a Geriatrics and Palliative Medicine, Stadtspital Waid und Triemli, Zurich, Switzerland; FGPG Board member
b Geriatrics and Palliative Medicine, Spital Affoltern am Albis, Switzerland
Zurich/Berlin/Vienna, approved by the Board of the Association for Geriatric Palliative Medicine (FGPG) (www.fgpg.eu) on 22 March 2020.
While the whole population is at risk from infection with the coronavirus (SARS-CoV-2), older people – often frail and subject to multimorbidity – are at highest risk for severe and fatal disease. Experience from Italy shows a median age at death of 79 years for men and 82 for women . Severe illness with an uncertain outcome and end-of-life situations call for good palliative care for the patients concerned. The Association for Geriatric Palliative Medicine (FGPG) promotes the integration of a palliative care approach and skills into the care of elderly and very elderly people – both in the inpatient setting and at home. The current pandemic and the publication of the SAMS Guidelines “COVID-19 pandemic: triage for intensive-care treatment under resource scarcity”  have prompted the FGPG to prepare these recommendations for practice.
Advance care planning (ACP)
A severe course of COVID-19 illness is to be expected in particular in elderly patients with multimorbidity. Despite hospitalisation and intensive care, mortality in this group is very high: in the experience of intensive-care specialists, very few mechanically ventilated elderly patients with acute respiratory distress syndrome (ARDS) survive. For this reason, the question whether hospital admission is indicated for elderly COVID-19 patients with multimorbidity needs to be very carefully considered; it may only be appropriate in the event of complications of concurrent diseases. Most people would prefer to die, not in an intensive-care unit, but in their familiar environment. Accordingly, advance care planning is of crucial importance before, or at the latest when, the infection is diagnosed.
“Open, adequate and sympathetic communication with the patient and, if he wishes it, also with his relatives, is an important aspect of palliative treatment and care. A comprehensible, repeated and stepwise explanation enables the patient to develop realistic expectations, to express his own wishes and to make decisions” . Explaining not only the serious nature of the infection and the poor prognosis – even with intensive care – but also the possibilities of palliative care allows the patient to make an autonomous decision on how to proceed. The individual decision is to be discussed with the relatives caring for the patient and appropriately documented (advance directive, emergency care plan), and it must be accessible at all times, e.g. for emergency physicians. If a patient decides against hospital treatment, plans should be made for palliative care in the (nursing) home setting.
Palliative care measures
All pharmacological measures (table 1) must be adapted to the possibilities of the care setting in question. As the patient’s condition may deteriorate very rapidly, prescriptions should be made in advance for the problems expected to arise, and documented in an emergency plan. The drugs, together with the equipment required for their administration, must be available at the site where care is to be provided. As well as oral dosage forms, an alternative subcutaneous formulation is also to be prescribed.
|Fever||Paracetamol: 4× 500 mg tab/supp|
Metamizole: 4× 500–1000 mg tab/drops/ supp
|In addition, physical methods|
|Respiratory distress||Supplemental oxygen, if available|
Morphine 2%: 5 (–10) drops, up to hourly
Morphine hydrochloride: 2.5–5 mg s.c., up to half-hourly
With existing opioid treatment, increase doses accordingly
|Let in fresh air|
Raise upper body
|Acute respiratory distress||In addition to morphine:|
Midazolam nasal spray 0.5 mg per spray
Midazolam 1–2 mg s.c., up to 4 times per hour
|For severe respiratory stress, regular sedation with 2 mg midazolam s.c.|
|Anxiety||Lorazepam expidet 1 mg, up to 4 times daily|
Midazolam (see above)
|Cough||Morphine drops/s.c., as described above|
Codeine 50 mg tab, up to 3 times daily
|Pain||Morphine (as for respiratory distress)||If required regularly, possibly fentanyl or buprenorphine transdermal|
|Nausea||Metoclopramide 10 mg tab/drops/s.c., 4 times daily|
Domperidone 10 mg orodispersible tab, 4 times daily
|Delirium||Haloperidol 5–10 drops/1 mg s.c., 6 times daily|
Midazolam (as for acute respiratory distress)
|Create a calm environment|
|Dry mouth||Regular oral hygiene||Parenteral fluids are not helpful, more of a burden|
|For subcutaneous administration, a butterfly needle can be inserted and fixed (2 finger breadths below the clavicle) by a nurse. Repeated venepuncture can thus be avoided, and the relatives can be instructed on the procedure for injections.|
Separate recommendations are available for the treatment of patients with COVID-19 in the inpatient setting:
- Palliative ch: https://www.palliative.ch/en/professionals/task-forces/fokus-corona/
- German Association for Palliative Medicine (DGP): https://www.dgpalliativmedizin.de/neuigkeiten/empfehlungen-der-dgp.html
Care and support
If patients are cared for at home, the necessary support must be provided by nursing professionals and, if possible, by mobile palliative care (MPC) teams. If required, MPC teams are also to be called in to residential and nursing homes to ensure optimal treatment. In complex situations, regional palliative medicine specialists can be consulted (www.palliativkarte.ch).
In spite of any ban on visits to care homes, relatives must be offered the chance to be with the patient and say goodbye, while complying with protective measures. They should also receive appropriate support.
Fachgesellschaft Palliative Geriatrie FGPG. Grundsatzpapier Palliative Geriatrie
Fachgesellschaft Palliative Geriatrie FGPG. Grundsatzpapier Autonomie und Selbstbestimmung im Blick auf die Palliative Geriatrie
Header image: © Wernerimages | Dreamstime.com
Dr. Roland Kunz, Chefarzt universitäre Klinik für Akutgeriatrie und Zentrum für Palliative Care, Stadtspital Waid und Triemli, Tièchestrasse 99, CH-8037 Zürich, firstname.lastname@example.org
1 Istituto Superiore di Sanità Caratteristiche dei pazienti deceduti positivi a COVID-19 in Italia. www.epicentro.iss.it/coronavirus/bollettino/Report-COVID-2019_20_marzo_eng.pdf
2 Swiss Academy of Medical Sciences (SAMS) and Swiss Society for Intensive Care Medicine (SGI). COVID-19 pandemic: triage for intensive-care treatment under resource scarcity. Guidance on the application of Section 9.3 of the SAMS Guidelines «Intensive-care interventions». 2020. sams.ch/en/coronavirus
3 Swiss Academy of Medical Sciences (SAMS). Medical-ethical guidelines: Palliative Care. 2006, updated 2013. p. 9. www.assm.ch/dam/jcr:0676cb80-e902-4634-ae54-91f2bfc679c6/guidelines_sams_palliative_care_2012.pdf
4 palliative ch. Die Begleitung Sterbender. Unterstützung für Angehörige und freiwillige Helferinnen und Helfer. 2019. https://www.palliative.ch/fileadmin/user_upload/palliative/publikum/4_Angebote/Broschuere_Die_Begleitung_Sterbender_de_RZ_web.pdf
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