Palliative care considerations for cardiovascular clinicians in COVID-19

Abstract

The accelerating pace of severe illness associated with the COVID-19 pandemic has created unique demands for symptom management, complex decision making, and end-of-life care by a workforce under unprecedented emotional and physical stress. Cardiovascular (CV) clinicians are increasingly called to assist in the frontline pandemic response due to the substantial burden of CV complications 1 and growing shortages of specialized critical care providers. In this perspective, we outline key palliative care needs exposed by the pandemic and provide resources that may be useful to front-line clinicians in attending to these concerns. Challenge 1: psychological stress and mental health The psychological impact of the COVID-19 pandemic on patients and clinicians has been profound. 2 Regardless of disease exposure, feelings of fear, anxiety, and helplessness are pervasive in outbreaks of infectious disease, and have been linked to provocation or exacerbation of a range of psychiatric disorders, including depression, anxiety, panic, somatoform disorders, post-traumatic stress disorder, delirium, psychosis and even suicidal ideation. 3 Psychological stress may be compounded by prolonged quarantine and social isolation, which fragments traditional community support networks and limits access to routine mental health services, and by financial stress related to the loss of employment or income. A comprehensive psychosocial assessment should be integrated into the standard evaluation of all patients with COVID-19 illness. Key components of the evaluation are assessment of underlying vulnerabilities (including preexisting physical or psychological illness), identification of specific sources of stress (social isolation, infected friends or family members, financial obligations, caregiver burden), inventory of specific symptoms (depression, anxiety, insomnia), and sources of emotional and spiritual support. 4 Online tools to enhance clinical decision making and facilitate assessment of symptom severity are available from the American Psychiatric Association at https://www.psychiatry.org/psychiatrists/practice/dsm/educational-resources/assessment-measures. For those at highest risk, a multidisciplinary approach may be most helpful, with coordinated engagement of social workers, psychiatry, nursing and palliative care providers tailored to individual patient needs with attention to ensuring consistent messaging across disciplines. Since direct access to these resources may be limited by infection control precautions, telemedicine consultations are a reasonable alternative, and may be enhanced through the use of multi-participant videoconferencing to permit collaborative input from the patient, interested family members, and relevant members of the multidisciplinary team. For those who do not require formal mental health evaluation, supportive interventions designed to promote wellness and enhance coping may be relevant, many of which are readily available to patients and providers online (Table 1 ). Table 1 Relevant palliative care resources for cardiovascular providers. Table 1 Mindfulness/stress reduction • Headspace - https://www.headspace.com (free to many providers) • 10% happier – https://www.tenpercent.com (free to healthcare providers) • UCLA mindfulness program - https://www.uclahealth.org/marc/mindful-meditations Online cognitive behavioral therapy • Evermind - https://evermind.health • Sanvello – https://www.sanvello.com (free access during COVID-19) Symptom management guidance • Treatment protocols - https://covidprotocols.org/protocols/15-palliative-care/ Advance care planning assistance • Vital TALK - https://www.vitaltalk.org/guides/covid-19-communication-skills Challenge 2: symptom management Among patients with serious COVID-19 illness, dyspnea and respiratory distress are cardinal symptoms. 5 Management of dyspnea is largely supportive, including supplemental oxygen for those with hypoxia, judicious use of bilevel positive airway pressure and noninvasive ventilation, and early institution of mechanical ventilatory support for those with progressive disease. For patients with refractory symptoms or those who are not candidates for ventilatory support, utilization of palliative interventions, including anxiolytics and narcotics, may be necessary. Moreover, as patients progress to end-of-life, there may be increasing need for strategies to manage terminal delirium, heightened airway secretions, and pain. In the absence of dedicated palliative care supports, CV providers may need to rapidly become facile with self-directed management of these issues. A useful compendium of resources developed by our group that includes specific guidance regarding pharmacologic interventions for care of terminal illness is provided at https://covidprotocols.org/protocols/15-palliative-care. Challenge 3: goals of care discussions and advanced care planning Although no age is spared, the greatest burden of serious illness related to Covid-19 falls on the elderly and those with preexisting chronic disease, who are especially prone to protracted intensive care unit stays and medical futility. Accordingly, early conversations regarding goals of care and preferences for lifesaving interventions including mechanical ventilation and cardiopulmonary resuscitation are critical. Proactive engagement with patients when they are able to make their own decisions may ease the burden on family members and caregivers who may later be challenged to make end-of-life decisions from a distance. Since not all clinicians are comfortable with these discussions, we believe that an important early priority is to provide frontline providers with basic training and tools to initiate these conversations along the lines proposed by the Serious Illness Care Program. 6 Non-physician team members including nursing, social work, and chaplaincy may be critical catalysts for these discussions, particularly when resources are constrained. Practical guidance for cardiology providers initiating these conversations is available online at https://www.vitaltalk.org/guides/covid-19-communication-skills. Challenge 4: support for health care providers Health care workers (including first responders) may experience symptoms of anxiety and depression related to the psychological stress of intensified work schedules, fear of contracting infection or passing the disease to friends and family members, and emotional trauma from the loss of patients and colleagues, as well as existential stress created by the conflicting motivations of altruism and self-preservation. Stress on healthcare providers may be compounded when patient care demands outstrip traditional care frameworks and necessitate redeployment of providers to unfamiliar care settings or crisis conditions force battlefield-style triage of limited resources. Institutional leadership must emphasize self-care as a key component of the response to the pandemic. Crisis support, virtual group meetings, and access to individual therapy are critical, but should be complemented by efforts to buttress resilience among providers through restriction of prolonged work hours, provision of temporary housing to limit viral exposure to family members, and ensuring access to healthful diversions, including fitness and stress reduction programs. In summary, the COVID-19 pandemic has challenged health care systems to provide care on an unprecedented scale to patients with critical respiratory illness. Clinicians joining in the frontline response must endeavor to supplement aggressive medical intervention with equally robust attention to the broader human costs of the pandemic. By effectively leveraging the contributions of multidisciplinary team members including social workers, chaplaincy, psychiatrists, and palliative care clinicians, CV specialists may be able to more completely address psychological stress on patients and caregivers, symptom management, and advance care planning while simultaneously attending to crisis support for peers and colleagues (Fig. 1 ). Fig. 1 Palliative care challenges and solutions for the COVID-19 pandemic. Fig. 1