2020; Volume 21, No 4, April
Lessons from the Literature
Under My Microscope
Dr. Tania Pastrana. Used with permission.
IAHPC Research Advisor Dr. Tania Pastrana selects one article from recently published medical literature and describes why it is worthwhile.
(Opinion) Managing COVID-19 in Low- and Middle-Income Countries
Hopman J, Allegranzi B, Mehtar S. JAMA. Posted online March 16, 2020. DOI: 10.1001/jama.2020.4169. Full text.
I could not ignore the topic of the day, even though everyone is probably overloaded with information about COVID-19. This 21st century pandemic has raised many questions about virology, the environment, global/local relationships, economics, and palliative care. Searching the literature for this column, I found 1,219 hits on COVID 19 in MEDLINE, but not one for palliative care. Some might conclude that the palliative care community doesn’t play a role in the acute infectious pandemic.
However, the IAHPC Definition of Palliative Care is highly relevant: it addresses the palliative care transition from chronic and noncommunicable diseases to acute and infectious disease, and aims to improve the quality of life of patients afflicted with serious health-related suffering, their families, and their caregivers.
It is shockingly clear that COVID-19 is causing serious health-related suffering.
The most vulnerable to COVID-19 — those with higher morbidity and mortality risk — are older people with comorbidities (e.g., cancer, HIV, tuberculosis, malaria, chronic disease, etc.). Millions of these people live in low- and middle-income countries, where the health system and scarce resources for diagnosis and ICU treatment are unlikely to meet the need. In many of these countries, access to morphine for the treatment of respiratory distress associated with COVID-19 is still limited or nonexistent. An added burden is the complicated grief that results from the unexpected death of a loved one in a time of social isolation and lack of physical contact. Both the population at risk and the necessary interventions are relevant and a concern of palliative care.
Hopman and colleagues, who published this paper about the management of COVID-19 in low- and middle-income countries, conclude that “China has illustrated that the COVID-19 pandemic can be limited when public health outbreak response strategies and tactics are implemented early.” And we can learn from Italy, where Constantini et al call on governments “to recognize the essential contribution of hospice and palliative care to the COVID-19 pandemic, and ensure these services are integrated into the health care system response. Availability of personal protective equipment and setting-specific guidance is essential.”1
References
1. Costantini M, Sleeman KE, Peruselli C, Higginson IJ. Response and Role of Palliative Care during the COVID-19 Pandemic: A national telephone survey of hospices in Italy. MedRxiv. Posted online March 20, 2020.
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Media Watch: COVID-19
The articles below are selected from Barry R. Ashpole’s weekly report, Media Watch.
Adoption of COVID-19 Triage Strategies for Low-Income Settings
Proposed COVID-19 triage algorithm for low-income settings without established local transmission.
Lancet Resp Med — 11 March 2020 – Despite major advances in epidemic preparedness, Africa remains uniquely susceptible to novel coronavirus disease 2019 (COVID-19). According to the Infectious Disease Vulnerability Index, 22 of the 25 countries most susceptible to an infectious disease outbreak are in Africa... While preparing a response to COVID-19 outbreak in Uganda, we read Jinnong Zhang and colleagues' work with great interest. We commend the authors for distilling complex information regarding triage and clinical care for patients who have a novel pathogen, for which there is little evidence, into a succinct flowchart. DOI: 10.1016/S2213-2600(20)30114-4.
Click on image to enlarge the accompanying flowchart, reprinted from The Lancet Respiratory Medicine, Ayebare RR, Flick R, Ikware S, Bodo B, Lamorde M. Adoption of COVID-19 Triage Strategies for Low-Income Settings, published online 11 March 2020, Copyright 2020, with permission from Elsevier.
End-of-life care in the emergency department for the patient imminently dying of a highly transmissible acute respiratory infection (such as COVID-19)
Canadian Journal of Emergency Medicine | Online – 26 March 2020 – This document provides a framework for healthcare providers caring for Emergency Department patients with confirmed or suspected COVID-19 who are nearing end of life (EoL). Care of the imminently dying patient should not differ significantly from standard best palliative care practices, but there are some pertinent modifications to consider with respect to: 1) Non-pharmacological management; 2) Pharmacological management; 3) Withdrawal of life sustaining treatments; and, 4) Support for staff who are providing EoL care.
COVID-19: Doctors urge conversations about dying
U.K. | BBC News – 21 March 2020 – Palliative care (PC) doctors are urging people to have a conversation about what they would want if they, or their loved ones, became seriously unwell with Coronavirus. We should discuss all possible scenarios – even those we are not “comfortable to talk about,” they said. Medics said the virus underlined the importance of these conversations. New guidelines are being produced for PC for COVID-19 patients, the BBC understands. Dr. Iain Lawrie, president of The Association for Palliative Medicine of Great Britain & Ireland, told the BBC that PC teams around the country were working together to create the guidance. He said the impact of the virus was likely to change how PC would be delivered in future.
Editor’s note: The guide referred to in this article is now available as a freely available PDF.
Also of interest:
- (BMJ editorial) Bearing the Brunt of COVID-19: Older people in low and middle income countries
- Updated Prison Hospice Backgrounder. Additions from research journals and the lay press include compassionate release, inmates on death row, a review of palliative and end-of-life care in prisons, and aging in prison.
Resource: Preparing for COVID-19: Long-Term Care Facilities, Nursing Homes This Centers for Disease Control and Prevention site contains information for health care professionals, schools, workplaces, return-to-work criteria, and how to prepare to care for COVID-19.
Media Watch monitors the literature and the lay press on issues specific to the quality of end-of-life care. It is international in scope and distribution. View current and back issues here.