Table 2.

Summary of findings (n = 18).

Author(s)	Participant(s)	* JHNEBP StudyDesign	Facilitators of Palliative Care in Ambulatory Care Organizations during COVID-19	Barriers of Palliative Care in Ambulatory Care Organizations during COVID-19
Mishra et al. [1]	Outpatient cancer centers offering palliative care	4	Creation of a plan to control for resource limitation and personnel mobility restrictions Specialist palliative care centers need to coordinate and involve other primary-and secondary-level healthcare systems of their regions for providing a quality palliative care for all cancer patients when they are in need Admit (to inpatient) only those patients who require urgent in hospital palliative intervention Stockpiling adequate drugs, instruments, and resources Develop standard protocols for symptoms management Educate the patient and family Shift the care model to a family-centric one Build up communication skills and triaging priority patients for in-hospital and community-based palliative care services	Inadequate social support Lack of advanced care planning Inadequate information Fear of unknown disease Social distancing leads to difficulty in accessing family support for psychological, social, and physical symptoms management Poor peer support Limited visitor entry at home and hospices makes it difficult to maintain the integrity of family-centered care Difficulty in end-of-life care communication and shared decision making regarding advanced care planning due to physical distancing Difficult communication due to less face-to-face contact. Caregiver social distancing augments the feeling of loneliness, anxiety, and stress Limited access to telehealth due to lack of expertise in technology Economic stress due to loss of job Limited access to bereavement services Healthcare system (45) inadequate palliative care resources due to diversion for care of the large number of infected persons Quarantine of healthcare workers following an exposure also leads to shortage of workforce Ethical dilemmas in triaging resources Difficult access to opioids due to strict laws Psychological stresses, anxiety, fear of infection, insomnia, and posttraumatic stress disorder among healthcare workers Lack of personal support system for healthcare workers Difficulty in coordinating among multiple disciplines involved in cancer care Lack of adequate standardized protocol for different oncological treatment Lack of adequate hospices, especially in developing countries Lack of community-based healthcare workers during pandemic Unavailability of good network at remote areas for accessing teleconsultation
Jänig et al. [5]	US military medical treatment facilities	4	Palliative care was mentioned in the triage flowchart if a patient’s condition was worsening and there was not a realistic chance of improvement if they were transferred to an ICU; in this care, palliative care must be an option	N/A
Tran et al. [6]	Palo Alto Medical Foundation Palliative Care and Support Services	4	Creation of a triaging tool for patients needing palliative care during the pandemic maintained the safety and quality of care to other vulnerable populations Rapid transition of most consults to telehealth visits, triaging patients, and determining the risk associated by visiting/caring for patients in their home or facilities Frequent communication among interdisciplinary teams and use of the triage tool were found to be beneficial in keeping patients and staff safe while providing quality palliative care to those in need during the pandemic (patient scheduling benefit)	N/A
Roberts et al. [7]	Palliative care experts in primary care, including social work, pharmacy, nursing, and medicine at Johns Hopkins Bayview Medical Center (outpatient)	3	Weekly meetings included personal check-ins, creative brainstorming, candid peer-to-peer communication, and outcome-oriented organization and accountability Dissemination of a concise, user-friendly provider education that would enable primary care clinicians to identify potential management strategies for patients with COVID-19 who elect to remain at home for end-of-life comfort care Strong focus on organizational methods with creative nonhierarchical collaboration for outpatient providers Mnemonics and scripts as roadmaps identified as highly useful as providers care for their patients Study identified a lack of palliative care knowledge and resources available for outpatient primary care physicians, thus resulting in the development of a mobile app and toolkit to guide clinicians in discussions with COVID-19 patients electing to stay home for end-of-life services	Provider education gap identified in primary palliative care for outpatient clinicians during the COVID-19 pandemic Outpatient providers expressed communication gaps in protocols and best practices regarding palliative care
Cals et al. [8]	Primary care medical practices	3	The Consortium Research Family Medicine was started as a partnership among the 8 university departments to identify patients requiring palliative care during COVID-19 A registry database enabled providers to identify the number of positive COVID-19 patients or highly suspicious COVID-19 patients that died at home under the care of their general practitioner and whether they had received palliative care services from their primary care provider	Overcrowded ICU wards and hospitals were highlighted in the media, while outpatient providers were expected to provide continued palliative care to COVID-19 patients Access to care was determined to be inconsistent across the Netherlands, and, in some regions with the highest number of cases, there was more palliative care being done at home than in other areas
Lally et al. [9]	Department of Psychosocial Oncology and Palliative Care, Dana Farber Cancer Institute, Boston, MA	3	A palliative care clinic transitioned into a palliative telehealth clinic to continue/expand access to care The transition into palliative telehealth allowed for sicker patients to get easier access and stay protected during COVID-19 The telehealth transition during the pandemic enables a much higher level of interdisciplinary care among a wide range of medical providers Patients often initiated conversations about their goals and preferences at a higher level using telehealth resources to enable better palliative care during COVID-19 Increased scheduling flexibility was experienced by the clinic	Many regulatory, legal, and financial barriers to telehealth arose early in the transition Concerns such as lack of body language cues and the resultant difficulty in responding appropriately to emotion were difficult to assess via telehealth Some patients were unable to use video-based platforms, and phone became the only option for patients not wanting to risk an in-person encounter People without video access were forced to choose between the risks associated with an in-person visit versus a lower-quality telephonic palliative care visit
Trianti et al. [10]	Multiple outpatient clinic palliative care patients	2	The psychological impact of the pandemic in patients in the hospice appeared negligible. One could also argue that social isolation might conversely lead to a reduction in anxiety due to reduced input from the social environment.	However, patients under ambulatory palliative care reported measurable anxiety caused by COVID-19 that was comparable to the effect reported by the control population Considerable degree of anxiety experienced by the patients who visited the general practice of 4.5 out of 10 on the visual analog scale Patients under ambulatory palliative care experienced a similar (albeit moderate) degree of anxiety as patients visiting the general practitioner’s practice
Morris et al. [11]	Brigham and Women’s Hospital, Boston, MA, USA	4	Organizations can implement basic bereavement outreach, using palliative care tools and psychological strategies to prepare families for the death of their loved ones and to support them afterward in the initial months of their bereavement Care processes and communication skills identified as essentials services during palliative care in a pandemic	An urgency exists from a public health perspective to expand bereavement services in an attempt to mitigate poor bereavement outcomes
Oseni et al. [12]	Family practitioner clinics	4	Study identified that family practice physicians are often the first point of contact with COVID-19 patients; thus, incorporating the full spectrum of care to these patients at home can help mitigate the need to go to the hospital and help prevent the spread Efforts should be focused on educating and providing resources to primary care physicians in treating, mitigating, and offering end of life care to COVID-19 patients	Home visit and hospice care increase the cost of healthcare to patients and are mostly available to those who can afford it More flexibility of protocols suggested for disease management, training of caregivers, and providing appropriate technology including telemedicine to minimize the contact and promote social distancing
Pai et al. [13]	Staff nurses working in the wards/outpatient departments of a reputed palliative care center	4	Nurses providing palliative care experienced the following facilitators: Counseling and emotional support Appreciation and reward Use of telenursing services	Nurses providing palliative care experienced the following barriers: Fear of acquiring infection and risking own health Fear of harming family members or losing loved ones Changes in sleep, eating patterns, and concentration issues Worsening of chronic health problems Fear of avoidance from the community Access to palliative care services
Arya et al. [14]	Multi-specialty clinics	4	Providers advised to stockpile medications and supplies used in palliative care, train staff to meet palliative care needs, optimize space, refine systems, alleviate the effects of separation, have critical conversations, and focus on marginalized populations to ensure that all patients are cared for equitably Preparing and distributing sufficient numbers of “palliative medication kits” could help address this issue in any setting with substantial numbers of patients who might not survive. Have spiritual care staff and social work ready to manage common psychosocial needs such as grief and bereavement	Palliative care services are needed across many different care settings, including intensive care units, hospital wards, emergency departments, and long-term care centers (access issues) In a pandemic, patient autonomy to choose life-prolonging measures or location of death could be severely restricted as a result of public health directives and resource availability Some patients are isolated at end-of-life stages
Inzitari et al. [15]	Post-acute facility	3	Advanced care planning with reasonable therapeutic effort for each patient facilitated palliative care Accelerated screening of patients and staff through polymerase chain reaction (PCR) tests Acute care treatment of COVID-19 was balanced with palliative and geriatric care, mainly oriented toward preventing and managing delirium using nonpharmacological interventions	Instituted lockdown to external visitors
McKenna et al. [16]	Advanced care planning initiative	3	Three advanced care planning key themes were identified: (a) feeling emotionally safe enough to have such sensitive conversations is vital; (b) participating in the HLD process increases the confidence of those participants who worked in health and social care, to undertake ACP conversations; (c) planning ahead is a complex, staged process rather than a single record-making event This article identified advanced care planning as a facilitator to effective care during the pandemic	N/A
Wei et al. [17]	New York City Health + Hospital system pandemic established protocols	4	Provision of daily updates by telephone and used tablets for virtual visits Expanded palliative care team held virtual consultations with families to discuss advance care planning and end-of-life decisions	N/A
Seminara et al. [18]	Medical home visit program embedded in the Divisionof Geriatrics at Staten Island University Hospital in New York	4	Benefits of telehealth for families and patients were identified in the article Defining the most critical cases first proved beneficial Establishment of pre-visit and post-visit protocols for palliative care Addressing staff concerns surrounding motivation and honesty of issues experienced, and identifying most vulnerable patients during the pandemic	Fear of encountering COVID-19 precipitates poor decision making Inadequate supplies of timely diagnostics for COVID-19 adversely affect services for homebound patients A lack of personal protective equipment also diminished services by vendors such as visiting nurses and physical therapists COVID-19 triggered altered end-of-life decisions by those afraid to be without loved ones in the hospital
Page et al. [19]	Home-based care strategy and experience of the Cipla Palliative Care and Training Center	4	N/A	Difficulty in accessing medical care in the event of increased symptom burden Obstacles in reaching hospitals at time of emergencies or end of life Limited access to medication, and social distancing causing isolation, leading to psychosocial burden Lack of bereavement support
Cheng [20]	Medicine and geriatrics department	4	Caregivers respond rapidly and flexibly Caregivers ensure protocols for symptom management are available, considering redeploying staffs and volunteers to provide psychosocial and bereavement care and using technology to communicate with patients and providers Mobile consultative team should be available in situation of difficult symptoms control, for instance, in cancer patients who were already receiving opioids for pain, or when goals of care became unclear in advanced cancer patients	Immunosuppressed status of some cancer patients, whether caused by the disease itself or the treatment, increases their risk of infection compared with the general population
Weinstein et al. [21]	Penn Medicine Head and Neck Cancer Service Line	4	Ethical care guidelines guided by professionals and experts in this field, including inpatient and outpatient care for patients with head and neck cancers Extension of medication treatment to prevent frequent in-person visits Consideration for decreased frequency of in-person visits and imaging studies Telehealth should be utilized for end-of-life care and palliative care through Penn health Much or all of end-of-life care can be delivered at home via telehealth visits	N/A

* Johns Hopkins Nursing Evidence-Based Practice (JHNEBP) levels of strength of evidence: level 1, experimental study/randomized control trial (RCT); level 2, quasi-experimental study; level 3, nonexperimental, qualitative, or meta-synthesis study; level 4, opinion of nationally recognized experts based on research evidence/consensus panels; level 5, opinions of industry experts not based on research evidence.