Abstract
The coronavirus disease 2019 (COVID-19) pandemic has highlighted the central importance of palliative care to our increasingly strained healthcare system. Palliative care is specialized care for people struggling with serious illnesses. Its aim is to improve the patient's quality of life by providing expert-level symptom management and skilled communication and by supporting caregivers to ensure patients and their families receive goal-concordant care. 1 Faced with a reality that patients with frailty and serious illness are the most vulnerable to critical illness and death, early inquiries into patient and family wishes were essential to avoid preventable suffering. To prevent spread of the virus, patients' loved ones were not allowed inside of hospitals across New York, further emphasizing the importance of proficient communication between patients, their families, and the healthcare teams.
During the pandemic, our frontline clinicians at New York City Health + Hospitals (NYC H+H), the largest public health system in the country, faced exceedingly high volumes and acuity with limited resources. NYC H + H cares for over 1.1 million patients annually, serving communities rich in ethnic, racial, and cultural diversity, where many patients—and even healthcare workers—live in multigenerational homes and are often new arrivals to the United States. At peak surge on April 8, 2020, our healthcare workers delivered care to over 2,500 patients hospitalized with COVID-19 per day, withstanding intensive care units filled at 3 to 5 times beyond normal capacity. At the height of the surge, the number of deaths exceeded 500 per day within New York City alone. 2 In addition to existing national palliative care workforce shortages 3 and resource limitations specific to safety net systems, 4 the pandemic brought additional hazards of our own healthcare workers falling ill to the disease. 5 Despite the adversity, our safety net system delivered an efficient and streamlined system-wide effort to meet the rapidly growing palliative care need. In this commentary, we share our experience and lessons learned as the epicenter of the pandemic.
Optimizing Existing Workforce
The unprecedented patient volume and rising critical care needs demanded quick action. For example, one of our hospitals, Lincoln, expanded their intensive care unit capacity from 34 beds to 195 beds to accommodate the need. 6 Bed capacity, however, represented only one piece of the puzzle. Hospital administrators also recognized that they needed to focus immediate attention on ensuring the facility was staffed with enough individuals possessing the appropriate skillsets. Prior to the surge, only a small number of our 11 acute care facilities had the equivalent of the full traditional palliative care interdisciplinary team consisting of 1.0 full-time equivalent each of a physician, advanced practice provider, social worker, and chaplain. During the surge, several factors further strained the scope of the existing teams. Some palliative care team members were asked to redeploy to inpatient areas by local leadership, raising concerns that palliative care needs might not be met. Fortunately, palliative care redeployment was avoided once it became abundantly clear that palliative care was a vital part of the COVID-19 response efforts. As members of the interdisciplinary team fell ill, they were quarantined in their homes. The remaining palliative care providers found themselves committing long days and nights in the hospital, some sleeping in their offices, amid the quadrupling demand for consultations. Many teams changed their practice to meet the demand by increasing the number of “curbside” consultations, investing more in coaching primary teams to approach tough conversations independently, stationing in high-acuity areas (emergency rooms and intensive care units) to proactively meet the rising needs, 7 and supporting all members of the interdisciplinary team to function at the top of their capacity to ensure all consultations ordered were addressed.
Across the system, other specialties—including geriatrics, psychiatry, psychology, critical care, and ambulatory care—were tapped to help meet the increased need for palliative care. Formal email requests were sent from the system leadership team to elicit volunteers for palliative care to the system ambulatory, social work, and geriatrics councils and coordinated with the local leadership to align feasibility in redeployment. Because of the wide variability in surge levels among individual sites and frontline clinical needs, deliberate care was taken to avoid top-down mandates and to focus on voluntary support.
Recruiting External Volunteers
Through assistance from both the city and state, calls for external healthcare worker volunteers were made to support New York City. 8 In-person as well as remote volunteers played a significant role in providing the COVID-19 palliative care response. Although some in-person palliative care volunteers arrived to help, most were recruited to cover emergency medicine, inpatient medicine, and critical care areas. In a time of crisis, a fresh set of eyes and an eager resolve to help went a long way. Furthermore, military healthcare personnel, coordinated by US Department of Defense, arrived to aid our hospitals, which further augmented the workforce and fostered a sense of stability.
To supplement our palliative care services further, a national outreach was made through social media (LinkedIn, Twitter) for telepalliative medicine volunteers (TPMV). 9 The highly successful outreach enlisted 413 volunteers—150 physicians, 96 chaplains, 66 nurse practitioners, 39 nurses, 28 social workers, 15 medical students, 2 physician assistants, and 17 other—to support NYC H+H. Cohorts of 20 were rapid-credentialed and onboarded to provide remote palliative care consultations from across the United States, averaging 3 days for rapid credentialing and onboarding. Five sites agreed to participate in this program, which included daily coordination between the central team, volunteers, and the site leads. A total of 109 TPMV consultations were completed in the first 14-day period, with positive feedback from both the site leads and the remote volunteers regarding the program value. Given its initial success, the program continues still at the time of writing, with expansion to focus more upstream on vulnerable patients, such as those residing in our post-acute care facilities.
Increasing Telehealth Capacity
Unfortunately, increased exposure to COVID-19 significantly impacted our frontline healthcare workers across the United States. 5 Fear of becoming infected or bringing the virus home to their families was common among most healthcare workers, as was the concern about recruiting and maintaining adequate staffing to meet the surge. Amplifying recommendations to standardize telehealth, even within inpatient settings, led to the prioritization of both healthcare worker and patient safety. 10 If safe and appropriate for patient care, care teams were encouraged to use voice and video communication with patients; when physical patient contact was needed, the minimum number of team members were allowed to enter the room. This was ideal for follow-up visits when patients were clinically improving or stable.
Telehealth in the inpatient settings met additional challenges compared to previous outpatient-based telehealth workflows. First, unlike clinics, most inpatient encounters with patients were unscheduled. Before the pandemic, inpatient palliative care teams received rolling requests for consultations throughout the day, with the expectation that they should respond within a 24-hour period, or within the day, or immediately for more emergent situations. During our surge, the number of emergent situations rose exponentially. To complicate matters, patients were sometimes not in their rooms, due to various testing and procedures. Furthermore, palliative care teams faced the added challenge of coordinating additional care team members at the same time to hold time-sensitive patient and family meetings.
Second, the equipment required for optimal telehealth visits are not readily available for all parties, especially the patients. At peak surge, our palliative care teams found themselves using their own smartphones, downloading various video calling applications—eg, WhatsApp, Duo, Skype, FaceTime—in order to teleconference patients with their loved ones. NYC H + H was able to secure 1,300 iPad tablets for the system shortly after the surge began, with prioritization for the palliative care teams, but this required additional staffing and logistical coordination for seamless operation. For remote consultants to coordinate video telehealth with the patient and a family member, a staff member had to enter the patient room to set up, troubleshoot, and disinfect the video tablet apparatus. This often placed the onus on an already busy healthcare worker, including the primary medical team, the nurse, medical assistant, or a palliative care team member, which did not help with video use compliance. Models for inpatient telehealth palliative care consultations during COVID-19 were published, 11 however specific strategies for under-resourced settings were lacking. The addition of a dedicated team member or volunteer who can coordinate these video calls between the palliative care consultant, the patient, and family may be needed in the future.
Considerations and Lessons Learned
In-Person vs Remote Volunteers
The delivery of effective palliative care, especially in complex situations, is often predicated on team function. The addition of new team members during a crisis has the potential to compromise team function. In general, the volunteer recruits mitigated this issue with their overwhelming enthusiasm and assisted in whatever was necessary. Additionally, the volunteers provided the space for families to share emotion and crucial detail on the patients' identities—a sacred space that before the COVID-19 pandemic, many of us took for granted. At a time when core hospital team members struggled to keep up with the influx of new critically ill admissions, the ability to call upon a highly trained workforce, equipped with energy, compassion, and fervent desire to help proved invaluable for many of our sites.
Even with the arrival of hundreds of in-person volunteers, our system still required additional palliative care staffing support in some facilities. Our remote TPMV initiative allowed the most dynamic, day-to-day flexibility in redeployment to cover any fluctuation in consultation needs. It also leveraged a much wider pool of volunteers, as it accessed the entire country, which accommodated the busy hospital schedules of individuals who made time to help. The remote volunteers spanned 3 times zones, offering flexibility to cover late evening calls, provide weekend coverage, and follow up with patients and families outside of their designated TPMV shifts. Most volunteers could not, however, travel to New York City and stay for a week or more away from their families or jobs. Last-minute needs could be met more easily, as the work could be done from the convenience of their homes. With remote volunteers, food, transportation, and housing were not required, which alleviated significant administrative coordination burdens.
In-person volunteers offered unique advantages compared to remote volunteers, however. Because of the sheer volume and rapid deterioration of patients with COVID-19, certain tasks such as timely and comprehensive documentation were not prioritized. Many clinicians on the ground did not have the chance to chart until after their shifts were over, thus anyone remote who was charged with speaking to a patient's family would be unable to give accurate, up-to-date information based on the electronic health record alone. This meant the TPMVs needed a point-person on the ground to help clarify questions about institutional norms and policies, provide contact information for certain unit staff or consultant team members, and navigate local cultural traditions. Sometimes, these complexities limited the types and number of consultations given to remote volunteers, as it was easier for the in-person palliative care member to do it themselves. Due to these operational burdens, 6 out of 11 acute care sites declined using remote volunteers. Some facility administrators felt they had adequate in-person staffing while others were concerned that this never-before trialed remote volunteer program—in a health system lacking an existing telehealth infrastructure—might require considerable amounts of logistical troubleshooting, for which there was no time to spare.
Pandemic Palliative Care Insights
Overall, both in-person and remote volunteers received overwhelmingly positive feedback and praise from site leads for their service and shared similar reflections on their experience. System leadership organized structured debriefings for the volunteers, which were well attended. A few themes emerged from these sessions. First, the volunteers were surprised by how warmly welcomed they were by families they had never called before, even if the updates they offered were often inconclusive and bleak. One palliative care volunteer shared that patients' families would often inquire about the wellbeing of the provider calling and send wishes of good health to the hospital workers during the call. This touching response to a general sense of collective suffering in New York City spoke to the ubiquity of the COVID-19-related devastation surrounding us. Finally, remote volunteers were quite struck to discover that many patients had already lost multiple family members to COVID-19 and, in some cases, were the sole survivor in their household.
The pandemic posed challenges to and a steep learning curve for goals of care exploration, even for expert navigators. Early in the pandemic, treatment options were unclear and often under public debate. As a result, it was difficult to be conclusive about whether aggressive critical care would benefit a patient, based on their clinical goals. Furthermore, in light of reports from Italy and China, there was early concern over potential vital resource scarcity, which posed an uncomfortable ethical layer to consider, one that many of us had, up until this point, been fortunate enough to never encounter before. New York City boasts dozens of state-of-the-art centers of excellence—the dynamics of scarce resource allocation were unfamiliar to even our most experienced clinicians. Fortunately, our system was able to avoid employing the ventilator allocation protocols—drafted with national experts prior to the surge—out of an abundance of caution.
Working Upstream in Advanced Care Planning
As we prepare for a potential second wave in New York City, we are proactively working upstream to initiate goals of care exploration with patients at high risk of morbidity and mortality from COVID-19. Our 5 post-acute care facilities include populations of high-risk older adults with severe chronic disease, including dementia, heart failure, and chronic obstructive pulmonary disease. Both local and international reports during the COVID-19 pandemic have expressed concerns about the impact of COVID-19 on nursing homes and long-term care facilities.12,13 Early palliative care involvement in chronic illness can produce many benefits, including an increased understanding between patients and their care teams. 14 Patients who have had the chance to engage in thoughtful, iterative discussions about their values with sufficient guidance, may approach the end of life with more autonomy, dignity, and peace. As a result, their families have reported fewer grief-related complications.15,16 Preexisting advanced directives may not be sufficient to ensure goal-concordant care during the COVID-19 pandemic. 17 Pandemic-specific palliative care calls for upstream reiteration of goals by skilled providers surrounding specific topics, including intubation and hospitalization.
Automatic triggers for palliative care consultations remain an area of potential exploration. Many hospitals in our system drafted COVID-19-related triggers for palliative care consultations, with the goal of upstreaming advanced planning for patients hospitalized with COVID-19 prior to anticipated deterioration. Such triggers included palliative care consultations for patients with 2 or more chronic conditions and an oxygen saturation below 88% on room air, or below 92% on supplemental oxygen, or for intubated patients who developed renal failure. Although these triggers were put in place, the overwhelming volume of surge patients—along with very rapid clinical deterioration—quickly nullified the plans, again illustrating the importance of flexibility. A possible solution for this is to use electronic health records as a tool to automate palliative care consultation orders based on validated trigger tools available to all NYC H + H staff through the Center to Advance Palliative Care website. 18
Conclusion
The COVID-19 pandemic swept through New York City, leaving a great deal of suffering in its wake and increasing the demand for palliative care. Despite the largescale devastation, our health system was able to unite, organize, and effectively meet the growing need for palliative care for our patients and their families. We have learned that palliative care services are scalable in the safety net in the face of an evolving pandemic, even despite nationwide palliative care workforce shortages. However, the success of our pandemic palliative care effort was built on significant system-wide collaboration, logistical support, and flexibility. The pandemic underscored the importance of moving goals of care conversations more upstream in order to optimize goal-concordant care. Further, we have shown that remote telepalliative care consultations can appropriately enhance a safety net health system's ability to address unmet palliative care needs. Next steps for our system are to incorporate lessons learned during the pandemic to continue meaningful long-term investments in palliative care. This includes revisiting previously conducted needs assessments of palliative care in our communities to account for the impact of COVID-19, leveraging electronic health records to create triggers for automatic consultations based on specific validated criteria, and helping other health systems navigate palliative care response efforts as they experiencing their pandemic-related surges. Finally, we note that our pandemic palliative care response would not have been possible without the motivated clinicians who, despite moral distress and exhaustion inherent to the surge, pressed on to deliver the best possible care to our patients.