COVID-19 pandemic: palliative care for elderly and frail patients at home and in residential and nursing homes

Zurich/Berlin/Vienna, approved by the Board of the Association for Geriatric Palliative Medicine (FGPG) ( www.fgpg.eu ) on 22 March 2020.

Background

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 [1]. 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” [2] 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” [3]. 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.

Table 1 Treatment recommendations for the most common expected symptoms (care provided by Spitex/relatives at home or by nursing staff in a home)

Symptom	Measures	Notes
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 Provide reassurance
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.

Further useful information can be found in the palliative ch booklet on supporting the dying (Die Begleitung Sterbender) [4].

Separate recommendations are available for the treatment of patients with COVID-19 in the inpatient setting:

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.

COVID-19 pandemic: palliative care for elderly and frail patients at home and in residential and nursing homes

Background

Advance care planning (ACP)

Palliative care measures

Care and support

Further reading

References