Complexities of Corona Virus Disease-19: The Role of Palliative Care at a Veterans Affairs Hospital

Introduction

The pandemic that began in late 2019 due to the Severe Acute Respiratory Syndrome Corona Virus 2 (SARS-CoV-2) has caused tremendous suffering with lingering effects. Patients afflicted by the Corona Virus Disease-19 (COVID-19) resulting from SARS-CoV-2 experience a host of physical symptoms and medical uncertainty confounded by separation from loved ones. Owing to this, those who die from this illness have atypical end-of-life processes, often dying in the company of health care professionals rather than those familiar to them.

Older adults face both an increased risk of death from COVID-19 and medical complications, such as delirium, which are exacerbated by social isolation. ¹ Palliative care involvement has been widely recommended for those burdened by COVID-19 to enhance symptom management, establish goals of care, and provide family support, including bereavement. ² Despite this, there is little guidance reported on the role of palliative care in acute care settings during a pandemic. ³

Within our Veterans Affairs (VA) health care system, we frequently care for older adults with multiple medical and psychiatric comorbidities. As we anticipated a surge of COVID-19 patients entering our acute care hospital in the Spring of 2020, our interdisciplinary palliative care team collaborated to establish and carry out best practices. In this brief report we share our experience caring for medically and psychosocially complex veteran patients who died from COVID-19. We highlight factors unique to caring for an older veteran population with COVID-19 and provide recommendations for palliative care teams caring for older adult populations.

Methods

We conducted a retrospective chart review of patients who died from COVID-19 in our VA acute care hospital between March 31, 2020 and May 19, 2020. Dates were selected based on coincidental timing of a surge of COVID-19 cases in our facility. Patients were included if they died from a COVID-19-related complication. Patients were excluded if they did not die from COVID-19. Deaths were identified using the Veterans Health Information Systems and Technology Architecture (VistA) and cross-referenced with the nurse quality manager.

Two authors (J.L.M. and L.M.S.) performed detailed chart reviews and extracted data from the electronic health record (EHR). We recorded activities of daily living (ADLs) before admission based on preadmission home care and clinic or facility notes. ADLs at admission were extracted from the nursing admission note. Medical comorbidities were defined as chronic illnesses that might predict worse outcomes, as well as other conditions associated with severe COVID-19. ⁴ Medical comorbidities included cardiovascular diseases, pulmonary diseases, diabetes mellitus, obesity, hematologic dyscrasias, active malignancy, and neurologic disorders, including dementia. We identified dementia if it appeared in the active problem list with supporting documentation in a progress note or admission note, or if documentation of cognitive testing was consistent with a dementia diagnosis. Psychiatric comorbidities included diagnoses defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as being mental health disorders. ⁵ We included diagnoses present in the active problem list in the EHR and documented in clinical notes during the index admission. Detailed medical diagnoses included in the analysis are listed in Appendix Table A1.

This project was reviewed by the VA Boston Healthcare System Research and Development Committee and was determined to be nonresearch. All data were reviewed and collated by the authors.

Results

A total of 33 patients died from COVID-19 in acute care during the time period reviewed. On average, the patients who died were 83.2 years of age with 5.0 medical comorbidities. A majority (85%) were dependent for at least one ADL and 39% carried a diagnosis of dementia. Two-thirds of these patients did not have a do-not-resuscitate (DNR) order on admission and all had a DNR order at the time of death. All patients identified as male (Table 1).

The VA cares for a psychosocially complex group of patients. We explored our patient subset with focus on psychosocial characteristics that might impact end-of-life decision making. Notably, more than one-third (39.4%) had at least one psychiatric comorbidity with depression and post-traumatic stress disorder being most prominent. Nearly half (45.4%) had a decision maker selected or appointed who was not a spouse or first-degree relative. The vast majority (87.8%) were in an institutional environment before admission, which mirrors the ADL dependence described earlier (Table 2).

Palliative care was involved in the care of 87.9% of the studied patients who died from COVID-19. Involvement included either a palliative care team consultation or primary medical attending physician care by a hospice and palliative medicine-trained physician. In patients for whom palliative care was involved in a consultative role, the average number of days between admission and palliative care consultation was 3.54 days. Less than half of patients (42%) were transferred to the intensive care unit (ICU). Thirty percent of patients were directly admitted, bypassing the emergency department (ED). Of the three patients seen by palliative care in the ED, none were transferred to the ICU. The average length of time between palliative care consultation and death was just more than one week (Table 3).

Discussion

Our results are consistent with other findings suggesting worse outcomes for older patients with COVID-19 and comorbid medical illness. ⁴ Our acute care hospital is a 120-bed facility, resulting in a smaller sample size of inpatients who died from COVID-19. However, the population studied is representative of the larger population receiving palliative care consultation in our acute care hospital. Despite the average octogenarian age, comorbidities, and need for ADL assistance of the patients who died, two-thirds had unspecified resuscitation preferences at the time of admission. This highlights the importance of proactive goals of care conversations with at-risk patients. Early exploration of what is most important can guide recommendations on life-sustaining treatments that are likely to preserve a patient's perceived quality of life and align with their values. As part of our planning for an anticipated surge of cases in the inpatient setting, members of our palliative care team proactively called patients in the care of our outpatient team to discuss their goals of care in the context of the COVID-19 pandemic. These conversations were meant to complement similar work that was being done in the primary care setting at our medical center. Given the ongoing COVID-19 crisis, it is prudent to continue proactive goals of care conversations to help insure concordant treatment in the event of hospitalization with COVID-19 infection.

The psychosocial complexity of the patients we care for is also highlighted in the population we reviewed. It is known that patients with serious mental illness have increased risk of medical illness and functional limitations. ⁶ More than one-third of our sample were at additional risk for worse outcomes at the time of presentation because of comorbid mental illness. Designated surrogate decision makers are essential for patients with dementia or the delirium so common in acute illness from COVID-19. Fortunately, all but one of the patients who died during this time had either a designated health care proxy or guardian upon admission. Interestingly, nearly half of our sample's designated decision makers were not spouses or first-degree relatives, defined as a children or siblings. Limited communication due to illness or visitation restrictions placed great burdens on those asked to make these decisions. Palliative care clinicians are often called upon to guide these delicate end-of-life decisions and, under these circumstances, this role became even more essential.

Our palliative care clinicians were involved in the care of a majority of patients who died in our inpatient setting during our COVID-19 surge. As the surge progressed, we became more seamlessly integrated. We were also able to provide consultation earlier in the course of disease. Notably, patients who died in the hospital without ICU admission were more likely to have earlier palliative care involvement (2.8 days vs. 3 days). Our recommended practices can be divided into three broad categories—patient care, colleague care, and bereavement care—and are summarized in Table 4.

Proactive daily conversation with both nursing staff and clinicians caring for patients with COVID-19 helped to identify those who would benefit from enhanced symptom management, conversation around goals of care, and support of their loved ones. Embedding our team in person with the intensive care teams lent additional support to the teams caring for the most critically ill of these patients, many of whom died during this time.

Although our team typically coordinates bereavement calls for patients in whose care we have been involved, we volunteered to coordinate these calls for all patients who died in our inpatient setting during this time. We did this because of the expectation that bereavement might be more complicated, even if a patient did not die from COVID-19, with more visitation restriction and general global socialization changes.

The circumstances under which our health care system has found itself are both humbling and melancholic. Our goals in sharing our team's experience are to provide information on what we found helpful and lend support to those caring for patients experiencing similar clinical conditions with a focus on alleviating this joint suffering.