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Dr. Felicia Knaul Weighs in on the Importance of Palliative Care in the Time of COVID-19

Felicia Knaul, Ph.D., director of the Institute for Advanced Study of the Americas and professor at the University of Miami Miller School of Medicine’s Department of Public Health Sciences, has been a long-time advocate for worldwide palliative care, as well as created and designed research and advocacy networks.

Among them was The Lancet Commission on Global Access to Palliative Care and Pain Relief, where she served as chair from 2014 to 2017 and lead-authored the report “Alleviating the access abyss in palliative care and pain relief – an imperative of universal health coverage.”   

In the time of COVID-19, Dr. Knaul, who is an expert in Latin American health systems and social sectors and an international health economist, weighed in on the importance of palliative care in tackling the pandemic.  

Q: Palliative care’s main patient population are those who are elderly, frail, and/or with underlying chronic or serious illnesses. As this population is most at risk for the novel coronavirus, how important is it for palliative care to be a part of the COVID-19 response worldwide?

A: Essential. Palliative care is the prevention and relief of suffering for people facing life-threatening illness and requiring end-of-life care. Today, that includes tens of thousands of patients with COVID-19 who are seriously ill and require hospitalization. There are many lessons to be learned from the palliative care community at this time, especially in settings unaccustomed and/or ill-equipped to provide support around death and dying.

Q: What do palliative care specialists specifically have to do during this pandemic?

A: During this pandemic, palliative care specialists must provide symptom control to mitigate the suffering of their patients and those who are affected by COVID-19. In addition, the palliative care community has a crucial role to play in coaching and training health care professionals and volunteers with less experience in end-of-life care and should employ and advise on ethical principles for triage and provide for creative solutions regarding the need for bereavement support. Finally, the appropriate and balanced approach to the use of opioid medications for relieving suffering is the realm of palliative care specialists and will be much needed during this pandemic. 

Q: When a patient with a chronic or serious illness diagnosed with COVID-19, the diagnosis can potentially put the patient in worse health and could even lead to death. How would palliative care be one of the best routes to take in a case like this?  

A: The guiding principle of palliative care is to reduce suffering and maintain the dignity of patients and their families in the face of life-threatening or life-limiting illness and at end-of-life. In cases where a patient is either very unlikely to survive invasive treatment or is unable to access critical care, palliative care is the route to best alleviate suffering. It is important to conceive of palliative care as a process that is integrated with treatment, begins with diagnosis, and is offered to all patients and families when faced with a life-threatening illness whether or not that illness results in death. There is a standard used by the WHO to determine the palliative care course of action during humanitarian emergencies.

Q: If resources are limited, an elderly patient who is in a late stage of a chronic illness may not be prioritized for care in an intensive care unit. How can palliative care help this scenario?    

A: Guidance from the WHO recommendations around palliative care during humanitarian crises and emergencies would help guide these decisions. There is an ethical imperative to tend to the suffering and provide comfort for all individuals, and palliative care is the field equipped to do so.

I want to highlight that the majority of countries currently lack the opioid pain relief medications to attend to even a small proportion of pre-COVID-19, palliative care needs. Unless they immediately apply emergency measures to increase stocks working with the International Narcotics Control Board, tens of thousands more patients may die in pain. In my opinion, this is one of the most urgent issues to attend to and it is one that the palliative care community has been insisting on for a very long time for low- and middle-income countries. We shared these data in the University of Miami-led Lancet Commission Report on Palliative Care and Pain Relief published in 2017.

Q: Families may be prohibited from visiting patients who are acutely or chronically ill. Decisions and conversations may not be as clear and might need to be made on long-distance. What are some components of palliative care that could relieve a situation like this?

A: There is no doubt that this physical distance from loved ones will generate added suffering for both patients and families – both patients receiving palliative care who will need to be especially careful about physical distancing and those with COVID-19. I believe that it will be crucial to make full use of technology to support families in keeping in touch, and this, in turn, means added demands on already over-stretched medical care personnel. The expertise and experience of the palliative care community in managing painful and complex conversations about death and dying, the prioritization of reducing suffering, and the ethical guidelines to do so, provide a framework to communicate with families and guide decision making.

Q: Would you say that palliative care is just as critical as fluids, fever reduction, ventilators, masks, and gloves?   

A: These are inputs that are crucial to the provision of effective, quality medical care and protecting all health workers. There is no either-or in this pandemic – all are required though we are witnessing tragic situations in which essential medicines, equipment and services are severely lacking. In low-and-middle-income countries, the divides will be orders of much larger magnitude.

Q: How can palliative care also be helpful to nurses, physicians, and their colleagues who are at risk and working on long hours?  

A: There is a lot of psychosocial and physical stress on healthcare workers at this time.  They will need access to support to manage both that stress and the grief of losing patients. Palliative care can provide coaching and guidance for other groups of health care workers and there are already a number of organizations offering access to training and materials.

Q: Is there anything else that you would like to add?

A: The neglect of palliative care and pain relief has been a constant of global health that has gone on for far too long. The COVID-19 pandemic must force us to rapidly change our ways and prioritize the mitigation of suffering alongside the search for a cure and the commitment to treatment.

 
Felicia M. Knaul, Ph.D., Karen J. Burke, M.P.H., in collaboration with Amanda Torres
Published on April 1, 2020