Professor Dr Christoph Ostgathe is President of the European Association for Palliative Care (EAPC), and a palliative care physician at the Universitätsklinikum Erlangen, Germany. Here he asks if palliative care teams are prepared for what may be their important role in the current crisis and calls for us all to share thoughts and experience on #pallicovid
Currently it seems that there is not a moment when there is not some new information about the worldwide spread of the coronavirus. Many people I talk to share the feeling of being overwhelmed by something they cannot control. The truth of today is the wrong of tomorrow. We are all hoping that the people in power in our countries are well informed about the necessary measures even if they are taken, not taken or taken late. To be honest, this is my impression; not in all cases, in all countries this seems to be the case! Crisis makes good presidents but also reveals the bad ones.
What strikes me currently, is that for the first time in my life and my career, this major public health crisis is not something that has happened to others somewhere in the world, far away, out of sight. No, this is happening right now in front of our eyes, in our countries. Suddenly, I understand many things much better. This is a harsh lesson, how shameful that it has taken a pandemic that impacts on Europe for us to truly understand what has, so often, been a reality in other parts of the world. Making us learn from experience.
For palliative care services, many scenarios in the corona crisis were unimaginable. In times of a pandemic crisis, when scarce resources have to be utilised fully, services that are not directly integrated into the care of the mass influx of corona-infected patients may be reduced in staff or even closed; palliative care may be assessed as a non-essential service. But palliative care is key. The patients most significantly affected by COVID-19 are the elderly, weak and sick, many of them patients that we would perceive as patients with palliative care needs. Whereas the mortality of positive-tested patients in different countries ranges currently between 0.3-7.1% , the coronavirus associated mortality in this frail and elderly population is exponentially higher. The average age of deceased patients positive for COVID-19 is 79.5 years (median 80.5, range 31-103, IQR 74.3-85.9) and 99 per cent have at least one other illness . It is therefore clear that there is no doubt about the value of palliative care as an approach in every clinical setting where corona patients are cared for and for specialised support where more complex multidimensional symptoms/problems occur. And this all in a context of the necessary isolation and hygiene safety measures, hampering in itself social inclusion as one major palliative care paradigm.
What has happened, mainly in northern Italy (and most likely soon in many other countries), is that there are insufficient resources to meet demand. There are high numbers of infected, and very sick people: not enough well rested medical staff, tests, intensive care beds, ventilators, other life sustaining devices. There are, anecdotally, situations in which prioritisation/triage are necessary to decide who will be ventilated, and who will not, who has a chance to live and who must die. Doctors and nurses are and will, not only in northern Italy, be confronted with these clinical, ethical and humanly challenging issues daily in the coming weeks and months. Palliative care cannot solve this alone, but we can be an important support. As palliative care specialists, we are commonly confronted with difficult treatment decisions and can be instrumental in balancing different perspectives, embracing psychological, social and spiritual issues of patients, their families and the staff caring for them.
A further situation that may also arise, as we focus on the pandemic plans, is that whilst the majority of patients with coronavirus will be treated in intensive and intermediate care units, other hospital units such as palliative care units, may be used as overflow for other patients that are not in a palliative care situation. This will require palliative care physicians, nurses and other healthcare professionals to step up and be flexible in their working practices.
Are we as palliative care teams really prepared for what may be our important role in the crisis?
Are we seen as an important partner within the crisis plans of our services? During this crisis, in palliative care we need to step up and ensure that we are proactive; that we fully utilise our well-honed skills and competencies and prove that we are an important part of our hospitals and our services crisis plans. It is important that we are able to speak out loud where there is treatable suffering in this crisis. We need to make it clear that in a pandemic like this palliative care is not a luxury, it is a human right!
Share your thoughts and experience on #pallicovid
Be prepared for all of the new challenges we are all likely to face and be flexible as we try to find new answers. We have set up a page on our website and really want you to share your experiences and thoughts. Please visit the EAPC’s web page, Coronavirus and the Palliative Care Response, for latest resources including scientific journal collections, national guidelines, videos and much else. Join the conversation at #pallicovid