Lukas Radbruch, Professor of Palliative Medicine at the University Hospital Bonn, and Claudia Bausewein, Chair for Palliative Medicine at Munich University and Director of the Department of Palliative Medicine at Munich University Hospital, Germany.
As of last night, 5 April, Germany has reported 98,765 corona infections, and 1,524 deaths from Covid-19. (1) The German healthcare system braces for the expected deluge. This does not only concern emergency departments, pulmonology wards and intensive care units, but also palliative care services, as a significant percentage of patients with Covid-19 and comorbidities will not be receiving intensive care. This may be because the prognosis is just too bad or because the patient does not consent to the intervention.
In addition, the healthcare system is reducing all elective procedures, and nursing homes are locking down to follow the physical distancing regulations, and this leads to more non-corona patients being left out in the cold and thus turning to palliative care.
In our palliative care services, right now it seems to be even more quiet than usual. The volunteer services have stopped visiting patients though they try to keep contact via telephone. The palliative home care services have also reduced the number of home care visits as much as possible, providing telephone advice instead. In most palliative care units, visits to patients are regulated and sometimes limited only to imminently dying patients.
There are the first signs of the impact of the pandemic. The husband of one of our patients in the palliative care unit lives in a nursing home, which has locked down according to social distancing regulations in our federal state. The nursing home staff told him that he cannot leave to visit his wife in the hospital, or he would be banned from coming back to the nursing home. Having nowhere else to go, he chooses to stay.
Yesterday, one of us had to tell the family of a deceased patient that the regulations do not allow more than 10 persons at the funeral, and they were shocked.
But most of our time is spent with preparations. How will we access personal protective equipment, including FFP2 masks, once we have our first Covid-19 patient in palliative home care? Do we have enough opioids and other medications to treat breathlessness in the palliative care unit, the hospital, and the home care service? We are not allowed to stockpile though; the national competent authority (Bundesopiumstelle) has issued regulations that hospital pharmacies may stock medications only for four weeks, and eight weeks for medications used in the corona epidemic (using the previous year’s consumption for comparison). There seems to be no real shortage, but bottlenecks occur with the supply as everybody tries to stockpile. Most hospitals are increasing their intensive care bed capacity and the number of ventilators, with a handsome bonus paid by the German Ministry of Health for each new intensive care bed with ventilatory support. These new beds require parallel increases in the intensive care medications, including opioids, and staff…
We are also trying to contribute our palliative care expertise on decision-making and symptom control to the discussions in other healthcare areas. We have participated in numerous discussions on different levels about triage concepts, decision-making algorithms and symptom control training.
Last week, the German Association for Palliative Medicine produced recommendations on decision-making and symptom control, which have rapidly been implemented as an expert-level guideline by the Association of Scientific Medical Associations in Germany. These guidelines, which are regularly updated, focus on the management of Covid-19 symptoms such as breathlessness, anxiety, delirium and agitation. An English translation is available.
In addition, the Association has contributed to recommendations on decision-making and triage, together with six other medical associations. In these discussions on triage, however, we were astonished how quickly the person-centred approach is being abandoned, in favour of a purely utilitarian approach. Our palliative care perspective seems to be needed, explaining that triage systems must not put a value on human life, neither related to age, nor to social factors. There is a fundamental difference between a patient whose ventilatory support is discontinued because the prognosis is futile and the indication for ventilation has thus vanished, and a situation where ventilatory support is discontinued because the ventilator is needed for another patient with (slightly) better chances of survival. Managing scare resources without falling prey to unethical selections will be challenging.
These deliberations are all about planning for a catastrophic scenario, and right now our clinical work is ‘business as usual’. But the situation is changing weekly, sometimes even daily. This is the calm before the storm.
Reference and links
- Source: BBC News 5 April 2020. John Hopkins University, national public health agencies.
- Contact Lukas Radbruch by email.
- Read more posts on Coronavirus and Palliative Care 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 (including those of the German Association for Palliative Medicine in German and English), videos, scientific journal collections. Please email us if you have new or updated resources to share.
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