Palliative Care as Essential to a Hospital System's Pandemic Preparedness Planning: How to Get Ready for the Next Wave

Abstract

The sudden and unprecedented increase in seriously ill patients with COVID-19, coupled with both the lack of core palliative care training and expertise among frontline providers and the specialty-trained palliative care workforce shortage, produced immediate challenges to meet the needs of this novel seriously ill patient population. In this article, we describe the rapid expansion and creation of new specialty palliative care services across a health system to meet demands of the COVID-19 surge in New York City. During April 2020, 1019 patients received inpatient specialty palliative care consultations across the Mount Sinai Health System. This overview demonstrates how palliative care services can be titrated up rapidly to meet the acute increase in hospitalized persons with serious illness due to COVID-19, and how these services tailored to the changing needs across a health system.

Introduction

The COVID-19 pandemic forced New York City (NYC) hospitals to develop innovative programs to treat unprecedented numbers of seriously ill persons. By May 1, 2020, 164,505 patients¹ had been hospitalized with COVID-19 across NYC and 13,000 had died.² The large numbers of patients with distressing symptoms, uncertain prognoses, and rapid loss of decisional capacity necessitated that hospitals rapidly expand their ability to provide palliative care.³ Core palliative care knowledge and skills—symptom management, assessment of illness understanding and prognostic awareness, elicitation of goals/values, and care coordination—were needed for thousands of patients. This article describes Mount Sinai Health System's (MSHS) response to this need.

Pre-COVID, 5/8 MSHS hospitals in NYC had well-developed palliative care consultation teams. The flagship hospital—Mount Sinai Hospital (MSH)—also had a 14-bed inpatient palliative care unit (PCU) and embedded palliative care clinicians (physicians, nurse practitioners, nurses, or social workers) within medical and surgical intensive care units (ICUs), hospital medicine, and the emergency department (ED). In April 2020, the NYC peak month of the pandemic, 1019 patients received palliative care consultations across MSHS—more than a twofold increase in the pre-COVID monthly volume. Table 1 details palliative care patient characteristics pre-COVID and during April 2020.

Table 1.

Consultation Volume before the COVID-19 Pandemic and at the Peak of the Pandemic (April 2020) across the Mount Sinai Health System, Including Mount Sinai Hospital, Mount Sinai West, Mount Sinai Morningside, Mount Sinai Queens, and Mount Sinai Brooklyn

	Pre-COVID (November 2019–February 2020), n (%)	COVID surge (APRIL 2020), n (%)
No. of consultations, total	509	1063
Initial consult	452	1019
Reconsult	40	31
H&P	17	13
Adaptation of existing services
PCU	87	114
of embedded services
ED (location at time of consult)	6	29
ICU (location at time of consult)	70	261
Hospital medicine	32	150
De novo program
PATCH-24	-	174
Demographics and hospitalization
Age, mean (median)	69.8 (71.5)	73.5 (75.0)
Female	273.8 (54)	504 (47.4)
White	169.8 (33)	325 (30.5)
Length of stay, mean (median)	20.5 (12.3)	16.1 (11.0)
In-hospital mortality	170.3 (33)	647 (60.8)
Palliative care utilization
Days from admit to consult, mean (median)	9.9 (4.5)	6.9 (4.0)
Days from consult to discharge, mean (median)	11 (5)	9.5 (5.0)
Karnofsky performance status at admission, mean (median)	47 (46)	50.8 (50.0)
Karnofsky performance status at time of consult, mean (median)	33 (30)	23.9 (20.0)
Discharge disposition
Died	170.3 (33)	647 (60.8)
Home/home with services	128.8 (25)	135 (12.7)
Hospice (any setting)	87.8 (17)	72 (6.8)
Rehab/SNF/SAR	51 (10)	108 (10.2)
Other	71.3 (14)	102 (9.6)

Of note, these data do not include Mount Sinai Beth Israel because this hospital was not using the same electronic health record.

ED, emergency department; H&P, history and physical; ICU, intensive care unit; PATCH-24, PAlliaTive Care Help line-24; PCU, palliative care unit; SAR, subacute rehab; SNF, skilled nursing facility.

Adaptations and Expansion of Existing Palliative Care Services to Meet the Pandemic's Demands

PCU structural adaptation

The inpatient PCU was modified to provide expert symptom management and end-of-life care for persons with COVID-19.⁴ All rooms were converted to negative pressure and changed to allow for continuous patient monitoring and medication/ventilator adjustments while minimizing staff exposure to potential infection (e.g., gas lines extension for ventilators placed outside of rooms, transparent glass panels installation in all doors, high-resolution cameras with video feed to the nursing station, and specialized intravenous [IV] lines installation for IV pump placed outside of the rooms).

Emergency departments

Our model of an embedded palliative care clinician within the MSH ED was expanded across MSHS. At our largest ED (MSH), the embedded palliative care physician was supplemented with a palliative medicine fellow to provide rapid palliative care in-person consultation during peak hours (11 a.m.–7 p.m.). At the other MSHS EDs, we embedded a palliative care fellow supervised by an off-site specialty-trained palliative medicine attending physician. In addition, within each ED, residents (psychiatry, radiation oncology, neurology, dermatology, ophthalmology, and dentistry) who were redeployed to work with the embedded palliative medicine specialists were trained in how to screen patients for palliative care needs through communication with the primary clinical team, identify their surrogate decision makers, conduct noncomplicated goals of care discussions, and liaison with families. Specifically, they completed a one-hour communication skills training (see Communications skills training) and one-hour overview of procedures, including use of tailored template (see below). The PAlliaTive Care Help line (PATCH)-24 service (see below) provided additional telephonic support (7 p.m.–11 a.m.).

Intensive care units

Within MSH's seven critical care units, we embedded Certified Hospice and Palliative Nurses (CHPN), postgraduate fellows, and/or attending physicians. Clinicians focused on identifying patients with complex symptoms and symptom management needs (e.g., severe breathlessness requiring opioid titration in the setting of deteriorating end-organ function) and patients or surrogates who required assistance with complex medical decision making, understanding treatments and their likely outcomes.

Hospital medicine

Pre-COVID, a palliative care-trained social worker (SW) was embedded within hospital medicine to assist with goals of care discussions and transition management.⁵ During COVID, additional SWs were rapidly trained and embedded within hospital medicine to assist with COVID-specific discussions about illness understanding, prognostic understanding, and eliciting goals and values. These SWs were not making medical recommendations, but rather they collaborated with the primary team to build off these conversations to discuss medical decision making.

Newly Created Services to Meet COVID's Challenges

PAlliaTive Care Help line-24

A telephonic PATCH-24⁶ was created early in the pandemic to supplement our programs to offer 24-hour telephonic palliative care consultation to clinicians (teleconsultation) and patient's families (telemedicine). The line was available to clinicians and patients who presented to these MSHS hospitals as well as a temporary 70-bed field hospital. A group of medical students volunteered to receive and direct calls to the team of palliative care physicians. The virtual format allowed us to expand our staff to include volunteer palliative care clinicians from other health systems, and leverage hospital social workers and chaplains to provide bereavement support to these families across MSHS.

Communication skills training

Even our most experienced palliative care clinicians struggled due to the pandemic's unprecedented challenges: the volume of patients with rapidly progressive respiratory failure with symptom management and communication needs, the lack of decisional incapacity in so many patients and the reliance on surrogate decision making, the rapidity with which conversations needed to be conducted, and the visitor restrictions requiring virtual discussions. Soon after the first COVID patients presented to MSHS, communication experts within our faculty created conversation scripts and one-hour virtual training sessions to facilitate rapid focused goals of care discussions in-person with patients and virtually with surrogate decision makers. During these sessions, clinicians learned how to (1) apply communication scripts to goals of care conversations; (2) deliver different types of COVID-specific serious news in a clear, meaningful, and timely manner; and (3) employ these skills across care settings and virtually. We utilized the scripts to train both clinicians with serious illness communication training and those who were deployed to assist the palliative care team in engaging in these conversations (https://www.capc.org/covid-19/communication).⁷

In 13 sessions, we trained 143 geriatrics and palliative medicine providers (24 fellows, 38 attending physicians, 12 advance practice nurses, 3 CHPNs, and 3 SWs). In addition, we trained redeployed residents (radiation oncology, physiatry, psychiatry, and ophthalmology) and deployed them to work within our EDs to conduct these conversations. Finally, we employed 18 out-of-state palliative care physician volunteers to conduct virtual conversations with families to further extend our services.

COVID-specific electronic medical record template

We developed and implemented a focused template to facilitate clear documentation of our streamlined consultations to meet COVID's novel demands. The template included a goals of care discussion section that mirrored the COVID-specific communication skills training to succinctly document recommendations. The assessment/plan focused on symptom management recommendations, identification of surrogate decision maker(s), future treatment plan, and recommended referrals. This template was used for 279 consultations, decreasing documentation time from ∼15 to 5 minutes per consult or 46.5 hours of clinician availability.

Opportunities for Health Systems with Fewer Palliative Care Resources

We recognize that we are reporting from a well-resourced health system. For those smaller health systems, we recommend that your team identify where there is the greatest clinical need (EDs and ICUs) and which clinicians are willing to broaden access to fundament palliative care domains. Next, train those clinicians in core palliative care skills and deploy them to the locations with the greatest need. In our experience, clinicians, including medical trainees (residents and fellows), social workers,⁵ and chaplains, want to help the medical teams, patients and families, and share the responsibility of providing patient- and family-centered care. Clinicians self-selected to participate in special training to expand the scope to of their care to include core palliative care skills. These clinicians always had backup from the specialty-level palliative care team members, and were offered regularly scheduled debriefings, alongside our faculty, staff, and trainees.

Summary

To meet the demands of seriously ill COVID patients in the setting of limited resources and workforce, we expanded our staffing with employed clinicians and out-of-state volunteers; created a 24-hour telephonic service; extended our clinical services to areas of greatest need (EDs, ICUs, and hospital medicine); created new tailored communication trainings that enhanced frontline providers' baseline skills; and implemented novel structural and procedural adaptations to colocate patients at the end of life, maximizing patient comfort and staff safety. These approaches ensured that patients with COVID-19 and their families had access to expert symptom management, serious illness communication and support, and frontline clinicians received needed support as they faced tremendous time pressure, emotional distress, and exhaustion.

Disclaimer

The content is solely the responsibility of the authors and does not necessarily reflect the official view of the National Institute of Aging or the Veterans Administration. There are no relationships with industry.

Funding Information

L.P.G. received support from the National Institute on Aging (NIA) (K23AG049930). R.S.M. received support from National Institute on Aging (NIA) (5P30AG027841-12, R33AG065726) and the National Palliative Care Research Center.

Author Disclosure Statement

No competing financial interests exist.