Authors contribution statement
All authors have made a significant contribution to this article from
concept to implementation and publication.
Abstract
Healthcare services are being confronted by a daily dilemma of who can
receive critical care and who cannot. In a palliative care clinic, this
apprehension gets exemplified, as these patients have limited life
expectancy. The head and neck region further makes things critical, as
it comprises of all the sites through which the SARS-CoV-2 can be
transmitted. This document strives to define the ways in which the head
and neck cancer services can contribute to better patient care in a
triage context. Practical steps suggested are protective equipment use,
ensuring access to critical drugs (such as opioids), greater use of
telemedicine consultations, discussing advance care plans and embracing
the role of a wider community support.
Keywords: COVID-19, Coronavirus, Palliative care, Head Neck, pandemic
Introduction
Less than a decade ago, the Worldwide Palliative Care Alliance and the
World Health Organization (WHO) declared palliative care as a human
right.(1) But still in the best times, palliative services are under
resourced world over. As health systems are strained by the ongoing
pandemic, providing this essential service has become an unaddressed
ethical challenge. Healthcare services are being confronted by a daily
dilemma of who can receive critical care and who cannot. In palliative
care services, this apprehension gets exemplified, as these patients
have limited life expectancy.
In some sense, both COVID-19 and head and neck cancer patients receiving
palliative care run a similar disease course. Resources are frugally
rationed, time is always short, patients deteriorate quickly and
families are counseled regarding the grim prognosis. What’s worse is
when a patient receiving palliative care contracts the severe acute
respiratory syndrome coronavirus-2 (SARS-CoV-2), it will result in
isolation measures extending to the inevitable.
The head and neck region further makes things critical, as it comprises
of all the sites through which the SARS-CoV-2 can be transmitted –
oral, oropharyngeal, nasal and laryngopharyngeal. Most guidelines
suggest that healthcare workers dealing with these sites either defer
management of these patients or use appropriate protective measures.(2)
This has led to many centers rescheduling appointments indefinitely
causing a significant delay in their treatment. This scenario is not
limited to low- and middle-income countries with most western countries
facing similar if not worse shortages of critical care. In a time where
hospital resources are sparse even to treat patients requiring
definitive care, how does one provide palliative care? This document
strives to define the ways in which the head and neck cancer services
can contribute to better patient care in a triage context.
Approaches to respond
The primary goal of all head and neck oncology centers today is to
triage patients and avoid unwanted hospitalizations and intensive care
that would aggravate the need for rationing services. Most of the
centers across the world have implemented some form of contactless
appointments, be it virtual or telephonic. Routine home care through
these approaches can be very effective in triaging patients early.
Whenever possible the referral system should be decentralized to
accommodate patients at freestanding hospice or home care centers. To
encourage this, certain administrations have relaxed rules whereby
hospices can provide appropriate services to insured patients under
their medicare and medicaid packages.(3) However, this would lead to
hospice services facing an excessive amount of referrals, which could in
turn require their own triaging systems and use of teleconsultation.
Prescriptions can also be given for longer periods so that patients do
not need to return in short intervals. Palliative clinics have also
started allocating resources, including personnel, more efficiently in
preparation for the pandemic.
Education and Counseling
All measures undertaken should be aimed at preserving and prolonging
life. Most people infected with SARS-CoV-2 will survive and recover. For
those dying as a consequence of the infection who do not wish to have
active or invasive treatments, the switch in focus to high quality,
compassionate care at the end of their life is equally important. Hence
it is of utmost consequence to explore and documented the preferences on
further management and goals of care. Patients with decision-making
capacity should be appropriately counseled before embarking on any
procedure, highlighting the heightened risk of contracting the
SARS-CoV-2 virus and possibly disseminating in the community. If the
patient/relatives express a wish for hospitalization, they should be
informed of the fact that the admission may not be ultimately be put
into practice if there is a lack of medical indication, particularly in
a situation of scares resources. Few guidelines have suggested a “three
talk” approach that includes a team talk, option talk and a decision
talk.(4) In addition to educating and counseling patients, palliative
care providers should coach the front line staff on methods to deal with
negative emotions and communicating empathy. If the disease course can
ensue a delay of several days, the physician should decide on medical
indication for a local hospital or hospice transfer depending on the
following:
- Severity and complexity of the symptoms and additional care needs
- On the nursing home/ambulatory care capacity of delivering quality
palliative care
- Availability of palliative care unit resources
- Patient’s request
Emergency department visits
Pain and dyspnea are the most common complaints that patients receiving
palliative care present with to the emergency department.(5) Both
COVID-19 and non-COVID-19 conditions (lung metastasis, superior vena
cava obstruction, upper airway tumors, etc.) can cause distress or
breathlessness towards the end of life. By virtue of its anatomy, head
and neck patients can pose a serious threat to the attending healthcare
workers. All patients should be treated as potentially COVID-19
positive. Non-invasive approaches should be attempted where possible.
Cough hygiene should also minimize the risk of transmission. Standard
practice guidelines for intubation and emergency tracheostomy for
COVID-19 positive or unknown patient should be followed.(6) Emphasis
should be placed on the safety of medical personnel through proper use
of personal protective equipment. Once airway is established, suctioning
should be done on a closed system and a trach collar is preferred.
Patients should not be admitted in the hospital for prolonged periods
and dealt with on an outpatient basis.
In general, a symptom-based approach should be adopted. It is imperative
to correct what is correctable either through non-drug approaches for
mild to moderate disease and drug approaches when required, for example
prescribe antibiotics for a bacterial infection. In case of fever, few
guidelines have suggested to withhold ibuprofen as concerns have been
raised about its possible role in COVID-19.(4) Alternate non-steroidal
anti-inflammatory drugs may be prescribed.
Pain management
Pain management is an integral part of palliative care. Long before the
coronavirus hit us, the opioid crisis has been a global controversy. The
WHO estimated that 80% of the world has insufficient access to the
required opioid analgesic.(1) With supply chains being affected around
the world there have been severe shortages of intensive care drugs, such
as morphine, at hospitals treating the COVID-19.(7) This has
precipitated in an acute shortage of these critical pain medications
among palliative patients. Other opioid substitutes such as
buprenorphine and methadone are now being handed out without
prescription during the COVID-19 crisis in some countries as a harm
reduction strategy for people who are dependent on opioids.(8) This
could further exhaust the supply of essential drugs needed for pain
relief among these countries. Even though it has been established that
opioids are necessary for cancer pain, a large part of palliative care
patients will face barriers to relief of such suffering.(9)
During this pandemic, careful triaging of head and neck patients
intended to or currently receiving palliative care is necessary to
prevent further denuding of critical care resources. Early referrals,
where patients are not having a significant symptom burden, could be
temporarily avoided during the crisis. This would allow palliative care
providers to focus on urgent needs for consults in situations such as
management of severe/refractory symptoms, shared decision making and
managing anticipatory grief. There is a troubling amount we still do not
know about the SARS-CoV-2 infection. One thing certain is that the
disease poses a serious hazard to those with compromised immune systems
such as cancer patients. In this vulnerable population, COVID-19 could
be much worse and more fatal than the cancer itself. The WHO has issued
guidance on maintain essential health services during the pandemic with
a focus on maternal care, immunization and emergency services among
others, but no mention of palliative care.(10) A pandemic is often a
powerful amplifier of suffering through physical and mental distress,
and financial and social instability. As head and neck cancer care
providers it is imperative we deliver the best possible care to patients
with the resources at hand, irrespective of their outcomes. In this time
of crises, we need to remember to withdraw life sustaining treatments
not life sustaining care, and deliver comfort focused treatments and not
comfort focused care.
Resources for patients and healthcare providers:
- Worldwide Hospice and Palliative Care Alliance
http://www.thewhpca.org/covid-19
- International Association of Hospice and Palliative Care (IAHPC)
Palliative Care and Covid-19
http://globalpalliativecare.org/covid-19/
- COVID-19 Communication Tools from
https://docs.google.com/document/d/1uSh0FeYdkGgHsZqem552iC0KmXIgaGKohl7SoeY2UXQ/preview
- Center to Advance Palliative Care (CAPC) COVID-19
Toolkit https://www.capc.org/toolkits/covid-19-response-resources/
- American Academy of Hospice and Palliative Care COVID-19 Resource
http://aahpm.org/education/covid-19-resources
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Almuhanna M, et al. A Practical Approach to the Management of Cancer
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An International Collaborative Group. The Oncologist. 2020 Apr 3;
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