures like hand hygiene, etiquettes to be followed to prevent the spread of infection, screening for relevant history and when to seek attention in case of need for testing.
Shanti Avedna Sadan hospice in Mumbai is no longer taking new admissions due to the current COVID-19 crisis.
Doctors are doing a tele-medicine consultation for patients who have appointments scheduled for routine follow-ups. Hospital authorities has created a call center kind of facility in the hospital premises for the same.
We are facing challenges in carrying out our services. Tele-consultations are a means, but we feel a sense of incompleteness as we miss the in-person contact. We have to take care of staff and hence we function with less number of staff at a point of time. There is no regular academic sessions now. We miss our Volunteer counsellors and we have to modify and triage the psycho-social assessment and interventions.