Coronavirus disease 2019 (COVID-19) has brought a tsunami of suffering that is devastating
even well resourced countries. The disease has wreaked havoc on health systems and
generated immense losses for families, communities, and economies, in addition to
the growing death toll. Patients, caregivers, health-care providers, and health systems
can benefit from the extensive knowledge of the palliative care community and by taking
heed of long-standing admonitions to improve access to essential medicines, particularly
opioids for the relief of breathlessness and pain.1, 2, 3
For low-income and middle-income countries (LMICs), the COVID-19 pandemic is likely
to be even more severe than in high-income countries. There will probably be a high
burden of COVID-19 in settings where there are weak health-care systems, lack of access
to clean water and disinfectants, poor outbreak preparedness, severe shortages in
personal protective equipment (PPE) and medical technology, challenges in enforcing
physical distancing regulations, and reliance on informal employment. In such settings,
it is expected that patients with severe COVID-19 who are unable to access the limited
supply of intensive care resources or hospital beds will suffer and die at home, where
they would be cared for by family members without PPE and access to relevant information,
training, or palliative care resources. These caregivers will probably become infected
and spread the disease. Additionally, if resources are reallocated to respond to COVID-19,
patients with other life-limiting conditions could find themselves pushed out of their
health-care settings with reduced access to opioid medication.
During the COVID-19 pandemic, access to essential palliative care at end-of-life,
including bereavement support, will be limited in the face of high demands in all
countries. There will be increased isolation and suffering for palliative care patients
and those who are bereaved.4, 5 Strict physical distancing regulations to slow disease
transmission mean that patients who die from COVID-19 will usually be without loved
ones by their side, who in turn will be unable to say goodbye or undertake traditional
grieving rituals.4, 6 Providers of palliative care, including private hospices, will
require additional human and financial resources.
Basic palliative care training to all medical and nursing students has been the recommendation
of the palliative care community for many years,
and had it been heeded, the health-care workforce would be more prepared for this
pandemic. Online training is available to help prepare medical personnel to provide
some palliative care at all levels of care. Now is the time to insist on rapid capacity-building
for clinicians7, 8 in symptom control and management of end-of-life conversations.3,
9 Smartphones and telemedicine can facilitate at-home activities supported by health-care
professionals and volunteers without physical contact for people who are isolating
Immediate-term and long-term strategies to extend palliative care during and after
the COVID-19 pandemic are shown in the panel
Strategies to extend palliative care during and after the COVID-19 pandemic
Immediate responsiveness to adapt to pandemic parameters
Optimise cooperation and coordination
Initiate formal and informal pathways for collective action and exchange by governments,
bilateral and multilateral organisations, civil society, and the private sector based
on the principle of solidarity.
Preserve continuity of care
Ensure the availability and rational use of personal protective equipment and encourage
self-care among palliative care health-care professionals and all caregivers.
Ensure an adequate and balanced supply of opioid medication to all patients for relief
of breathlessness and pain by instituting the simplified procedures of the International
Narcotics Control Board.
Conduct rapid training for all medical personnel to address additional palliative
care needs of COVID-19 patients.
Engage technology partners to equip community health workers with telehealth capabilities
to virtually conduct home-based palliative care activities.
Enable families to virtually visit and partake in health decisions with loved ones,
especially at the end of life to address the almost universal fear of dying alone.
Enhance social support
Enlist informal networks of community-based and faith-based organisations to mobilise
and train a citizen volunteer workforce that is ready and able to teleconnect with
patients in need of basic social support, delivering on palliative care's cornerstone
Assess emerging needs
Link with contact tracing activities and testing sites to collect data from the general
public to better understand the social dimension of pandemic suffering.
Long-term preparedness strategies that embed palliative care into the core of medicine
Expand all medical, nursing, social work, and community health worker curricula, as
well as training of clergy, to include core palliative care competencies.
Establish standard and resource-stratified palliative care guidelines and protocols
for different stages of a pandemic and based on rapidly evolving situations and scenarios.
Support for health-care workers and strategies, such as peer counselling, regular
check-ins with social support networks, self-monitoring and pacing, and working in
teams, to mitigate the impact of continued exposure to death and dying, breathlessness,
desperation, and suffering need to be deployed across health systems. These strategies
need to include the palliative care workforce worldwide because their patient groups
are usually at increased risk from COVID-19 and the least likely to be triaged into
intensive care.4, 11
Adoption of triage for clinical decision making, including who will receive ventilator
support, marks a deterioration in use of person-centred care in favour of utilitarian
Palliative care rejects the comparative valuation of human life and upholds the allocation
of resources using the key ethical principles of justice and beneficence such that
previous treatment adherence should not be a consideration in defining access to care.
Universal do-not-resuscitate orders should be rejected. The cornerstones of clinical
decision making must be strict differentiation of clinicians who provide care from
those who make triage decisions
and patient-centred assessment of the medical indication, applied in conjunction with
the will of the patient.
Most importantly, patients triaged not to receive intensive care or ventilatory support
require adequate relief of suffering, especially for breathlessness.
In COVID-19 patients with breathlessness, clinical experience suggests opioids—a common
palliative care intervention—can be safe and effective and should be widely available.
The relief of the COVID-19-related, huge additional burden of serious health-related
suffering will require opioids and especially inexpensive, off-patent injectable and
immediate release oral morphine.
Yet the poorest 50% of people in the world have access to only 1% of the globally
distributed opioids in morphine-equivalent and as a result access to opioid medication
in many countries, even for palliative care, is inadequate.1, 17 Patients in LMICs
with respiratory failure from COVID-19 will be largely unable to access opioids, as
pre-existing scarcity will be exacerbated by increased use of opioids in hospital
We propose that LMICs need to rapidly adopt two strategies. First, national opioid
medication reserves have to be increased to build up a stockpile for the COVID-19
pandemic. The International Narcotics Control Board (INCB) has called on governments
to ensure continued access to controlled medicines including opioids during this pandemic,
reminding them that in acute emergencies it is possible to use simplified procedures
for the export, transportation, and provision of opioid medications.
To avoid cost escalation, pooled purchasing platforms need to be adopted, including
making information on price-points public and accessible.1, 19 Second, rapid, basic
training on rational use of opioid medications must be offered to all primary caregivers
and health-care professionals in emergency departments and intensive-care units and
much of this can be done online.20, 21
In this most challenging time, health responders can take advantage of palliative
care know-how to focus on compassionate care and dignity, provide rational access
to essential opioid medicines, and mitigate social isolation at the end of life and
caregiver distress. The call to fully incorporate palliative care into global health1,
22 could finally be realised in the urgency of the pandemic. If so, the COVID-19 pandemic
will have catalysed medicine to better alleviate suffering in life and death.