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VIEWPOINT
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 586-587  

Palliative care in COVID pandemic: Need of the hour in testing times!


1 Department of Anaesthesia, ABVIMS, Dr. RML Hospital, New Delhi, India
2 Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. IRCH, AIIMS, New Delhi, India

Date of Submission06-Sep-2020
Date of Decision21-Sep-2020
Date of Acceptance01-Oct-2020
Date of Web Publication6-Nov-2020

Correspondence Address:
Nishkarsh Gupta
Department of Onco-Anaesthesia and Palliative Medicine, Dr. B.R.A. IRCH, AIIMS, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_496_20

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How to cite this article:
Rustagi K, Gupta N. Palliative care in COVID pandemic: Need of the hour in testing times!. Med J DY Patil Vidyapeeth 2020;13:586-7

How to cite this URL:
Rustagi K, Gupta N. Palliative care in COVID pandemic: Need of the hour in testing times!. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Nov 27];13:586-7. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/586/300148



“COVID-19” is a buzz word in scientific literature presently. Various studies and opinions are being reported across journals and different social media platform. Recently, a thought-provoking case report has been published in this journal.[1] The authors have emphasized on the importance of integration of palliative care in intensive care unit (ICU).[1] The patient population at maximum risk to succumb to COVID-19 are the old and frail patients or those with numerous chronic medical illnesses.[2] Hence, the authors have highlighted the importance of palliative care integration in ICUs for symptom control, psychological support, spiritual support, and complex decision-making. They have enumerated several reasons explaining the probable barriers – the lack of awareness among patients for palliative care, lack of adequate resources, lack of knowledge about legislation about the end-of-life care, physical barriers interrupting patient–doctor relationship, ineffective communication, etc.

COVID-19 has spread across the globe in 210 countries since its beginning in Wuhan, China, and caused a large number of infections across the globe. Currently, no part in this globe is spared of this disease. The unpredictable course of illness creates psychological distress for both patients and their caregivers. The overburdened health-care systems, with unfavorable and stressful working conditions along with logistic issues, may pose dilemmas for the health-care professional. The social or physical distancing needed for management of COVID patients may create an emotional barrier between health care workers (HCW) and the patients. This may create a guilt the minds of HCWs and may affect their decision-making capacity. In the case, authors have described a geriatric patient with multiple comorbidities with COVID-19 pneumonia with respiratory failure who was admitted in the ICU for mechanical ventilation. This patient whom authors have described was an ideal candidate for palliative care, but due to delay in decision-making regarding withholding of life support system, this patient was provided medically futile treatment with no/little hope of cure or benefit.[3] This case report highlights the importance of advanced care directives and surrogate decision maker. The early integration of palliative care for patient care is highly appreciated, however some other aspects are also to be reconsidered in such complex cases. Though we all start our medical practice with Hippocrates oath, where we swear by God to endorse various medical ethics, in routine practice, we tend to ignore the first principle of medical ethics – autonomy.[4] It refers to the freedom of patients to decide and choose for themselves. An autonomous person is often in the best position to determine what would be good and bad for them. In the entire case scenario, the patient herself was not inquired about her wishes and choices for medical treatment.

Another pitfall is the lack of involvement of specialist palliative care physician in the scenario. Because the primary care treating physician and the caregivers are not having the same opinion regarding medical treatment, another more experienced and well-trained palliative care physician could have been involved in this scenario. The quality of palliative care is suboptimal in ICU setups due to various limitations including inadequacies in skills of clinicians and infrequent and late engagement of the palliative care specialist.[5] In the current pandemic, the family meetings have been replaced with telemedicine consultations. These telemedicine consultations have helped in the uninterrupted and regular functioning of various essential clinical services. However, when the primary team has done their best to palliate the patient, but their endeavors are unsuccessful, one should proceed for a “face-to-face” consultation.[6]

This case also highlights the significance of the advance directives (ADs). In the present case, if the patient had already laid down her wishes regarding her future course of treatment for health-care providers to follow, maybe this could have altered the treatment course. Many patients who are unable to convey their wishes regarding the medical treatment, AD/living will crystallizes their wishes in a legally accepted document and helps in reducing the utilization of life-sustaining treatments, which adversely affect the quality of life in these patients. However, the concept is uncommon among the Indian population. The legislation and the complexity of the procedure of recording a legally valid AD is another barrier in its effective implementation.

The development and implementation of standard protocols for the integration of palliative care in ICU are critical, especially in the current situation of the COVID-19 pandemic in a country like ours with limited resources. Knowledge and education regarding the significance of ADs can reduce the disagreement between physician and caregiver in the decision-making process. The physicians must act in conjunction with medical ethics, to ensure the appropriate transition of patient from curative treatment to palliative management and the end-of-life care. Also, it should be remembered that they are not obliged to adhere to any medically futile treatment, within legal and ethical boundaries.



 
  References Top

1.
Management of critically-ill elderly COVID-19 patient with severe comorbidities in the Intensive care unit: Missed Palliative care! - A Case Report.  Back to cited text no. 1
    
2.
Nikolich-Zugich J, Knox KS, Rios CT, Natt B, Bhattacharya D, Fain MJ. SARS-CoV-2 and COVID-19 in older adults: What we may expect regarding pathogenesis, immune responses, and outcomes. Gero Sci 2020;10:1-10.  Back to cited text no. 2
    
3.
American Medical Association: AMA Ethics Guideline 2.035: Futile Care. American Medical Association. Available from: http://www.ama-assn.org/ama/pub/category/2830.html. [Last visited 2020 Sep 05].  Back to cited text no. 3
    
4.
Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 7th ed. Oxford: Oxford University Press; 2012.  Back to cited text no. 4
    
5.
Wysham NG, Hua M, Hough CL, Gundel S, Docherty SL, Jones DM, et al. Improving ICU-based palliative care delivery: A multicenter, multidisciplinary survey of critical care clinician attitudes and beliefs. Crit Care Med 2017;45:e372-8.  Back to cited text no. 5
    
6.
Powell VD, Silveira MJ. What should palliative care's response be to the COVID-19 pandemic? J Pain Symptom Manage 2020;60:e1-3.  Back to cited text no. 6
    




 

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