Providing end-of-life care in the emergency department: Early experience from Médecins Sans Frontières during the Covid-19 pandemic

While most infections attributable to SARS-CoV-2 (Covid-19) are mild, a considerable percentage of affected people require hospitalisation and critical care. In European and North American centres, the mortality rate amongst individuals that are hospitalised, particularly those requiring mechanical ventilation, is high [[1], [2], [3]].

Earlier identification of impending severe disease is imperative to reducing mortality from CoVid-19 [4]. Health authorities and others responding to the epidemic should prioritise activities that support this life-saving approach, which includes improving access to health care for persons that are most susceptible to develop critical illness. However, as evidenced in Europe and the USA, maintaining access to health care and prioritising care for the most vulnerable during an epidemic are complex. While resource allocation related to shortages of critical equipment has been heavily emphasized in reports coming from European and North American settings, in African contexts these shortages are more pronounced, and high-complexity care is non-existent in numerous regions. Given underlying issues of access to care in many locations, patients frequently present to African emergency services in an advanced stage of disease suffering from organ failure that cannot be reversed.

While the emergency department is not typically an environment associated with the provision of palliative care, we anticipate that the gravity of presentation of certain CoVid-19 patients, particularly those with underlying comorbidities, means that some will be more appropriately treated with informed, symptom-based end-of-life care than aggressive resuscitation. The decision process regarding resource allocation is outside the scope of this paper, but the scale of this pandemic highlights the necessity to implement ethical and compassionate palliative care in settings where it has not previously been considered.

Médecins Sans Frontières (MSF) has combined research and field-based experience to develop a guidance document for clinicians with limited experience in the provision of palliative care, including those working in emergency services. In this paper we describe how evidence-based palliative care protocols can be adapted to less-resourced contexts at the necessary scale for a rapidly spreading epidemic whilst still respecting the physical and emotional needs of critically unwell individuals and their families.

Strategies for palliation

The guidance document: Covid-19 Resource Allocation and Palliative Care – Strategic Framework (Appendix A), is based upon the principles of ethical decision making, management of symptoms, communication with, and psychosocial support for, patients and families, and acknowledges the stress that the provision of this care places on clinicians. Respect for local customs and use of local interlocutors is central to the guidance.

Ethical considerations

In all environments, the decision to proceed with end-of-life care must be based on clinical findings and be considered as a deliberate act of patient care, as opposed to a choice of withholding or reallocating care. The guide provides field teams with transparent and objective assessments of disease severity and assessment of comorbidities, which can help clinicians – including those in the emergency department – adopt a more standardized and transparent decision-making process regarding goals of care, limiting implicit or overt bias.

Symptom management

Both pharmacological and non-pharmacological measures are foundational to the management of end-of-life symptoms. The guide provides clear descriptions of clinical signs that may be associated with patient suffering (useful for those unfamiliar with these presentations), a guide to estimate severity, as well as a stepwise approach to the management of each symptom. Underlying causes for each symptom are also provided, which can help clinicians better understand the pathophysiology of their patient's presentation.

In some contexts where MSF works, the availability of certain agents used in palliative care is significantly restricted. The guide therefore provides various alternatives to be trialled in the event of certain medications being unavailable, acknowledges the barriers to accessing medications and provides practical support for clinicians that may wish to negotiate with local or national authorities in order to improve availability for those in need.

Psychosocial support and communication with patients and families

The goal of end-of-life care is to ensure comfort and dignity during the dying process. In addition to symptom management, it involves support to both patient and family's psychological, social and spiritual wellbeing. Often an area neglected by emergency room clinicians, the capacity to incorporate this component of care is further hindered in an epidemic situation by large numbers of admissions. The MSF guide contains practical tools for health care providers to communicate with patients and families about grave prognoses and the implementation of an end-of-life plan of care, including strategies to address more extreme emotional reactions. While acknowledging the impact of certain infection control measures on the ability to provide psychosocial support (such as restrictions on family visits), the guide highlights the need to consider inventive technological solutions, and to involve key members of the community and other local partners, to bridge the gap between customary end-of-life practices and those compelled by this pandemic.

Support for clinicians

The moral distress associated with a clinical judgment to proceed with end-of-life care can be significant for certain clinicians, particularly those unaccustomed to such discussions or decisions, and particularly in a situation with mounting workload and limited resources. While the provision of standardized assessment tools and shared decision-making frameworks can mitigate this distress, MSF maintains open and frequent communication with staff involved in the care of Covid-19 patients and incorporates discussions regarding the provision of palliative care into pre-departure briefings for clinicians.

Conclusion

The Covid-19 pandemic has meant that areas not traditionally linked to palliative care, such as emergency departments, are becoming environments where clinical decisions about providing a peaceful and dignified end of life are being made and carried out. MSF has developed a practical guide to the provision of palliative care that may be adapted to numerous contexts, and allows clinicians, including those in the emergency department, to use evidence-based tools to provide compassionate end-of-life care in difficult or lower-resourced settings.

Appendix A. Supplementary data

COVID-19 Resource Allocation and Palliative Care - Strategic Framework + Algorithm EN.