Palliative Care for Patients with Cancer During the COVID-19 Pandemic

In a paper published in JAMA Oncology, Ambereen K. Mehta, MD, MPH, of the University of California, Los Angeles, Santa Monica, and Thomas J. Smith, MD, of the Sidney Kimmel Comprehensive Cancer Center, discussed the necessity for palliative care services for patients with cancer to continue amidst the coronavirus disease 2019 (COVID-19) pandemic. 

The American Society of Clinical Oncology (ASCO) recommends that every patient with advanced cancer see a palliative care team within 8 weeks of diagnosis. However, as a result of the pandemic, palliative care teams have now had to adjust their best practices to fit the needs of the current environment. 

“Through ongoing national conversations, palliative care practitioners are asking whether we should be adding exposure risk to the patients we see, who are often the most vulnerable,” the authors wrote. “As a field, we must not shrink away by decreasing services provided. Instead, our care can still be provided in creative ways that remain consistent with the core of how we practice outside these unique circumstances.”

Overall, the authors suggested that the challenges of the pandemic can be broken down into 3 populations, including outpatients, inpatients who are COVID-19-positive, and inpatients who are COVID-19-negative. 

In the ambulatory setting, telemedicine has become an internal strategy to provide early palliative care. Newly updated regulations are allowing palliative care professionals to continue refilling and writing new opioid prescriptions using telehealth. Additionally, telemedicine has provided hidden advantages, such as allowing practitioners to see patients’ home environments, which is information that is generally unavailable in traditional clinic visits. 

“Anecdotally, we have observed that patients at higher risk of poor outcomes if exposed to COVID-19 are becoming more proactive about advance care planning,” the authors wrote. “Before adopting this as the norm, health care professionals should remember that at least 1 randomized study of weekly palliative care teleconsultations vs usual in-person palliative care visits showed significantly more anxiety and higher distress in the telehealth group.” 

In the inpatient setting, palliative care teams have also had to utilize telemedicine for patients with and without COVID-19, as personal protective equipment has become limited. Moreover, family and caregiver visitation has been restricted, and for patients who do have COVID-19, clinical decline can be rapid; leaving little time for families and caregivers to make difficult decisions. 

“Video visits address 2 barriers: (1) they provide a form of face-to-face communication and (2) they allow multiple health care professionals to engage patients/ families/caregivers simultaneously, which can be a challenge in person,” explained the authors. "Patients, despite COVID-19 status, require advance care planning and may be more likely to have these conversations with growing fears of limited medical resources and prolonged isolation.” 

Importantly, palliative care providers also offer expertise on the management of complex symptoms, including those such as dyspnea, anorexia, and delirium. Even further, management of these symptoms by palliative care teams can help lessen the burden of patient care on primary health teams. 

“Delivering excellent symptom management also provides emotional relief for staff having to care for patients with COVID-19 without a cure,” the authors wrote. “Instead of sending our patients to inpatient hospice, we can provide comfort care in the hospital. This protects hospice personnel who would otherwise have to see these patients, obtain hospice admission consent, and complete regular clinical assessments.” 

Notably, palliative care professionals also have a history of supporting colleagues in their disciplines. This includes caring for interdisciplinary teammates such as nurses, chaplains, social workers, and pharmacists. Now more than ever, the authors indicated that palliative care providers must protect these interdisciplinary team members by not duplicating efforts, including dividing patient lists and seeing patients independently. 

“In these troubling times when we have to be cognizant of our patients’ and our safety, we should not hold back on providing palliative care services,” the authors wrote. “In an era of ventilator shortages and tough choices, it is time for palliative care practitioners to lean into patient care in creative ways that will define and solidify our identity as a field.”

Reference:

Mehta AK, Smith TJ. Palliative Care for Patients with Cancer in the COVID-19 Era. JAMA Oncology. doi:10.1001/jamaoncol.2020.1938.