Palliative Care Consultation During the COVID-19 Pandemic

In This Article

Abstract and Introduction

Abstract

During the coronavirus disease 2019 (COVID-19) pandemic, patients experienced rapid clinical decline requiring urgent conversations about their wishes for care. Palliative care advanced practice registered nurses developed a workflow to provide early palliative care consultation to every COVID-19 patient under investigation admitted to a 368-bed acute care hospital in the United States. A retrospective exploratory study was conducted on the initial surge from March 1 to May 31 of 2020. A nonrandomized 2-group design used descriptive and inferential statistics to compare elicitation of patient care preferences for patients who received early palliative care consultation with those patients who did not receive a palliative care consult. Early palliative care consultation resulted in a higher number of patients establishing a decision-maker (99%), changing code status (46%), changing goals of care (46%), and transitioning to comfort care (24%). In those patients not receiving palliative care, fewer patients established a decision-maker (10%), changed code status (7%), changed goals of care (4%), or transitioned to comfort care (3%). During the first COVID-19 surge, early palliative care consult performed by advanced practice registered nurses resulted in a higher number of patients establishing decision-makers and changing care preferences before decompensation due to COVID-19, thus helping patients avoid potential suffering caused by unwanted medical interventions.

Introduction

The coronavirus disease 2019 (COVID-19) pandemic has made an unprecedented impact on the health care system with the total cases in the United States reaching more than 33 million and total deaths approaching 593 000 per the Centers for Disease Control and Prevention, as of June 1, 2021.^[1] Reports suggest approximately 20% of patients infected with COVID-19 develop severe disease requiring hospitalization, with 25% requiring intensive care unit (ICU) admission.^[2,3] Advanced age and comorbidities are risk factors for a severe course, with death occurring 12 times more frequently than in patients without these risk factors.^[4] Dying in the hospital setting is associated with higher physical and emotional discomfort, lower quality of life, and prolonged grieving among families and caregivers.^[5] Dying during a pandemic carries additional suffering related to social isolation with limited health care worker interaction, and families prohibited to visit and spend precious time with their loved ones.^[6]

Early palliative care (PC) consultation has been shown to decrease length of stay, increase transition to do not resuscitate (DNR)/do not intubate, and decrease the utilization of resources including ventilators, tracheostomy placements, and decreased cost related to earlier transition to comfort care.^[7,8] An "early" PC consultation is defined in the literature as occurring within 72 hours of admission.^[8] This acute care hospital has a provider-initiated, consult-based PC service 7 days a week that is composed of 3 advanced certified hospice and PC advanced practice registered nurses (APRNs). The PC team is not currently interprofessional, relying on hospital chaplains for spiritual care support, with a goal to replace the previous PC social worker, which was placed on hold during the pandemic.

During the initial pandemic surge, the PC program referral volume increased by an average of 46.7%, with program penetration increasing by an average of 23.2%. The average time from referral date to PC consultation was 0.38 days. Coronavirus disease 2019 presented unique challenges with delays in receiving COVID-19 test results and patients rapidly decompensating necessitating urgent conversations; therefore, goals-of-care conversations were needed before receiving the COVID-19 test result. During a rapid response, crucial resources from the ICU including a critical care physician and an ICU charge nurse are called to the patient's bedside along with the internal medicine attending physician, nurses, and interdisciplinary team. Because of high patient volumes and acuity in the ICU, it was difficult for the rapid response team to repeatedly be pulled away throughout the day. Palliative care APRNs developed a strategy in collaboration with critical care and internal medicine physicians to provide early PC consultation to every COVID-19 patient under investigation (PUI) on the medical-surgical units and ICUs. Little is known regarding the impact of a PC consult during a pandemic, and COVID-19 is an area of rapidly emerging research.

The purpose of this study was to evaluate the impact of early PC consultation on patient care preference elicitation during a pandemic in the acute care setting by comparing outcomes of patients who received an early PC consult with patients who did not receive PC. The aim was to review outcomes including identifying a medical decision-maker, change in code status, change in goals of care, transition to comfort care, and discharge disposition, to determine whether early PC involvement impacted a patient's hospital course.

Table 1. Comparison of Age and Length of Stay
	PUIs, Early PC (n = 174)			PUIs, No PC (n = 152)			t	df	P
	Mean	Range	SD	Mean	Range	SD	t	df	P
Age, y	71.5	29–97	17.0	58.6	18–98	19.7	6.22	298	<.0001
LOS	7.3	0–78	8.9	6.2	0–99	10.3	−4.48	299	<.0001

Abbreviations: df, degrees of freedom; LOS, length of stay; PC, palliative care; PUIs, patients under investigation; t, t test.
Independent t test (2-tailed, significance of .05) was used.

Table 2. Comparison of Other Demographics
	PUIs, Early PC (n = 174)		PUIs, No PC (n = 152)
	n	%	n	%
Sex
Female	89	51.1	84	55.3
Male	85	48.9	68	44.7
Race
American Indian or Alaska Native	3	1.7	1	0.67
Asian	7	4	1	0.67
Black or African American	7	4	7	4.6
Native Hawaiian	1	0.05	0	0
Other	3	1.7	0	0
White	128	73.6	118	77.6
Unknown or declined	1	0.05	3	2
Ethnicity
Hispanic or Latino	24	13.8	22	14.5
Non-Hispanic or Latino	150	86.2	130	85.5
COVID-19 status
Positive or presumed positive	75	43.1	18	11.8
Negative	99	56.9	134	88.2

Abbreviations: COVID-19, coronavirus disease 2019; PC, palliative care; PUIs, patients under investigation.

Table 3. Comparison of Palliative Care Outcomes
	PUIs, Early PC (n = 174)		PUIs, No PC (n = 152)		z Score	P
	n	%	n	%	z Score	P
Identification of decision maker	173	99.4	15	9.9	−16.33	0
Change in code status	80	46	11	7.3	−7.78	0
Initiation of comfort care	80	46	5	3.3	−8.76	0
Change in goals of care	42	24.1	6	4.0	−5.13	0

Abbreviations: PC, palliative care; PUIs, patients under investigation.

Table 4. Comparison of Discharge Dispositions
	PUIs, Early PC (n = 174)		PUIs, No PC (n = 152)
	n	%	n	%
Transferred to ICU during stay	50	28.7	24	15.8
Died as inpatient	30	17.2	5	3.3
Died as inpatient with comfort care	29	16.7	5	3.3
Died inpatient without comfort care	1	0.6	0	0
Inpatient hospice	10	5.7	0	0
Inpatient rehabilitation facility	3	1.7	0	0
Home without services	83	47.7	101	66.4
Home with home health	15	8.6	11	7.2
Home with hospice	7	4	0	0
Skilled nursing facility	20	11.5	11	7.2
Long-term care acute	2	1.1	1	0.7
Transferred to different acute care hospital	0	0	1	0.7
Inpatient psychiatric facility	4	2.3	21	13.8
Against medical advice or other	0	0	5	3.3