Integrating Palliative Care Services in Pandemics and Emergencies Preparedness and Response Plans

The coronavirus disease 2019 (covid-19) pandemic has brought an unimaginable crisis to healthcare systems worldwide. The SARS-CoV-2 virus is highly potent in transmission among community and healthcare settings. The cases of COVID-19 have rapidly increased worldwide. The data reveals an average of 200,000 new cases every day and a global death toll of over 2.5 million at the time of writing this article.1,2 Like other countries, Oman has confirmed at least 143,955 cases and over 1,500 deaths in March 2021.2 Restrictive measures such as physical distancing, visitor restrictions in healthcare facilities and burial and funeral restrictions have been implemented and strictly monitored.

Magnitude of the Problem

It is well-recognised that, sadly, many patients did not survive this pandemic.2 Physical distancing and a hospital ban on visits make patients’ death especially difficult; they suffer the disease alone and die in the hospital without their relatives’ support. News of death is often regarded as the most painful event a family will receive and it is the start of the grief and grieving process.3–5 Healthcare providers lack the knowledge and skills to provide care to grieving families. Relatives are often found isolated and crying during the terminal phases of their loved one’s life.6

The Increasing Demand for Palliative Care

Palliative care, according to the World Health Organization, is: “an approach that improves the quality of life of patients and their families facing the problems associated with a life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment, and treatment of pain and other problems: physical, psychosocial and spiritual”.7 The effectiveness and cost-effectiveness of palliative care, both in the hospital and at home, are well documented. It preserves patients’ rights and promotes patient-centred care.8,9 Experts from King’s College London have produced worldwide projections of the future of palliative care. It is estimated that by 2060, 48 million people per year will die from severe health-related illnesses and 83% of these individuals will be from low and middle-income nations.10

During the pandemic, it became more evident that palliative care is an ethical imperative. It is globally recognised that palliative care is a health system strengthening intervention. Evidence suggest that palliative care services have a role to play in supporting the wider health system and a survey in the Middle-East region has shown that palliative care services have the capacity to support the wider health system with additional support and resources.11,12 Palliative care successfully supports the acute medical management plan by addressing the collective suffering of COVID-19 patients and tailoring curative options according to the needs of the individuals. In particular, those who rapidly deteriorate and those who are not suitable for admission to the intensive care unit, all being attained within a context of maintaining human rights.13,14 Moreover, the large disease burden of COVID-19 and implementation of restrictive measures to contain the spread of Coronavirus also have complicated issues of grief and bereavement process for patients, their families and healthcare providers. Attending to these issues is where palliative care has made the most significant impact.15,16 All of these challenges amplify the importance of developing an evidence based approach to provide palliative care during pandemics.

In Oman, palliative care is currently provided for patients in the National Oncology Centre, which is limited to pain management and control of symptoms. Some initiatives have been taken to promote the service. Oman Cancer Association in partnership with the Ministry of Health trained 360 Omani nurses and 20 primary care physicians in palliative care from April 2013 to February 2017. Furthermore, a website called Oman Palliative Care was created for palliative care in 2019. However, the service is still in its early stages and it should be strengthened to provide different palliative care models and expanded to all medical conditions. This paper has suggested two recommendations to improve provision of palliative care in Oman during pandemics and healthcare emergencies.

INTEGRATION OF PALLIATIVE CARE INTO PREPAREDNESS AND RESPONSE PLANS

Challenges have emerged during the COVID-19 pandemic. These include rationing care when resources are limited and withholding non-beneficial treatment and palliative treatment options to treat breathlessness and other distressing symptoms of COVID-19. Palliative care services provide an extra layer of support to manage these challenges.11,12 Integrating palliative care services into preparedness and response plans would require appropriate guidelines to standardise care, adequate policies and legislations, capacity building of healthcare workers in palliative care, accredited training and degree programmes; it would also require an advanced approach to deliver the service during a pandemic.17,18

ADVANCED APPROACHES TO DELIVER PALLIATIVE CARE DURING A PANDEMIC

Tele-palliative medicine

There is strong support for maximising the use of telemedicine in the provision of palliative care for inpatients, outpatients and patients at home; successful implementation requires robust health infrastructure support and technical expertise.19–24 Tele-palliative care allows for remote delivery of palliative care services such as symptom assessments, discussion of goals of care as well as counselling and bereavement support. This approach minimises exposure to the infection, reduces personal protective equipment use and reconnects the patient with clinicians and their family during the challenging times brought on by the COVID-19 pandemic.18,20

A 24/7 hotline access to the palliative care team

Applying creative interventions during a crisis situation are beneficial in reducing emotional distress and facilitating a supportive transition throughout the grieving process for patients as well as the bereaved families.25,26 Launching a 24/7 hotline access to the palliative care team was one of the interventions implemented during the COVID-19 crisis in the health system of Mount Sinai in New York City. The help line provides two support services: teleconsultation (physician-to-physician support) and telemedicine (palliative medicine-to-family). Telephonic support by a palliative care team assisted clinicians in conducting complex goals-of-care discussion and symptoms management during the peak of the COVID-19 pandemic in New York City and helped families to receive clear and timely information about their loved one’s condition, enabled patients and families to participate in decision-making, increased the development of trust and facilitated the process of grieving and healing.27 Developing hotline access to palliative care teams in Oman will allow provision of palliative care services in clinical sites in the highest need of support during pandemics and healthcare emergencies. This service will provide coverage of palliative care to all hospitals which lack hospital-based palliative care services.

Home-based palliative care

Evidence has shown that home palliative care programmes provide better management of distressing symptoms of dying patients.28 However, there is a lack of data on how this could be done during a pandemic. One study recommended availability of mobile palliative care teams for the Covid-19 patients who would prefer to die at home.17 Many studies have found clear benefits of interdisciplinary palliative care teams, because each discipline will have a unique role to function in the realm of psychosocial and spiritual care.28 Globally, the demand for home-based palliative care will substantially increase in the future.10 Developing this service in Oman is subjected to certain limitations. The greatest of which is the restrictive policies concerning pain medication that requires changing legislation by raising awareness within the community to allow people to be cared for at home.

Over the years, it is reasonable to expect that other pandemics or healthcare emergencies will emerge. Therefore, integration of palliative care into preparedness and response plans is a priority to alleviate suffering. Palliative care service should be considered as a critical component of a health system disaster response and a part of the global commitment to the Universal Health Coverage (UHC), which considers palliative care as an essential health service. It is suggested that integrating palliative care into response plans would foster reaching the UHC goals. Developing a national policy on palliative care will resolve many barriers to palliative care in general and will allow expansion of this service during pandemics and healthcare emergencies.