Best Practice in Clinical Ethics and Compassionate Care during COVID-19 Crisis: CHAPTER 3 - PALLIATIVE CARE

INTRODUCTION

• Clinical ethics is analytic and reflective. It gives clarity and suggests resolution.
• There is a difference between a patient-centred approach to clinical care on a normal day and a public-centred approach to clinical care during the pandemic crisis. Thus, clinicians face what we call moral distress (MD) during the pandemic, which results from a perceived violation of one’s core values and duties, concurrent with a feeling of being constrained from taking the ethical or right actions. 
• MD could originate from a different clinical decision-making flow and standard of care, an altered patient and physician relationship, the limited chance for the usual personal and compassionate care, and the constant conflict of obligations between patients, self, colleagues, and families. 

OBJECTIVES

• These chapters aim to guide and support clinicians, and eventually reduce the impact of public health-centred clinical care on clinicians, patients, and families. Along with practical steps and tools, they give clarity and suggests ways to resolve some of the most challenging clinical practice during the COVID-19 pandemic.

Best Practice in Clinical Ethics and Compassionate Care during COVID-19 Crisis

CHAPTER 3 - PALLIATIVE CARE

Ethical Questions:

1. When there are limitations to ICU/ventilator access and all other interventions to treat severe COVID-19 have been exhausted, is it appropriate to say, “There is nothing more that we can do?”
2. Is using morphine and sedative medication in the last days/hours of the life of severe COVID-19 patients appropriate?

Scenarios:

1. A 73-year-old lady with CKD stage 5 presents with worsening dyspnea and is found to be PCR+ve for COVID-19. Her serum creatinine is 980 umol/l and she has metabolic acidosis. She told her family clearly that she does not want any form of renal replacement therapy.
2. A 58-year-old gentleman was admitted with a large Middle Cerebral Artery infarct and poor GCS with a background of diabetes mellitus and hypertension. He developed fever and worsening oxygen saturation with tachypnoea during admission and was PCR+ve for COVID-19. There are no more ventilators available, and his O2 saturation is 80% on a 12L/min facemask.

Guiding Principles:

1. Palliative care is not merely providing care in the last days of life but is also applicable to all patients who have severe distress from any life-limiting illness regardless of interventions.
2. Palliative care considers care for the whole patient not merely for physical symptoms but also psychological, social, and spiritual problems.
3. Palliative care can be provided by any healthcare professional at a basic level and does not necessarily require a specialist in palliative medicine.

For COVID-19 patients who are severely ill, palliative care should be provided to address symptoms of dyspnoea and pain due to severe inflammatory pathology whilst still receiving acute interventions to prevent mortality. In patients who were not offered life support interventions due to their poor prognosis, palliative care must be provided as the failure to do so would be considered unethical.

Related chapters:

Chapter 1 - Crisis Decision-Making Support Pathways. http://doi.org/10.5281/zenodo.5111535  
Chapter 2 - DNR And End-Of-Life Care - Decision, Communication, And Management. http://doi.org/10.5281/zenodo.5111544  
Chapter 4 - Compassionate Care. http://doi.org/10.5281/zenodo.5105289 

For healthcare professional only