Prognosis and Palliative Care in COVID-19

IHA Grand Rounds 2 Apr 2020

Dr Kevin Wade, Palliative Care, KGH/CCSI Vicki Kennedy, CNS, Interior Health Palliative & End of Life Care

Overview

1. Prognosis in Covid-19 2. Discussing Goals of Care 3. Health Care Rationing 4. Non-ICU Supportive Management Orders

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Prognosis in COVID-19

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Prognosis in COVID-19 - Caveats

• Still early – detailed natural history and prognostic data at each phase of illness are lacking

• Most reports so far represent raw case-fatality rates

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PresenterPresentation NotesCase fatality rates are subject to biasUnderestimate by survivor delayOverestimate by not testing asymptomatic or minimally symptomatic

This data is mostly useful as we lead into the discussion of goals of care – the benefits of critical care and intubation may be very small in elderly patients with multiple comorbidities

Prognosis in COVID-19 • Varies widely by country • 6,320 cases including 66

deaths have been reported in Canada (PHAC, as of 1100hrs 30Mar2020)

• 935,957 cases including 47,245 deaths have been reported worldwide (www.worldometers.info/coronavirus)

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1.0% Case-fatality rate

Canada

5.0% Case-fatality rate

Worldwide

PresenterPresentation NotesWHO Formal Case-Fatality Rate 3.4%, from early March, based mainly on Chinese data

Prognosis in COVID-19 – By Age AGE ITALY

case-fatality rate (%)

CHINA case-fatality rate

(%) 80+ years old 20.2 14.8 70-79 years old 12.8 8.0 60-69 years old 3.5 3.6 50-59 years old 1.0 1.3 40-49 years old 0.4 0.4 30-39 years old 0.3 0.2 20-29 years old 0 0.2 10-19 years old 0 0.2 0-9 years old 0 0.0 Overall 7.2 2.3

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Case-fatality rates by Age-group in Italy and China (Onder et al., JAMA, 23Mar2020)

• Includes all confirmed cases

• Includes inpatients and outpatients

PresenterPresentation NotesItalian data as of 17Mar2020Chinese data as of 11Feb2020Note that Italian data includes all deaths (of any cause) in patients with Covid-19 confirmed on PCRItalian testing strategy may have played a part – testing shifted to only hospitalized patients

Prognosis in COVID-19 – By Age

Age distribution of patients with confirmed COVID-19 (Ruan et al. Intensive Care Med, 2020)

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• Data from 150 inpatients in Wuhan, China

Prognosis in COVID-19 – ICU Survival

Interval from onset of symptoms to death (Ruan et al. Intensive Care Med, 2020)

• Data from 68/150 inpatients who died in Wuhan, China

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Median 16 days from symptoms to death

2 peaks: 14 days and 22 days

PresenterPresentation NotesMedian time from ICU admission to death is 7 days (Yang et al. Lancet Respir Med, 2020)

Prognosis in COVID-19 – Cause of Death

53% 32%

8% 7%

CAUSE OF DEATH

RespiratoryFailure

RespiratoryFailure andMyocardial InjuryMyocardial Injury

Unkown

• Data from 68/150 inpatients who died in Wuhan, China

Cause of death (Ruan et al. Intensive Care Med, 2020)

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Prognosis in the ICU

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• Data from 52 critically ill patients in Wuhan, China

Baseline Characteristics of Survivors and Non-Survivors (Yang et al., Lancet Respir Med, 2020)

PresenterPresentation NotesWe still have not answered the question of whether a given patient would benefit from intensive care and intubationNeed to rearrange data from the Yang study, look across rows rather than down columns

Prognosis in the ICU – By Age

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• 75% Mortality in ICU patients 60+ yo

• 90% Mortality in ICU patients 70+ yo

Prognosis in the ICU - Comorbidities

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• 100% mortality (0/7) in ICU patients with cerebrovascular disease

• 78% Mortality (2/9) in ICU patients with diabetes

Prognosis in the ICU – Outcomes

Outcome of ICU Admission (Arentz et al. JAMA, 2020)

52%

10%

38%

Outcomes

Death

Transfer outof ICURemainCritically Ill

• Data from 21 critically Ill patients in Seattle

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PresenterPresentation NotesMean time to follow up of 7.5 days

Prognosis in COVID-19 - Summary • Case fatality rates are a moving target, likely

somewhere between 1-5% • Prognosis for hospitalised patients worse with

age • Prognosis for elderly and those with

comorbidities is very poor, even with aggressive interventions

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PresenterPresentation NotesStatistics here support the value of exploring patients goals and fears, especially with respect to intubation and ventilation.Patients and families are influenced by the media, and may be overly optimistic about the benefits of critical care.

Discussing Goals of Care

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MOST Indicators – Our Current State C2 C1 C0 M3 M2 M1 No

MOST Population %

MOST/Pop.

All Ages

46,350 2,322 7,714 11,011 3,773 1,613 695,698 768,481 9.5

65+ 25,069 2,106 7,183 10,517 3,633 1,526 139,251 189,285 26.4

85+ 2,423 514 2,482 5,446 2,197 862 10,229 24,153 57.7

Reference: Interior Health insight, MOST Indicators report, retrieved March 25 2020.

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PresenterPresentation NotesWe know from a BC 2016 public opinion poll that only about 10% of people have talked to their doctor about their health care wishes.

Of Interior Health’s 65+ population nearly 68% of people with a MOST indicator have a C designation.

And 40% of people aged 85 and older with a MOST indicator have a C designation.

In the midst of a COVID-19 pandemic this highlights the need to address this and have conversations around goals of care, so we can provide appropriate enhanced goal-concordant care to the population who have been identified as most vulnerable to COVID-19. Benefits of these conversations also include; better patient and family coping, eased burden of decision-making for families, higher patient satisfaction and improved quality of life.

Following that, we also need to consider triaging appropriately – so those people who are not offered life-sustaining measures are cared for appropriately and provided appropriate symptom management.

A publication from Arya et al., hot off the press from last month stated: “In a triage situation our obligation to provide palliative care for those denied life-sustaining measures is increased”.

Discussing Goals of Care in Serious Illness

• Current Time • Necessary • Earlier the better • Palliative Care is a ‘Team Sport’ • Purpose is not to establish a new MOST status,

but if the discussion naturally flows in this direction, explore this in your recommendations.

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PresenterPresentation NotesGoals of Care conversations are about the hear and now.In a perfect world everyone would be comfortable thinking and talking about their mortality, that death is a part of living and the circle of life. Everyone would have an Advance Care Plan, have had meaningful and real discussions with their families in advance, not only if they had a serious illness, but also thinking about ‘What If?’….kind of like insurance. And to top it off everyone would have formal and perhaps legal documentation completed.

This would be certainly helpful for the population and health care professionals in these extraordinary times where the COVID-19 pandemic is resulting in significant fear, anxiety, and unknowns. It would help to inform and provide understanding and context in Goals of Care discussions, considering the current circumstances, so that we are providing goal-concordant care.

The reality may be that we are not quite there yet…… which means now in a pandemic, Goals of Care discussions are necessary, they may be initial discussions, so the earlier Goals of Care conversations are held when a person is suspected of having COVID, and particularly when they are older and have a serious illness – the better.

Knowing that Palliative Care is a “Team Sport”, this is an important time for collaboration, communication and documentation amongst inter-professional team members. The key components of these conversations can be shared amongst the team and must be communicated amongst the team.

The purpose of discussing Goals of Care is not to establish a new MOST status BUT if the discussion naturally goes in that direction, then explore that in your recommendations.

Principles of Goals of Care discussions

• Person-centered and purpose-oriented • You will not harm your patient by talking about

their illness and the importance of planning • Anxiety is normal for both patients and

clinicians - acknowledge and validate the emotion(s)

• People want and need the truth about their prognosis to make informed decisions

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PresenterPresentation NotesPerson-centered and purpose-oriented: A publication from Kaldjian stated that “By making the patient’s most important goals of care the conversational focal point, decision making is patient-centered, purpose-oriented, and premised on the patient’s beliefs, values, priorities, preferences, and circumstances.”

You will not Harm your patient by talking about their illness:Ariadne (Dr. Gawande – founding ED) have found that “People who think through what is important to them and what their wishes are often feel less anxious, more at peace, and more in control”.

Anxiety is normal for both patients and clinicians – it is important to be compassionate, acknowledge and validate emotions that arise before and to enable you to move forward.

People want and need the truth: “The hallmarks of a successful goals of care discussion is that it allows everyone to take a step back from the intense focus, by considering the broader purpose and context of the intervention.” So specifically on whether the patient knows and understands all the possible outcomes (including lack of benefit and prolonged rehabilitation), and would want intubation and ventilation in the case of a COVID infection.

“Goal-oriented discussions take a larger, longer view. Framed by goals of care, conversation about decision making moves the question from “Would you like us to do this, ornot?” to “Will this help us achieve your goals of care, or not?” (Kaldjian, 2019)

“The central practical concern is to identify and discuss goals that should be pursued and the means most likely to accomplish them. These discussions should allow us to understand patients well enough to know what matters most to them”

Identifying those at high risk • Surprise Question • Clinical Frailty Scale • SPICT • Others….

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PresenterPresentation NotesNow you know the populations at risk, there are many tools available to help identify these people who would particularly benefit from discussing Goals of Care.

The Position Statement from Dr. Kow from the UBC Division of Geriatric Medicine Position on Frailty and ICU candidacy released last month indicated that people with a CFS score of 5 (mildly frail) or more have a typically poor prognosis if hospitalized for COVID-19.

https://www.google.ca/url?sa=i&url=https://twitter.com/ktcanada&psig=AOvVaw1s_E49pfpPkyUREzik6YZT&ust=1585872133075000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCKCWqKO4yOgCFQAAAAAdAAAAABAD

Elements of a Serious Illness Conversation

• Set up the conversation – asking permission • Assess understanding & information preferences • Share prognosis – “Wish/Worry”, “Hope/Worry” • Explore key topics – goals, fears, sources of strength,

family • Close the conversation – Recommendation “I’ve

heard you say...” • Communicate and Document with key health care

team members

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PresenterPresentation NotesThe literature has demonstrated that Conversations often fail to address key elements of quality discussions.Fortunately, adaptations of Ariadne Labs SICG, specific to COVID have been created and made available to clinicians through UBC and the BC Center for Palliative Care. These tools identify the key elements and provide patient tested language which they understand, will resonate and evokes a response. The Key elements are: Setting up the conversation. This builds trust and gives the patient control by gaining the person’s permission to proceed with the discussion

Assessing understanding of their illness (where they are right now and what further changes lie ahead for them) and preferences for information on what is likely ahead allows the clinician to provide the desired information and gives the clinician confidence to proceed with a difficult discussion

Sharing prognosis to the degree desired by the person and within limits known to the clinician, is a responsibility of clinicians, and enable patients to factor this information into their goals of care decisions. Framing this as a ‘Wish/Worry’, ‘Hope/Worry’ statement enables the clinician to align with the patients hopes, acknowledge their concerns, and be truthful while being sensitive.

Exploring Key Topics such as; Goals, Fears, Sources of Strength and what their Family knows about what is important to them helps to articulate their goals of care. All patients have goals besides living longer. Understanding patient goals aids the clinician in tailoring recommendations to address the person’s priorities.

Closing the conversation with Recommendations summarizing what you heard them say and provides recommendations in regards to their Wellbeing, their Illness and their Support System and reassures you will help them.

Finally, Communicating and Documenting the conversation ensures the health care team know about the discussion that took place.

Extra info just in case needed: What would you like to know about your illness, COVID-19, and what may happen if you were sick? What information do you need to help you make decisions about your future? How do you like to make decisions? Who would you like to help you? What are you afraid of about your illness and COVID-19?

Are there some kinds of medical care you may not want? What makes you feel that way? How do you feel about sharing these thoughts and feelings with the people who support you? If you have not already asked someone to be your substitute decision maker, who could fill that role?

Adapting to different clinical situations • If the patient is an ICU candidate

– Function – Trade-offs

• Patient/Family insists on ICU despite it not being an option – Consult – Re-iterate focus – Wish/Worry, Hope/Worry framework – Offer ongoing support

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PresenterPresentation NotesThese SIC tools provide adaptations for different clinical situations. If a person is an ICU candidate, it would important to explore the topic of Function and Trade-Offs.

Patients view impairment in function differently & make choices based on these perspectives. “What abilities are so critical to your life that you can’t imagine living without them” OR “What does meaningful quality of life look like to you?”

And allowing to reflect on trade-offs that might be necessary to achieve different outcomes promotes informed decision-making.“If you become sicker, how much are you willing to go through for the possibility of gaining more time?” (i.e. in the case of COVID infection, are they willing to go through intubation, ventilation and a potentially prolonged ICU stay for the possibility of survival?)

When a patient/family insists on ICU despite it not being an option:

• Consider requesting a consult from ICU, so they can share their perspective with the family.• Re-iterate/Focus on the active medical treatments that you will continue to provide to the patient, and Frame ICU in terms of the prolongation of suffering as opposed to provision of cure.• Use wish/worry/wonder: "I wish this weren't the case, but I worry that if we bring you to the ICU, you will suffer more. I wonder if we can take this opportunity to ensure you have a peaceful death."• Offer ongoing support: “We will be here for you/your loved one no matter what happens”

Ethical Framework

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PresenterPresentation NotesThis is an excellent framework that can guide health care professionals, and demonstrates that the perspectives and input of the patient, family and health care team are integral and equally important components to formulate goals of care.

Goals of Care - Billing • Multiple codes now allowed by Telehealth • 14063 (Palliative Care Planning Fee)

• For patients in community or assisted living • Must qualify for palliative care benefits program • Not for patients in residential/long term care • 30min minimum • $100

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PresenterPresentation NotesPractical applications – advance care planning is important both to your patients and for the health care system as a whole

Goals of Care - Billing • Multiple codes now allowed by Telehealth • 14033 (Complex Care Management Fee)

• Payable once per year for patients with 2 or more comorbidities in community or assisted living

• Must develop complex care plan incorporating patients values and goals

• $315

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Goals of Care - Billing • Multiple codes now allowed by Telehealth • 14077 (Facility Patient Conference Fee)

• To discuss goals of care with specialists or the interprofessional care team

• $40/15min increment

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Goals of Care - Billing • Multiple codes now allowed by Telehealth • 00114 (Long Term Care Facility Visit)

– Typically payable once every 2 weeks – $35.86

• 00127 (Terminal Care Facility Visit) – Payable in last 6mo of life – May use for virtual visit with patient, or with RN/LPN

if patient unable to use phone – $53.20

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Health Care Rationing

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Health Care Rationing

• Rationing and allocation of resources are very different from discussing and providing goal-concordant palliative care

• Dangerous to conflate these two processes

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PresenterPresentation NotesMedia and public focus has been very intent on rationing and the idea that patients will not have a ventilator availableWe need to be conscious of this when discussing goals of care – this is about what people want and will benefit from, not about what they can getFailure in this may lead to a loss of trust in caregivers and especially in decisions re goals of care

Health Care Rationing - Principles • Many existing frameworks

– Pittsburgh (White et al. Ann Intern Med 2010) – Maryland (Daugherty Biddison et al. Chest 2019) – New York Ventilator Allocation Guidelines (Zucker

et al., 2015) • “Soft utilitarianism” • Emphasize prioritization of short term survival

(eg SOFA score) over long term prognosis

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PresenterPresentation NotesNew York developed Ventilator Allocation Guidelines in 2015Eg by using SOFA score for short term survivalGoal is to avoid excluding certain groups (eg the elderly or disabled) arbitrarily

Health Care Rationing - Application • Rationing decisions are not made by the

treating clinician due to the stress and moral injury it imparts

• Separate “Triage Committees” decide on allocations by applying a framework or score

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PresenterPresentation NotesTriage committees usually consist of intensivists, ethicists, palliative care physicians - often similar to ethics committees

Symptom Management outside the ICU

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Hospital Transfer

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Symptom Management - Principles 1. Ensure all patients receive care 2. Avoid harm 3. Reduce suffering by providing appropriate

symptom control (esp of dyspnea) 4. Protect health care staff 5. Support families 6. Conserve resources (eg PPE, medications)

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PresenterPresentation NotesFor symptom management outside the ICUNot necessarily restricted to expected EOL patients

Dyspnea • Oxygen up to 6Lpm without generating

aerosols (Hendin et al., CJEM, 2020) • Avoid use of fans • Avoid nebulizers, CPAP, BiPAP • No evidence for bronchodilators/ICS unless

patient has underlying asthma/COPD

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PresenterPresentation NotesSome sources alternately say 15Lpm (VCH guidelines) – err on the side of caution given the lack of evidence for symptomatic benefitMed shortages of MDIs – salbutamol/atrovent both very short, don’t use for placebo effectTolerate some hypoxia – won’t increase their dyspnea

Dyspnea Opioids – Opioid Naive

• Morphine 2.5-5mg PO Q1H PRN • Morphine 1-2mg IV/SC Q30min PRN Or • HydroMORPHONE 0.5-1mg PO Q1H PRN • HydroMORPHONE 0.25-0.5mg IV/SC Q30min

PRN • Review often, start Q4H scheduled if using frequent

PRNs

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PresenterPresentation NotesAllow nursing staff to determine appropriate route based on patient assessment and riskSporadic reports of medication shortages esp parenteral hydromorphone in IHA, so use morphine in appropriate patients (younger w/ no renal impairment and no allergy)

Not necessarily only for expected EOL patients (ie M1/M2) – may also use in M3No evidence of increased mortality with low dose opioids in end stage COPD or pulmonary fibrosis, but evidence of increased mortality in acute decompensated CHFChoose wisely, discuss goals of care with patient

Dyspnea Opioids – Opioid Tolerant

• Calculate total daily dose

• Give breakthrough dose as 10% of the total daily dose, IV/SC Q30min PRN

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PresenterPresentation NotesUse of long-acting opioids is unclear, most patients seem to progress quickly to EOLFentanyl patch 12mcg/hrHydromorph-Contin 3mg PO BIDKadian 10-30mg PO Daily

Dyspnea • Consider transition to opioid continuous

IV/SC infusion if still taking frequent PRNs on top of regular dosing

• Minimizes risk to nursing staff from frequent dosing

• Talk to local nursing leads – easier than you think • Consult palliative care for help

– Provincial hotline 1-877-711-5757

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PresenterPresentation NotesAll parenteral opioids can be given as infusions – via CADD pump or IV pump – incl fentanyl, morphine, hydromorphone

Dyspnea • Consider palliative sedation if refractory

dyspnea with patient distress • Midazolam 1-4mg/hr CSCI • Methotrimeprazine 5-25mg Q8H and Q3H

PRN • Protocol and order set pending approval

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PresenterPresentation NotesCJEM article mentions dissociative dose ketamine as a temporizing measure until opioids take effect

Respiratory Congestion • For copious airway secretions • Glycopyrrolate 0.4mg IV/SC Q4H PRN • Atropine 0.6mg SC Q6H PRN • Atropine 1% (ophthalmic drops) 1-2 drops

SL Q4H PRN

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PresenterPresentation NotesSome notes mention scopolamine subcut or patch, less used in BC (much more widely used in Ontario), can be associated with delirium

Other Symptoms Pain

• Morphine 2.5-5mg IV/SC Q1H PRN • HydroMORPHONE 0.5-1mg IV/SC Q1H PRN

Fever • Acetaminophen 650mg PO/PR Q4H PRN

Agitation • Haloperidol 0.5-1mg IV/SC Q3H PRN • Methotrimeprazine 12.5-25mg SC Q4H PRN • Midazolam 0.5-1mg IV/SC Q30min PRN

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PresenterPresentation NotesGenerally pain dose is double the dyspnea dose of the equivalent medication and route

Symptom Management - Summary

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“All patients must be cared for”

https://palliativecare.med.ubc.ca/coronavirus/

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https://palliativecare.med.ubc.ca/coronavirus/https://palliativecare.med.ubc.ca/coronavirus/

Conclusion • Establish goals of care early – ideally before

any infection or decline, at their current place of care

• Many patients will not benefit from critical care measures

• Care for every patient, every time

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Questions?

• Kevin Wade • Kevin.wade@bccancer.bc.ca • 604-379-1655

• Vicki Kennedy • Vicki.kennedy@interiorhealth.ca • 250-212-7807

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mailto:Kevin.wade@bccancer.bc.camailto:Vicki.kennedy@interiorhealth.ca

Prognosis and Palliative Care in COVID-19OverviewSlide Number 3Prognosis in COVID-19Prognosis in COVID-19 - CaveatsPrognosis in COVID-19Prognosis in COVID-19 – By AgePrognosis in COVID-19 – By AgePrognosis in COVID-19 – ICU SurvivalPrognosis in COVID-19 – Cause of DeathPrognosis in the ICUPrognosis in the ICU – By AgePrognosis in the ICU - ComorbiditiesPrognosis in the ICU – OutcomesPrognosis in COVID-19 - SummaryDiscussing Goals of CareMOST Indicators – Our Current StateDiscussing Goals of Care in Serious IllnessPrinciples of Goals of Care discussionsIdentifying those at high riskElements of a Serious Illness ConversationAdapting to different clinical situationsEthical FrameworkGoals of Care - BillingGoals of Care - BillingGoals of Care - BillingGoals of Care - BillingHealth Care RationingHealth Care RationingHealth Care Rationing - PrinciplesHealth Care Rationing - ApplicationSymptom Management outside the ICUHospital TransferSymptom Management - PrinciplesDyspneaDyspneaDyspneaDyspneaDyspneaRespiratory CongestionOther SymptomsSymptom Management - SummaryConclusionQuestions?