Dr Danila Valenti is Medical Director of UO Rete delle Cure Palliative (SC), a palliative care unit in Bologna, northern Italy, and a member of the European Association for Palliative Care (EAPC) Board of Directors. Here, she explains some of the main challenges facing us in health care during the coronavirus crisis and shares advice for others who are approaching a similar situation in their country.
The Local Health Authority of Bologna serves a population of about one million inhabitants with:
- nine hospitals
- one university hospital
- one research institute.
In total there are approximately 3,000 acute beds
There is also:
- one Palliative Care Network with an Operations Centre
- one Home Palliative Care Specialist service (30 doctors), (ANT Foundation)
- three Hospices (10 doctors) (Hospice Seràgnoli Foundation)
- 14 Early Palliative Care Clinics (outpatient service, ambulatory patients – consulting home care – consulting in nursing homes) nine doctors, 30 nurses.
- 600 general practitioners
- 52 nursing homes.
The Italian experience
Following the COVID-19 outbreak in Italy, the main advice to others who are approaching a similar situation is: Rearrange, rearrange, rearrange. Palliative care services in this emergency must be flexible and adapt and change their organisation as needed to guarantee care to those who need it most.
The experience in Italy indicates that one of the main problems during this crisis has been the lack of availability of Personal Protective Equipment (PPE). This has proved to be the most important and limiting factor, not only in palliative care provision but for the whole healthcare system. In advance of escalation of the spread of the virus and of the subsequent increase in admissions of the critically sick, if possible, all countries need to try and convert the activities of manufacturing companies to produce PPE.
For patients who are not, or who appear not to be COVID+, in the absence of sufficient PPE, healthcare workers in palliative home care teams present a risk of transmitting the infection from patient to patient and from house to house.
Caring for patients at home
Due to the risk of harm to patients, home palliative care visits must be limited to those who actually need care. There are two options:
- Discuss and share with colleagues the cases of families at home in order to make better decisions about care and to share the weight of these decisions.
- Go to the patient’s home with appropriate PPE.
(a) Discuss and share the cases of patients who are discharged from hospitals (new patients).
(b) Share simple palliative care symptom management with colleagues (analgesics and other medication and route of administration).
(c) Produce a Palliative Care Drug Kit to leave in the home. This will enable management of all eventualities and should be supported by telephone. A 24-hour-a-day single phone number for palliative care advice for all patients, healthcare residences and long-term care providers should be available.
For patients who are COVID +
1. Patients hospitalised on COVID wards (which spring up like mushrooms every day) without wasting PPE [provide] enough for consultants (one of the most important and limiting factors).
In clean areas, palliative care teams wearing surgical masks are providing consultation services, with colleagues from the COVID departments on:
(a) treatments for pain and symptom management in particular (dyspnoea and palliative sedation);
(b) advice on how to talk to families to avoid the ‘Desaparecidos’ effect;
(c) ethical decision support;
(d) communication support with patients and family.
- 24-hour availability via a single telephone number for colleagues from the dozens of COVID departments (distributed across nine hospitals, one university hospital and one research institute, for a population of about one million inhabitants – Local Health Authority) for a, b, c above.
Telephone communication skills must be used, developed and implemented with:
- patients and caregivers whom we usually follow in palliative care
- COVID patients
- family members of COVID patients (never seen)
- colleagues needing our help.
Summary of my advice to others
Recommend policies to:
1. Implement manoeuvres to reduce contact with people and between people.
- Convert factories for the production of PPE.
For palliative care:
Reduce home visits only to cases that are not manageable by telephone, and always only with the appropriate PPE.
For immediate action:
Doctors and nurses, potentially even carriers, of contact must use surgical masks and always wash/disinfect the hands especially if they are in home care.
For COVID wards:
We bought cell phones and iPads for telephone contact between patients and families to be left on the COVID wards.
We have prepared immediate advice (one-page only sheet) on phrases-to-say/not-to-say strategies and to make these available. This, and other information, has been translated into English and is available on the EAPC web page, Coronavirus and the Palliative Care Response.
We have prepared immediate advice (one-page only sheet) on morphine use and palliative sedation.
And finally, I can’t emphasise enough my earlier advice: rearrange, rearrange, rearrange. As palliative care workers we must be flexible and adapt and change our organisation as needed so that we can guarantee care to those who need it most.
- Read another post on coronoavirus and palliative care by EAPC President, Prof Dr Christoph Ostgathe, on the EAPC blog.
- Coronavirus and the palliative care response: EAPC web page to source and share information, with many links to publications and resources including national guidelines, videos, scientific journal collections. Please email us if you have new or updated resources to share.
- Latest news and first hand information will continue to be shared on the EAPC Twitter, Facebook and LinkedIn. Join the conversation at #pallicovid
- See the current issue of Media Watch, compiled by Barry R Ashpole, which includes several articles and reports from the lay press on COVID-19 from the perspective of end-of-life care: http://bit.ly/2ThijkC