By JULIE MINDA
April 22, 2020
Because of infection control procedures now in place at hospitals nationwide, and because of how COVID-19 or ventilator treatment can incapacitate victims with critical or end-stage illness, facilities are having to rethink patient care protocols and policies, including how to handle complex patient care choices in the absence of advance planning documentation.
During an April 16 webinar, a panel of four palliative care experts, including clinicians and bioethicists, addressed some of the most challenging issues arising in this environment. "Palliative Care and COVID-19: Implications for Clinical Practice" was the latest in a series of webinars the Supportive Care Coalition and CHA have been hosting on Thursday mornings at 10 a.m. central since late March. Past webinars are available for replay, and registration is available for an April 23 webinar, at supportivecarecoalition.org/. Click on the COVID-19 link at the top of that homepage.
Panelists addressed previously submitted questions from participants on how to ascertain the care wishes of an incapacitated patient when they haven't set them down in writing or appointed a health care proxy. They also discussed how adaptations including the more widespread use of telemedicine may continue once the COVID-19 crisis has ended.
Advance care planning
The webinar took place on National Healthcare Decisions Day, an annual effort to raise awareness of the importance of advance care planning. The first question the panelists deliberated had to do with the fact that health care providers are facing challenges facilitating advance care planning discussions with hospitalized patients who have COVID-19. For example, obtaining signatures for legal documents, including a durable power of attorney for health care, is complicated by the need to isolate patients and restrict visitation to reduce the risk of contagion.
Just getting a power of attorney document signed can be a heavy lift. Isolation procedures greatly restrict who can enter a patient's room. The legal document generally requires two people who are not on the care team of the person who is executing the proxy to witness, and a notary to attest to, the signature. In some cases, having a physical document that has been in the hands of a patient with COVID-19 leave the room may violate infection control restrictions.
Panelist Dr. Olumuyiwa Adeboye, Ascension medical director of palliative care, acknowledged that while advance care planning is meant to be done in a calm setting observing best practices, the pandemic is making that very difficult to do. He said the more preparations facilities do before patients with complex needs arrive, the more structured and effective the process will be. He said providers who work directly with patients should have a firm grasp on applicable state laws as well as their own facilities' protocols. They should work creatively within those parameters to achieve the desired result of learning patients' wishes. For instance, they may use videoconferencing to consult decision-making surrogates who formerly would have been consulted in-person.
Dr. Gregg VandeKieft, medical director for palliative care for Providence St. Joseph Health's Southwest Region, noted that some states have been making exceptions to state law on advance care documentation to account for the current environment. For instance, New York Governor Andrew Cuomo is allowing for virtually obtained signatures for such documents, but only during the pandemic. Nate Hibner, CHA director of ethics, said organizations including the National Notary Association offer online resources on the legality of remote notarization.
Panelist MC Sullivan is chief health care ethicist for the Initiative on Palliative Care and Advance Care Planning for the Archdiocese of Boston. She said it is heartening that even though the pandemic is threatening providers' ability to use best practices for understanding, documenting and implementing patient wishes, they nonetheless are working diligently to overcome the barriers.
The second question panelists discussed had to with the impact of visitor restrictions put in place at hospitals to prevent the spread of COVID-19. The questioner said patients — and particularly those at the end of life — are distraught over not being able to see their loved ones.
Sullivan acknowledged that visitation restrictions can "blow to smithereens" the standards that palliative care promotes in usual times — to have a cohesive unit of family, patient and staff supporting the patient.
And VandeKieft said that policies around visitation can indeed change within facilities based on evolving understanding of COVID-19, whether or not patients are COVID-positive, and the availability or scarcity of personal protective equipment. He said to reduce confusion and frustration, it is important that there be one designated decision maker on visitation policies in each hospital, but that all affected departments be involved in giving input on the policies and that they all have a clear understanding of the policies. Most importantly, the policies should be equitable, clearly communicated and consistently applied throughout the facility, he said.
Adeboye said when a loved one is allowed to visit under compassionate care exceptions made for patients at the end of life it is essential that providers set expectations before the visitor comes to the hospital. For instance, they should tell a visitor if he or she will need to answer questions about their own health status, have their temperature checked upon entry and/or wear personal protective gear.
Hibner said it's important to recognize that when patients and families express frustration about visitor restrictions or prohibitions, the underlying emotion likely is fear. Patients and their loved ones may be afraid that if the patients are admitted to the hospital in critical condition with COVID-19, they will be isolated, cut off from visitors and will die alone. It is important to have ethically grounded policies and to apply them compassionately to assuage such fears, he said.
On the other side
The last question dealt with what the future might hold once the pandemic is over.
VandeKieft expects to see technologies that have come to the fore in the pandemic to remain in heavy use afterwards. For instance, providers who may have been reticent to offer some services, such as palliative care consults, over videoconference may now know it can be done effectively. Sullivan said some mental health providers have learned that sessions conducted over videoconferencing actually can be more focused and the content more nuanced than they'd expected.
Adeboye and Sullivan discussed the logjam of patients who have been postponing so-called elective procedures and care. They said it will be a challenge to determine how best to resume care for throngs of people who may be getting sicker without treatment. Sullivan said these people are anxious. She said providers will need to figure out how to prioritize returning patients. It will be a matter of social justice how this is done, she said.
Hibner said while there are countless questions emerging for health care providers throughout the pandemic — and countless questions will arise when the pandemic is over — what the ministry prizes and will continue to need is people who are well-formed. "We will continue to need wise people who can feel comfortable in the moment, taking in facts and grounded in their formation and virtues, to help us find the answers we need.
"We need ethical people focused on how decisions will impact other people," said Hibner.
Links to Catholic Health World coverage of prior Supportive Care Coalition/CHA webinars:
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