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CASE REPORT
Ahead of print publication  

Management of critically ill elderly COVID-19 patient with severe comorbidities in the intensive care unit: Missed palliative care!


 Department of Anaesthesia, ABVIMS and Dr RML Hospital, New Delhi, India

Date of Submission03-Jun-2020
Date of Decision11-Aug-2020
Date of Acceptance21-Sep-2020

Correspondence Address:
Prashant Sirohiya,
Department of Anaesthesia, ABVIMS and Dr RML Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_299_20

  Abstract 


The severe acute respiratory syndrome coronavirus 2 disease (COVID-19) pandemic is not just about medical management in intensive care units (ICUs). The old population and those with severe comorbidities and chronic illnesses are more prone to die due to COVID-19 infection and integrating palliative care support in ICUs is the need of the hour. However, during this pandemic, there is a clear lack of palliative care in ICUs due to several barriers which we will discuss in this particular case.

Keywords: COVID-19, palliative care, pandemic, supportive care



How to cite this URL:
Choudhary N, Sirohiya P. Management of critically ill elderly COVID-19 patient with severe comorbidities in the intensive care unit: Missed palliative care!. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Dec 6]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=319299




  Introduction Top


Severe acute respiratory syndrome coronavirus 2 disease (COVID-19) emerged in Wuhan, China, at the end of 2019 has caused global outbreak and is a major public health issue.[1] The core patient population targeted for palliative care is old-aged, debilitated, and/or underlying comorbidities or chronic illness which at the same time is at maximum risk from COVID-19.[2] Therefore, there is a clear need for palliative care services in intensive care units (ICUs) for symptom control, psychological support, spiritual support, and complex decision making. We present a case from similar subset that was managed in ICU while discussing the various barriers encountered while ensuring optimal palliative care.


  Case Report Top


A 79-year-old female, known case of uncontrolled diabetes mellitus and hypertension, presented with complaints of fever and cough for 2 days. She had a history of contact with a confirmed case of COVID-19. The sample for COVID-19 testing was sent and she was admitted to the isolation ward. Subsequently, she developed respiratory distress and was shifted to ICU with a provisional diagnosis of viral pneumonitis with Type I respiratory failure. Chest X-ray showed bilateral infiltrates. Complete blood count was suggestive of anemia with leukocytosis. She tested positive for COVID-19 and other than deranged blood sugar levels (fasting blood sugar - 312 mg/dl), remaining blood investigations were within normal limits. She was started on oxygen therapy through a nonrebreathing facemask with a reservoir bag and empirically started on broad-spectrum antibiotics. Initially, she responded well to treatment with controlled blood sugar levels. However, the patient condition began to deteriorate following 48 hours of admission (respiratory rate >40 per min, oxygen saturation {SpO2}-85%). Relatives were telephonically explained the prognosis and treatment options including palliative care with its legal formalities. Failing to take any decision on end of life care (EOLC), routine medical treatment was continued. She was intubated, and initially responded by maintaining SpO2 of 94%–95% at fraction of inspired oxygen (FiO2) of 0.8. However, the peak airway pressure was persistently high and showed an increasing trend. Ventilation protocol for acute respiratory distress syndrome was instituted with intermittent prone positioning. Despite all, the clinical condition continued to deteriorate with surging airway pressures, maintaining SpO2 of 78%–80% (FiO2-1.0). She suffered from sudden cardiac arrest and despite all efforts, she could not be resuscitated.


  Discussion Top


This case report reflects how a critically ill elderly patient with significant comorbidities is managed and treated with the curative intervention in ICUs. Newly adopted health-care policies during COVID-19 has made it difficult to render optimal medical services while ensuring all aspects of medical care have been righteously fulfilled without endangering the life of health-care workers. ICU services are not limited to pharmacological therapy but have extended armamentarium which includes psychological emotional and spiritual support to the patient as well as the attendants.[3] Mortality from COVID-19 is highest in the elderly population with comorbidities which raises two particularly important questions. First, should an alternative of palliative care be routinely provided as an early treatment option in ailing elderly patient? Second, given the limited resources to deal with this pandemic, diverting the resources from elderly patients with relatively poor prognosis to those with a better chance of survival would help in decreasing the overall morbidity and mortality rates. To our dismay, many countries are still in the process of inculcating palliative care as routine component of health-care system. The EOLC should be joint decision after being counseled by the treating physician considering the severity and prognosis of the ailment. It has legal implications which must be carefully addressed before rendering these services.[3],[4] Proper counseling plays crucial role in this decision making. However, the numerous barriers which we faced while providing palliative care in ICU in this case are mentioned in [Figure 1]. In this time of social distancing collective counseling involving the physician, patient and the caretakers is not feasible, and one must possibly rely on the audio-visual aids in the form of teleconferencing which lacks emotional quotient.[5] Rapid progression of disease state (as in our patient) with the fear of losing loved ones to this deadly pandemic might cloud their judgment. The health-care policy does not allow the family members to meet the patient suffering from COVID-19 which does not give loved ones the chance to spend time with them which could help them in decision making. In many countries (including India) do not resuscitate orders require legal proceedings which in the wake of this hour is tedious, time-consuming, and may not be prioritized by the various government agencies.[6]
Figure 1: Barriers to provide palliative care in intensive care unit

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The other point of concern is the quality of care which is greatly affected during this pandemic. The nursing care is facing multiple issues such as limited personal protective equipment, and insufficient trained staff to provide round the clock monitoring. At centers equipped with palliative care services, the relatives, or caretakers for an integral part of the palliative team. They act as assessment tool of the worsening symptoms which helps in titrating the medications for a pain-free journey of EOLC.[3],[7] Limiting access to only health-care workers results in isolation of patients. Spiritual and psychological support with a team approach involving psychologists, religious preachers, or social workers another pothole in the path to successful EOLC.[3],[8] Instituting the policy, the palliative care would help the terminally ill patients to ward off from their suffering. It would be greatly beneficial if palliative care can be instituted at an early stage considering elderly patient with poor prognosis.[9] It will also help to decrease the financial burden from the caregivers or the health-care system. In the time of this pandemic with the scarcity of resources, these can be diverted to patients with a better prognosis. Furthermore, the health-care procedure done on these patients' acts as a potential source of infection for the treating health-care worker, and by avoiding them the potential risk of exposure can be brought down considerably. As it is the right of everyone to live their lives, so is their right to EOLC and it must be respected.

To conclude, the need for integration of palliative care for chronic debilitating illness has been highlighted in the current pandemic. Triaging of patients will help clinicians to manage patients who can be cured and provide EOLC to those with severe incurable disease especially in countries with limited resources.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Adams JG, Walls RM. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA 2020;323:1439-40.  Back to cited text no. 1
    
2.
Nikolich-Zugich J, Knox KS, Rios CT, Natt B, Bhattacharya D, Fain MJ. SARS-CoV-2 and COVID-19 in older adults: what we may expect regarding pathogenesis, immune responses, and outcomes. Geroscience 2020;42:505-14.  Back to cited text no. 2
    
3.
Pahuja M, Wojcikewych D. Systems Barriers to Assessment and Treatment of COVID-19 Positive Patients at the End of Life. J Palliat Med 2021;24:302-4.  Back to cited text no. 3
    
4.
Powell VD, Silveira MJ. What Should Palliative Care's Response Be to the COVID-19 Pandemic? J Pain Symptom Manage 2020;60:e1-3.  Back to cited text no. 4
    
5.
Calton B, Abedini N, Fratkin M. Telemedicine in the time of coronavirus. J Pain Symptom Manage 2020;60:e12-4.  Back to cited text no. 5
    
6.
Radbruch L, Knaul FM, de Lima L, de Joncheere C, Bhadelia A. The key role of palliative care in response to the COVID-19 tsunami of suffering. Lancet 2020;395:1467-9.  Back to cited text no. 6
    
7.
Kunz R, Minder M. COVID-19 pandemic: Palliative care for elderly and frail patients at home and in residential and nursing homes. Swiss Med Wkly 2020;150:w20235.  Back to cited text no. 7
    
8.
Borasio GD, Gamondi C, Obrist M, Jox R, For the Covid-Task Force of Palliative Ch. COVID-19: Decision making and palliative care. Swiss Med Wkly 2020;150:w20233.  Back to cited text no. 8
    
9.
Dunning T, Martin P. Palliative and end of life care of people with diabetes: Issues, challenges and strategies. Diabetes Res Clin Pract 2018;143:454-63.  Back to cited text no. 9
    


    Figures

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