Abstract
Dear Editor:
Outbreaks of coronavirus 19 (COVID-19) have been reported in long-term care (LTC) facilities throughout the United States. Residents of these facilities live in proximity to one another and are at high risk for COVID-19 infection due to advanced age and underlying medical conditions. 1 Preliminary studies indicate high case fatality rates among LTC residents. 2
Residents of LTC facilities have many palliative care needs, including need for communication about preferences for medical interventions and management of symptoms related to chronic disease and its treatment. 3 In the midst of the COVID-19 pandemic, addressing these needs is critically important. Residents whose preferences are to forgo hospitalization or aggressive life-sustaining care likely have high symptom burdens needing to be managed at LTC facilities. In addition, residents, families, and facility staff could all benefit from additional psychosocial support during times of high stress and isolation, and specialist bereavement services may be needed in some instances. However, many facilities have significantly curtailed physical access to their buildings to limit virus transmission to vulnerable residents and staff, creating challenges to the delivery of palliative care in the LTC setting.
To meet the palliative care needs of LTC facility residents during the pandemic, we implemented a Palliative Care–LTC Partnership Program with support from the local Department of Health. LTC facility staff members identify residents with known or suspected COVID-19 infection and documented preferences to avoid hospitalization, mechanical ventilation, and cardiopulmonary resuscitation. The Palliative Care-LTC Partnership Program addresses several key palliative care needs.
Conservative Medical Management
To support residents wishing to avoid hospitalization, conservative medical management is provided in LTC facilities. Residents receive IV fluids, supplemental oxygen through nasal cannula, and laboratory testing as needed. Residents who decline despite supportive management are transitioned to a comfort-focused plan for end-of-life (EOL) care at the LTC facility. These measures allow facilities to provide goal-concordant medical care during the pandemic, and limit undesired hospital transfers.
Communication Support
Palliative medicine physicians contact the loved ones of each referred resident to discuss goals and preferences for medical care. They continue to engage in discussions about goals of care as needed, typically one to two times per week.
Symptom Management
Symptom management protocols support treatment of pain, dyspnea, and anxiety by LTC facility staff. Palliative medicine physicians assist with management of refractory symptoms.
Psychosocial Support
Upon referral, each LTC resident in the program is assigned a psychosocial team consisting of a social worker and chaplain with expertise in palliative care. The psychosocial team provides ongoing emotional and spiritual support to residents and their families. For those residents who die as a result of their illness, the psychosocial team connects families to specialized COVID-19 bereavement resources.
In its first month, the Palliative Care–LTC Partnership Program served 7 LTC facilities and 57 residents; 14 residents died at their LTC facility with support from the program. Further study is underway to understand the impact of the program on LTC facility staff and residents. This program represents a strategy to meet the palliative care needs of LTC residents during the COVID-19 pandemic.