Palliative Care

Where those with COVID-19 die, the predominant cause of death is respiratory failure.  Risk factors for dying include older age, male sex, low socioeconomic status, ethnic background, obesity and multiple comorbidities.  Decisions to progress to a palliative approach to care should be guided by an ethical decision making framework (see Ethics in ED Decision Making section). 

We recommend that, in addition to principles outlined in ACEM’s P455 Policy on end of life and palliative care in the emergency department [Link]:

1. Organisations have a multi-disciplinary approach to building an ethical decision-making framework to support clinicians who will need to make these decisions.
2. Early, senior ED clinician involvement in patient assessment is vital in guiding end-of-life decision making.
3. Staff caring for patients who will require end-of-life decisions are adequately trained to do so.
4. Organisations and community services will need to account for, and provide culturally appropriate care to, families who may not be able to visit their dying family member or attend funeral and mourning rituals.
5. Psychological support is available to staff caring for patients requiring end-of-life care.
6. Informed relatives and chaplaincy services wishing to have access to dying patients should be allowed to do so when PPE and isolation practices can be adhered to during and after the visit.
7. Appropriate medication protocols and clinical care pathways are available in the ED to ensure adequate and appropriate symptom management for dying patients.
8. Emphasis in end-of-life medication prescribing is placed on reducing coughing, vomiting and delirium in order to reduce risk of transmission of COVID-19.
9. Health services have a defined plan for safe management of deceased patients with suspected or confirmed COVID-19 disease including an ability to surge mortuary capacity as required.

We advocate for:

1. GPs and specialists caring for vulnerable patient groups, to initiate and document discussions with their patients about their choices and goals of care in the setting of this pandemic.
2. Patients with advance care plans ensure that their plans are up to date and reflective of their current wishes.
3. Organisations providing locations away from EDs to provide palliative care, being mindful that: 
   • Where a person wishes to receive end of life care in their own environment, and care can be safely delivered in this environment (from both a patient and staff / carer perspective), all efforts are made to facilitate this wish.
   • Existing palliative care facilities may be easily overwhelmed.
   • There be consideration of separation into COVID-19-positive and -negative streams.
   • Those caring for patients who are dying will also need PPE access, training and fit-testing.
   • Staff caring for dying patients are adequately trained to do so.

1. Palliative Care Australia, Statement on Coronavirus Disease (COVID-19) March 2020 [Link]
2. The following discussion papers and articles:
   • Hick, J. L., D. Hanfling, M. K. Wynia, and A. T. Pavia. 2020. Duty to Plan: Health Care, Crisis Standards of Care, and Novel Coronavirus SARS-CoV-2. NAM Perspectives. Discussion paper. National Academy of Medicine. Washington, DC. [Link]
   • Daugherty Biddison, E. L., Faden, R., Gwon, H. S., Mareiniss, D. P., Regenberg, A. C., Schoch-Spana, M., Schwartz, J., & Toner, E. S. (2019). Too Many Patients…A Framework to Guide Statewide Allocation of Scarce Mechanical Ventilation During Disasters. In Chest (Vol. 155, Issue 4, pp. 848–854). Elsevier Inc. [Link]
   • Daugherty Biddison, L., Berkowitz, K. A., Courtney, B., De Jong, M. J., Devereaux, A. V., Kissoon, N., Roxland, B. E., Sprung, C. L., Dichter, J. R., Christian, M. D., & Powell, T. (2014). Ethical considerations: Care of the critically ill and injured during pandemics and disasters: CHEST consensus statement. Chest, 146(4), e145S-e155S. [Link] 
   • Bhaskaran K, Bacon S, Evans S et al. (2021). Factors associated with deaths due to COVID-19 versus other causes: population-based cohort analysis of UK primary care data and linked national death registrations within the OpenSAFELY platform.  Lancet.  [Link]