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May 7, 2020

Palliative Care for Patients With Cancer in the COVID-19 Era

Author Affiliations
  • 1Palliative Care Program, Department of Medicine, University of California, Los Angeles, Santa Monica
  • 2Johns Hopkins Medicine, Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland
JAMA Oncol. Published online May 7, 2020. doi:10.1001/jamaoncol.2020.1938

With early studies suggesting that patients with active cancer are particularly susceptible to COVID-19, the current pandemic is forcing palliative care health care professionals to better define our identity as a field.1 With social distancing requirements, should we minimize patient contact to keep our patients and ourselves safe? As a relatively new specialty, are palliative care consults a luxury that we can hold off on to avoid overburdening the medical system? Are we essential medical personnel, or not?

Over the last decade, benefits of early palliative care have been well established. In fact, the American Society of Clinical Oncology suggests that every patient with advanced cancer see a palliative care team within 8 weeks of diagnosis.2 This has resulted in referral to palliative care as early as diagnosis and growth in outpatient palliative care services.3 Now, in the face of this pandemic, palliative care professionals face new demands and needs. It challenges our identities as clinical health care professionals. Hospital systems and palliative care teams are urgently reestablishing best practices for their patients, themselves, and their own families while balancing the risks and benefits of doing so.

Through ongoing national conversations, palliative care practitioners are asking whether we should be adding exposure risk to the patients we see, who are often the most vulnerable. As a field, we must not shrink away by decreasing services provided. Instead, our care can still be provided in creative ways that remain consistent with the core of how we practice outside these unique circumstances (Table). The challenges of this pandemic can essentially be considered for 3 populations: outpatients, COVID-19–positive inpatients, and COVID-19–negative inpatients.

Table.  Palliative Care Challenges When Caring for Patients in the COVID-19 Era
Palliative Care Challenges When Caring for Patients in the COVID-19 Era

As many people are sheltering in place, telemedicine has become an integral strategy to provide early palliative care in the ambulatory setting. Newly updated US Drug Enforcement Administration regulations allow palliative care professionals to continue writing new and refill opioid prescriptions using telemedicine. Prescriptions for new patients require both audio and video assessments. For return patients, video assessments are not necessary. Goals of care can be addressed using telemedicine to ease patient or caregiver distress and to prevent hospitalizations. Telemedicine has hidden advantages; video visits allow practitioners to see patients’ home environments—information that is unavailable in traditional clinic visits. However, we have also found that it can be difficult to rapidly establish trust with new patients. Being present, validating emotions, responding to questions, and using communication tools should continue to be implemented for virtual visits. Patients may even be more willing to have these conversations with someone other than their oncologist.4 Anecdotally, we have observed that patients at higher risk of poor outcomes if exposed to COVID-19 are becoming more proactive about advance care planning. Before adopting this as the norm, health care professionals should remember that at least 1 randomized study of weekly palliative care teleconsultations vs usual in-person palliative care visits showed significantly more anxiety and higher distress in the telehealth group.5

In the inpatient setting, palliative care practitioners are using telemedicine creatively for patients with and without COVID-19 because personal protective equipment is limited and family/caregiver visitation is restricted. Patients with critical illness are dying alone, and families/caregivers are distressed as they grieve for their loved ones from a distance. For patients with COVID-19, clinical decline can be rapid, providing little time for families/caregivers to make difficult decisions. Video visits address 2 barriers: (1) they provide a form of face-to-face communication and (2) they allow multiple health care professionals to engage patients/families/caregivers simultaneously, which can be a challenge in person. These tools allow us to continue providing early palliative care services, which are necessary now more than ever. Patients, despite COVID-19 status, require advance care planning and may be more likely to have these conversations with growing fears of limited medical resources and prolonged isolation.

Normally, palliative care professionals spend a significant amount of time providing patients/families with emotional support using therapeutic presence and touch. We can still provide this care but need to be efficient to have a similar influence while limiting physical contact. Time and availability are resources that other health care professionals may not be able to give when otherwise overwhelmed, and frankly, telehealth takes longer. It can also worsen the digital divide when computer-savvy families can participate in telehealth while others can only manage a phone visit. Psychosocial support is necessary to address both the fear of contracting COVID-19 and the emotional burden during diagnosis. During survivorship, guilt and posttraumatic stress disorder may develop. With a specialized and diverse skill set, interdisciplinary palliative care teams have resources to address these challenges.

Palliative care practitioners also offer expertise in management of complex symptoms, including dyspnea, anorexia, and delirium. Symptom management saves lives, simply put.6 Palliative care comanagement of these symptoms lessens the burden of patient care on primary teams. Delivering excellent symptom management also provides emotional relief for staff having to care for patients with COVID-19 without a cure. Instead of sending our patients to inpatient hospice, we can provide comfort care in the hospital. This protects hospice personnel who would otherwise have to see these patients, obtain hospice admission consent, and complete regular clinical assessments. It is essential before making the referral to hospice that we know the hospice is accepting new patients, has enough personnel, and has enough personal protective equipment. In both of our environs, this changes day to day.

Finally, palliative care professionals have a history of supporting colleagues in other disciplines. Now, more than ever, we should take the lead in emotionally supporting them, many of whom are equally afraid and overworked. This includes caring for our interdisciplinary teammates—nurses, chaplains, social workers, and pharmacists. We need to protect our interdisciplinary team and palliative care trainees by not duplicating efforts, which includes dividing patient lists and not rounding as a large interdisciplinary team, but rather seeing patients independently. Group rounding and sign-out can be performed through phone or video methods instead of in person.

Even in this pandemic, palliative care is not a luxury; it is a necessity. In these troubling times when we have to be cognizant of our patients’ and our safety, we should not hold back on providing palliative care services. In an era of ventilator shortages and tough choices, it is time for palliative care practitioners to lean into patient care in creative ways that will define and solidify our identity as a field.

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Article Information

Corresponding Author: Ambereen K. Mehta, MD, MPH, Palliative Care Program, Department of Medicine, University of California, Los Angeles, 1328 16th St, Room 207, Santa Monica, CA 90404 (akmehta47@gmail.com).

Published Online: May 7, 2020. doi:10.1001/jamaoncol.2020.1938

Conflict of Interest Disclosures: Dr Smith reported receiving personal fees from serving as coeditor, Non-Pain Palliative Symptoms, UpToDate. No other disclosures were reported.

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