Palliative Consults & PUIs for COVID-19

Thanks Katie. If you have a link to the University of Washington's protocols for Palliative Care,can you please share or send it via email to me: barberio@rutgers.edu. Thanks so much and please stay safe!! Judy

Glad to be involved and share. We, Palliative Care, are at the table for all the Covid 19 meetings, preparing, anticipating, considering all the issues in eventual 'surge'. For all the palliative care needs of patients and families as well as all the considerable support primary clinicians are needing.
We are all hoping this will be a state wide conversation and am always grateful and glad for this group's input, guidance and opinions in this very uncertain future.
sue

At Valley Hospital we also have visitation for dying patients and those currently on hospice. We are part of the Covid conversations and are working with leadership to make sure patients continue to get the care they need. We are recommending primary palliative care goals of care discussions ad we try to minimize exposure and increased use of PPE. Palliative care is creating a list of patients that would benefit from volunteer phone calls given that families are not at the bedside. We are also trying to support staff that feel overwhelmed and uncertain.

In the VA, visitation is now restricted except for the in-patient hospice unit. Visitation for anyone actively dying in our acute care hospital will be allowed if request is made to administration. All non-urgent outpatient clinics are now cancelled. Our team has been trained in telework over the past week. Soon, there will only be 1 provider on site; the other providers/social worker will conduct Video Connect consults and either video or telephone follow-ups for the outpatient population. All providers will rotate (telework vs on site) and anyone on assigned telework can still be called in on site if there is need. Our service chief has been involved with the COVID19 response plan, but no real plan is in place concerning automatic palliative care consults for those with (+)COVID-19. This is a very fluid situation and things are changing rapidly - so I'm sure we'll be more involved (although we already see almost all the ICU/critically ill patients).

Any involvement in 'ethics' of triage, rationing etc that anyone is aware of or involved with?

https://www.njspotlight.com/2020/01/new-rules-for-end-of-life-planning-and-palliative-care-in-nj/

file:///C:/Users/walthesr/Downloads/HastingsCenterCovidFramework2020.pdf

Hi all,
Thanks for your comments and input. It’s definitely a new experience and various levels of conversation and crisis.

Tina from RWJ has asked, “ Are you still doing bedside visits? Any of you doing telehealth visits? With or without videoconferencing? How are you billing without doing a physical exam?”.

We are providing palliative care consults in all three of our POSs; SNFs, clinic, and hospital. We have not made any modifications other then our pregnant and immunocompromised team members are not seeing airborne precaution patients or PUIs. In addition, we are offering telephonic and telemedicine palliative appointments and opportunities for all 3 POSs. With telemedicine the physical exam is a low to moderate detail; what ever you can visualize you document. There are telephonic non face to face encounter code and telemedicine codes. I can upload the documents of what I have; will be joining a billing meeting for further updates and refresher.

I hope you all are well. Sending love - Katie

Many of the SNFs are restricting visits. For the home we are screening consults and if need be, will see symptom management. We have been making telephone calls to check in on the home bound population. We will hopefully start telehealth visits this coming week. Inpatient we are seeing patients at the bedside. We are rotating members of the team and trying to keep them home whenever possible.

AHS MMC. Outpatient palliative moved to virtual visits using new EPIC express chart template so codes and smart phrases are all built in "verbal consent from patient for telephone visit given to minimize COVID-19 exposure". I still schedule these visits so that I can set aside time for calls. Its not much quicker than an in person visit, takes about 20 min for my established patients. Patients are super anxious as are we all so a fair bit of time is spent on "cheerleading" and addressing psychosocial needs as well as medication renewals. Thankfully relaxed the requirement for inperson opiate renewals for now. Trying to do telehealth visits with FT which is working. I have found the Dartmouth materials very helpful about initiating ACP POLST discussions. I have also had a huge turnover to hospice which is still up and running. I am wondering if patients are so terrified of coming to the hospital......Some lessons learned are to always block your number with *67 and warn patients call will come from unknown number or private number. Those are my late afternoons and evenings.

During the day it is all hands on deck for inpatient consults, each provider is assigned 2 COVID units and we are still seeing non-COVID consults as well. Every rapid response on a frail elderly person with dementia is putting so many at risk it is adding a new urgency to EOL discussions. Some new practice is NOT to call the busy ED or ICU provider, just have to wade in and call family. I have done some symptom pain management with patients in the hospital by telephone but have not had to do a GOC discussion that way yet.
Ethics teams gearing up and developing protocols and algorithms for decisions.

We are trying to prioritize Goals of Care discussions for patients who are COVID-19 positive, with co-morbidities, and full code. We are going into the rooms to have discussions, and are being mindful of the time. Gilly: can you share the link to the Dartmouth ACP/POLST materials?
Thanks to everyone for the input here, and wishing you each well.

Hi long post sorry!!! But you all probably understand and can offer guidance -as you may know I am based in the ED at MMC where several years ago we started trying to identify patients in need of palliative care/plant the seed as to GOC and refer to the PC team. This has been helpful in dealing with COVId although initially I think we were not being as proactive I am hoping we are now-3 weeks into this-that now our nurses and physicians are more aware of the potential for catastrophic outcomes in those with significant comorbidities -wenhave our palliative screening tool but doesn’t adequately trigger some of these patients! -we are trying to start the family conversations early/double check on presence of ACP documents and basically start primary pall care where we can. PC inpatient team have been helpful for those requiring symptom management and I have been circulating educational info on morphine dosing for our staff because many issues with dyspnea. Glad I had some great notes from several of you experts on managing this. In general ED staff are usually hesitant to give adequate morphine for dyspnea-especially if patient is. NOT yet comfort care. This is the most challenging case to manage. Or the other is where clearly the patient has COVId and has very poor prognosis. This was always challenging for nurses even without COVId-but now even more so.
One afternoon we had at least 3 older patients on morphine drips, one man arrived almost DOA and another required almost immediate intubation. Plus 2 young men also being intubated around the same time who were in their50s and basically healthy. That was a bad day. but we have had beautiful stories too of nurses in full pope holding the hands of the dying patients so they are not alone( many spouses too old and too dangerous to allow to visit) we allowed one wife in full Ppe to come to her husbands room-she chose to stay outside but watched while a nurse held his hand and spoke on her behalf. Any advice/comments welcome

Sue, you have done amazing work in the ED. You rock!
I am so inspired by the men and women I have worked with over the last month.Talk about stepping up... I feel our whole hospital had a crash course in palliative care and so many that shied away from difficult conversations have developed new skills and confidence. So impressive. I am struck by how we have all flexed and adapted our palliative approach and have still been able to care for patients and families. When I had to shift to working more remotely I agonized that I wouldn't be effective or helpful, that I wouldn't be able to function without the "relationship" I strive to develop with patient/loved ones. I could never have imagined that I would be able to develop that same connection with a phone call. I am feeling very humble and grateful...and very proud to be a nurse right now.

Thanks for your support Gilly!!! A lot of great collaboration going on-although some docs don’t seem to Understand that there are options inbetween comfort care and ICU/intubate !!!!