Need for Strengthening Palliative Care Services during COVID 19

Dr Devi Nair, Health economist, Goa Institute of Management; Dr Sreerupa Sengupta, Asst Professor, Goa Institute of Management and Dr Krishnanunni Raveendran, Resident, Sichuan University urge the healthcare community to extend their support to build up resources for palliative care services in India

The outbreak of COVID 19 pandemic is impacting the global population in drastic ways. The pandemic has caused unprecedented damage to lives and economies, and put enormous pressure on health systems. Both developed and developing countries are facing a shortage of ICU beds, life-supporting instruments like ventilators, dialysis machines, personal protective equipment (PPE) and medicines¹. Currently, with resources being diverted to effectively respond to COVID-19, patients with other life-limiting conditions are finding it difficult to access health care services. These patients may themselves being pushed out of their health-care settings with reduced access to continuous medication and care². 

Need to care for terminally ill patients

In the event of COVID 19 pandemic, many healthcare systems will force to implement a triage system (the process of determining the priority of patients’ treatments by the severity of their condition or likelihood of recovery with and without treatment), that may deny critical care treatment to some seriously ill patients. In that particular situation, there is an urgent need for strengthening of palliative care services to mitigate the impact of the pandemic on terminally ill.

Available data indicates that older people with underlying chronic health conditions such as chronic respiratory, cardiovascular or chronic kidney disease, diabetes, active cancer and more generally severe chronic diseases are more vulnerable to the novel coronavirus. Mortality and severity of infection have also shifted more towards these groups³. An association between COVID-19 and chronic non-communicable diseases (NCDs) has been reported from China, Italy, USA, UK and India. Hypertension, diabetes, cancer and chronic respiratory infections are the most common comorbidities observed in COVID-19 patients who were admitted in the critical care units in most of the countries⁴. For instance, a study in Italy reports, the majority of patients (96.2 per cent) who have died from COVID-19 had comorbidities. The most prevalent comorbidities observed were hypertension (69.2 per cent), diabetes (31.8 per cent), ischemic heart disease (28.2 per cent), chronic obstructive pulmonary disease (16.9 per cent), and cancer (16.3 per cent)⁵.

People with cancer are more vulnerable and this is the most challenging time for the cancer patients who need a continuum of care. In the UK, for example, even high priority cancer patients have been left with cancelled chemotherapy and surgical appointments. A recent survey by the American cancer society says, “half of the cancer patients who respond to the survey reported delays or interruptions in cancer care.”  The most common delays reported among the respondents are outpatient appointments (50 per cent), access to therapies (20 per cent), imaging procedures (20 per cent) and surgical procedures (8 per cent). About (38 per cent)of the respondents reported a notable financial impact that affects their ability to pay for care during pandemic⁶.

An opportunity to enhance palliative care

The current situation of the pandemic, with a dramatic increase in deaths associated with corona infection, has underscored the importance of palliative care. The need for palliative care has been expanding due to several factors – ageing of the world’s population, an increase in the rate of cancer and other chronic health conditions. Each year, WHO estimated about 40 million people globally, need palliative care; however, only about 14 per cent of the people who receive it⁷.

India, a country with limited public health resources and the health system is overburdened with the current pandemic, need to make decisions on how to provide uninterrupted care for patients who are terminally ill. COVID-19 has given us yet another opportunity to think about the scope of palliative care and how to expand and strengthen the palliative care services within the community. Health systems can take the advantage of the unique skills and strengths of palliative care services, know-how to focus on compassionate care with dignity, provide rational access to essential medicines, and mitigate social isolation at the end of life and caregiver distress. The salient aspects of palliative care such as communication, advance care planning, and symptom management are very much needed now more than ever⁸. 

Through palliative care, uninterrupted healthcare services can be provided to people who are old or are living with chronic health conditions to improve their quality of lives even in such a distress situation. For instance, cancer patients, for whom the continuity of care and time-sensitive services are vital, palliative care can ensure uninterrupted access to healthcare. In this context, it is worthwhile to mention that providing palliative care in hospital wards or Intensive Care Unit (ICU) can be complex and risky at this time. Thus, patients can be treated either in home-based palliative care or in hospice. In fact, home-based palliative care services are becoming increasingly popular among cancer patients⁹. Home is the place where people are most comfortable at the end of their lives, surrounded by their loved ones. Taking this into cognizance, home-based palliative care services have gone to the homes of patients to provide care and support services. Such an arrangement is also cost-effective as it reduces frequent travel to the hospital for follow up visits and treatments. Hospices are unique places which rapidly provide holistic care, including advance care planning in anticipation of acute deterioration. In response to acute pandemic crisis especially in resource-scarce settings, integrating the hospice and palliative care may improve the care for people who are deteriorating and at the end of life. It will also ensure access to essential health services by all and improve the overall effort to optimise survival of other patients also. A recent study in Italy demonstrated that the hospice sector has been able to respond flexibly and rapidly to the crisis created by the COVID-19 pandemic¹⁰. Unfortunately, the concept of hospice is still not expanded in India.

Need for training and guidelines

Following the outbreak of the pandemic, the World Health Organization (WHO) has issued guidelines on how to maintain all essential health services; but there are no updated guidelines for palliative care services. Given the circumstances and the burden on the healthcare system, palliative care ought to be an explicit part of national/ international response plans for the management of COVID-19¹¹. Basic palliative care training to all medical and nursing students has been the recommendation of the palliative care community for a long time, but it is still at a nascent stage. Furthermore, in many countries, palliative component and training are not included in medical curriculum¹². 

COVID-19 has impelled us to rethink and insist on capacity building among health care professionals and awareness creation on palliative care to the community. As health systems become strained under the pandemic, providing safe and effective palliative care, including end-of-life care, becomes critical but extremely difficult. Governments must urgently recognise the role of palliative care during the pandemic and ensure these services should be integrated into the health care system response in a creative way. It is imperative to focus on designing immediate strategies for effective implementation of palliative care during COVID-19. It is equally essential to plan for long term strategies beyond the pandemic to strengthen the palliative care services in order to deal with future disasters.

References 

1. The Lancet. Lancet Commission on Palliative Care and Pain Relief- findings, recommendations and, future directions. March 1, 2018. https://www.thelancet.com/ commissions/palliative-care, April 11,2020.
2. A.J. Sinclair and A.H. Abdelhafiz. Age, Frailty and Diabetes: Triple Jeopardy for Vulnerability to COVID-19 Infection. Clinical Medicine, 2020. https://doi.org/10.1016/j.eclinm.2020.100343. 
3. World Health Organization. Global Health Estimates 2016: Disease burden by Cause, Age, Sex, by Country and by Region, 2000-2016. Geneva, 2018. https://www.who.int/healthinfo/global_burden_disease/estimates/en/index1.html
4. Istituto Superiore di Sanità. Characteristics of SARS-CoV-2 patients Dying in Italy. Report based on available data on April 29, 2020. https://www.epicentro.iss.it/en/coronavirus/bollettino/ReportCOVID-2019_29_april_2020.pdf.
5. Onder G., Rezza G., Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA, Viewpoint, March 23, 2020. https://jamanetwork.com/journals/jama/fullarticle/2763667
6. American Cancer Society. Survivor Views, COVID-19 Affecting Patients’ Access to Cancer Care. Press release, April 15, 2020. https://bit.ly/2V9TavE
7. World Wide Palliative Care Alliance and WHO. Global Atlas of Palliative Care, January 2014. https://www.who.int/nmh/Global_Atlas_of_Palliative_Care.pdf
8. Lukas Radbruch, Felicia Marie Knaul, Liliana de Lima, Cornelis de Joncheere, Afsan Bhadelia. The key role of palliative care in response to the COVID-19 tsunami of suffering. The Lancet, April 22, 2020. https://doi.org/10.1016/ S0140-6736(20)30964.
9. Robert Guzzo, Alexander Kutikov et al. Coronavirus 2019 (COVID 19): Cancer care during the pandemic. Report on UpToDate COVID 19, May 8, 2020. https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-cancer-care-during-the-pandemic
10. Massimo Costantini , Katherine E Sleeman, Carlo Peruselli  and Irene J Higginson: Response and role of palliative care during the COVID-19 pandemic: A national telephone  survey of hospices in Italy: journal of palliative medicine, May 2020
11. WHO. Statement to the Press by Dr Hans Henri P. Kluge, WHO Regional Director for Europe, April, 30, 2020. http://www.euro.who.int/en/about-us/regional-director/statements/statement-we-cannot-allow-the-impact-of-covid-19-to-be-amplified-by-neglecting-other-vital-health-protection-measures
12. The Lancet. Palliative care and the COVID-19 Pandemic. April 11,2020. DOI:https://doi.org/10.1016/S0140-6736(20)30822-9