Dying patients with COVID-19: What should Hospital Palliative Care Teams (HPCTs) be prepared for?

OBJECTIVE: The COVID-19 pandemic is a care crisis of unknown duration which has seemingly not yet reached its peak in many countries. A significant number of elderly and frail people and those with underlying serious illness will continue to develop severe forms of the COVID-19 infection. Most of them are not eligible for intensive care treatment but can still expect palliative care - in many cases provided by a Hospital Palliative Care Team (HPCT). Several teams have already gained experience in caring for these patients and their families, others are preparing for it. METHOD: We report on a COVID-19 patient with pre-existing acute myeloid leukemia who was looked after by a HPCT until death. We discuss the challenges and difficulties while caring for COVID-19-positive palliative patients in a non-ICU setting. RESULTS: Hospitalization of the patient in an isolation ward caused an enormous burden for the dying patient and his family. Symptom control was particularly difficult because of rapid deteriorating dyspnea and the scarce presence of medical staff in the patient's room. SIGNIFICANCE OF RESULTS: COVID-19 patients who are not eligible for ICU treatment may have a particularly high need for palliative care. Since beds in specialist palliative care units are limited, the HPCT should be prepared to care for these patients. They may offer support in decision-making, optimize symptom control, and provide psychosocial care for patients and their families. Visiting restrictions aimed to protect the general public must be weighted against the patient's and family's suffering.

Physicians' attitudes toward end-of-life decisions in amyotrophic lateral sclerosis.

OBJECTIVE: This study aims (1) to assess physicians' attitudes toward different palliative end-of-life (EOL) practices in amyotrophic lateral sclerosis (ALS) care, including forgoing artificial nutrition and hydration (FANH), continuous sedation until death (CSD), and withdrawing invasive ventilation (WIV), and toward physician-assisted dying (PAD) including physician-assisted suicide and euthanasia and (2) to explore variables influencing these attitudes. METHODS: We used two clinical vignettes depicting ALS patients in different stages of their disease progression to assess the influence of suffering (physical/psycho-existential) on attitudes toward WIV and the influence of suffering and prognosis (short-term/long-term) on attitudes toward FANH, CSD, and PAD. RESULTS: 50 physicians from European ALS centers and neurological departments completed our survey. Short-term prognosis had a positive impact on attitudes toward offering FANH (p = 0.014) and CSD (p = 0.048) as well as on attitudes toward performing CSD (p = 0.036) and euthanasia (p = 0.023). Predominantly psycho-existential suffering was associated with a more favorable attitude toward WIV but influenced attitudes toward performing CSD negatively. Regression analysis showed that religiosity was associated with more reluctant attitudes toward palliative EOL practices and PAD, whereas training in palliative care was associated with more favorable attitudes toward palliative EOL practices only. CONCLUSION: ALS physicians seem to acknowledge psycho-existential suffering as a highly acceptable motive for WIV but not CSD. Physicians appear to be comfortable with responding to the patient's requests, but more reluctant to assume a proactive role in the decision-making process. Palliative care training may support ALS physicians in these challenging situations.

[Palliative Sedation: Comments on a controversial topic]. / Palliative Sedierung: Anmerkungen zu einem strittigen Thema.

Palliative Sedation: Comments on a controversial topic Abstract. Palliative sedation (PS) is an accepted medical practice for terminally ill patients. It intends the alleviation of unbearable suffering by intentionally lowering the level of consciousness. In contrast to physician assisted suicide and euthanasia, palliative sedation aims to relieve burdensome symptoms with no intention of hastening death. PC can be applied as "intermittent palliative sedation" or "continuous (deep) sedation until death". Most ethical controversies are related to the latter form of PS: 1: Is existential or psychosocial suffering a possible indication for PS? 2: What is the earliest possible time point to start PS? 3: The withdrawal or withholding of artificial nutrition and hydration during PS. A critical reflection of these ethical controversial aspects within the treatment team is highly desirable. However, the patient's well-being and the respect for the patient's decisions that are based on experiences which are made only by him or her, must remain the guiding principle for medical actions.

[The Development of Palliative Care Hospital Support Teams (HPCTs) in Bavaria from 2011-2015: Tasks, Acceptance, Structure and Funding]. / Entwicklung der Palliativmedizinischen Dienste (PMD) in Bayern 2011­2015: Aufgaben, Akzeptanz, Struktur und Finanzierung.

INTRODUCTION: Palliative care hospital support teams (HPCTs) provide inpatients from all departments palliative medical support. Seriously ill as well as dying patients, who are being treated in facilities that do not have their own palliative care unit, can benefit from these multi-professional teams just as much as patients who do not (yet) need to be admitted to a palliative care unit. At the end of 2015, 53 HPCTs, which were in accordance with the requirements established in the "Program for HPCTs" by the Bavarian Ministry of Health in 2009, had been approved in Bavaria. METHODS: Using a questionnaire that was distributed by mail (2011) and an online survey (2015), we asked all Bavarian HPCTs, which had been approved up until then, to answer questions regarding their tasks, the level of acceptance within their hospital, the structure of their staff and funding. In addition to questions, which were rated on an applicability scale from 0 to 10, there was also room for written comments. RESULTS: The return rate in 2011 was 77% (17 questionnaires) and 53% (28) in 2015. In sum, HPCTs were widely regarded as a suitable instrument for improving in-house palliative care (2011: median 7.8 (0-10) ±1.9, 2015: 7.2 (0-10) ±2.3; n.s.). The level of acceptance among the other departments of the hospital was assessed as being significantly higher in 2015 (7.2±2.3) than it was 4 years earlier (5.7±2.2; p<0.05). HPCTs cover various tasks, most commonly including "supportive conversations," "accompaniment in the dying phase," "pain therapy" and "discharge management." However, a decline in multi-professionalism within the teams could be seen, especially in the fields of psychology/psycho-oncology and spiritual care (p<0.05). Both surveys showed that an essential aspect in funding the teams was the supplementary payment ZE 60 for "complex palliative medical treatments." However, funding in general was predominantly reported as being quite difficult: only 29% of the HPCTs of 2015 indicated that all of their costs were covered. CONCLUSION: HPCTs in Bavaria take over important tasks in caring for seriously ill and dying patients and their families. According to their own appraisal, the level of acceptance within hospitals is improving. The hope is that new regulations, such as the new OPS 8-98 h (specialized complex palliative treatments provided by a HPCT), which was introduced in 2017, will solidify funding without jeopardizing the multi-professionalism that characterizes HPCTs.

Physician-assisted suicide, euthanasia and palliative sedation: attitudes and knowledge of medical students.

OBJECTIVES: In November 2015, the German Federal Parliament voted on a new legal regulation regarding assisted suicide. It was decided to amend the German Criminal Code so that any "regular, repetitive offer" (even on a non-profit basis) of assistance in suicide would now be considered a punishable offense. On July 2, 2015, a date which happened to be accompanied by great media interest in that it was the day that the first draft of said law was presented to Parliament, we surveyed 4th year medical students at the Technical University Munich on "physician-assisted suicide," "euthanasia" and "palliative sedation," based on a fictitious case vignette study. METHOD: The vignette study described two versions of a case in which a patient suffered from a nasopharyngeal carcinoma (physical suffering subjectively perceived as being unbearable vs. emotional suffering). The students were asked about the current legal norms for each respective course of action as well as their attitudes towards the ethical acceptability of these measures. RESULTS: Out of 301 students in total, 241 (80%) participated in the survey; 109 answered the version 1 questionnaire (physical suffering) and 132 answered the version 2 questionnaire (emotional suffering). The majority of students were able to assess the currently prevailing legal norms on palliative sedation (legal) and euthanasia (illegal) correctly (81.2% and 93.7%, respectively), while only a few students knew that physician-assisted suicide, at that point in time, did not constitute a criminal offense. In the case study that was presented, 83.3% of the participants considered palliative sedation and the simultaneous withholding of artificial nutrition and hydration as ethically acceptable, 51.2% considered physician-assisted suicide ethically legitimate, and 19.2% considered euthanasia ethically permissible. When comparing the results of versions 1 and 2, a significant difference could only be seen in the assessment of the legality of palliative sedation: it was considered legal more frequently in the physical suffering version (88.1% vs. 75.8%). CONCLUSION: The majority of the students surveyed wrongly assumed that physician-assisted suicide is a punishable offense in Germany. However, a narrow majority considered physician-assisted suicide ethically acceptable in the case study presented. Compared to euthanasia, more than twice as many participants considered physician-assisted suicide acceptable. There was no significant difference between personal attitudes towards palliative sedation, physician-assisted suicide or euthanasia in light of physical or emotional suffering. Educational programs in this field should be expanded both qualitatively and quantitatively, especially considering the relevance of the subject matter, the deficits within the knowledge of legal norms and the now even higher complexity of the legal situation due to the new law from December 2015.

Meaning in life in patients with amyotrophic lateral sclerosis.

The construct 'meaning in life' (MiL) has become increasingly important in palliative care. Several meaning-focused interventions have been developed recently. The aim of this study was to investigate MiL in patients with amyotrophic lateral sclerosis (ALS) and compare the findings with a representative sample of the German population. In the newly developed 'Schedule for Meaning in Life Evaluation' (SMiLE), respondents first list individual areas that provide meaning to their life before rating their current level of importance and satisfaction with each area. Overall indices of weighting (IoW, range 20-100), satisfaction (IoS, range 0-100), and weighted satisfaction (IoWS, range 0-100) are calculated. Results of our study showed that 46 ALS patients completed the SMiLE: the IoS was 74.7 ± 20.2, the IoW 88.1 ± 10.1, and the IoWS 76.3 ± 20.5. Satisfaction with MiL was negatively associated with disease duration and degree of functional impairment. After adjustment for age, sex, and marital status, the representative sample (n = 977) scored significantly higher in the IoS (82.8 ± 14.7) and the IoWS (83.3 ± 14.8). Compared to the general population, ALS patients list more meaning-relevant areas, are more likely to list partner, and less likely to list health. Thus, response shift seems to be a central coping mechanism in ALS patients. Regarding their major MiL areas, they shift their focus away from decreasing health status and towards supportive relationships.