Symptom Relief Is Possible in Elderly Dying COVID-19 Patients: A National Register Study

High Dyspnea Score, a Trigger for Specialist Palliative Care Utilization-Results from a Cohort Study on the Predictors of High Opioid and Benzodiazepine Use in COVID-19 Patients

Background: Patients with severe coronavirus disease 2019 (COVID-19) often rapidly deteriorate with severe dyspnea and should receive early specialist palliative care (SPC) as intensive symptom management may be required at the end of life. Currently, there is a paucity of data identifying triggers for early SPC involvement. Objective: To identify risk factors among nonventilated patients with severe COVID-19 who required high opioid and/or benzodiazepines (BZD) use for the control of dyspnea. Methods: This is a retrospective cohort study of nonventilated patients with COVID-19 admitted to the National Centre for Infectious Diseases in Singapore and seen by SPC between January 2021 and July 2022. We collected baseline demographics, comorbidities, 4C mortality score (International Severe Acute Respiratory Infection Consortium-Comprehensive Clinical Characterization Collaboration [ISARIC-4C]), and COVID-19 vaccination status. Clinical and laboratory results, dyspnea by numerical rating scale, and palliative-related treatments were recorded at the first SPC review, when symptoms peaked, and the last SPC review. Patients with morphine equivalent daily dose (MEDD) of ≥45mg and/or BZD use for dyspnea control were grouped as high users, while patients with MEDD <45mg and no BZD use were low users. Results: Among 234 patients, 119 (50.9%) were high users. Multivariate analysis showed that subjects with higher dyspnea (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.45-2.08) and lower ISARIC-4C scores (OR 0.77, 95% CI 0.67-0.88) at first SPC review were predictive of high users. High users also required higher supplemental oxygen and had higher inpatient mortality rates. Conclusions: High dyspnea score is predictive of high opioid and/or BZD use for symptom control in nonventilated patients with severe COVID-19. Such patients with high mortality rates should be seen early by SPC.

Symptom Management and Support in Dying Patients with Cancer and Coronavirus Disease-19-A Register-Based Study

OBJECTIVE

Little is known to what extent access to specialist palliative care (SPC) for cancer patients dying with coronavirus disease-2019 (COVID-19) affects the occurrence of breakthrough symptoms, symptom relief, and overall care, compared to hospital deaths. Our aim was to include patients with both COVID-19 and cancer and compare those dying in hospitals with those dying in SPC with reference to the quality of end-of-life care.

METHODS

Patients with both cancer and COVID-19 who died in hospitals (n = 430) and within SPC (n = 384) were identified from the Swedish Register of Palliative Care. The hospital and SPC groups were compared regarding the quality of end-of-life care, including the occurrence of 6 breakthrough symptoms during the last week in life, symptom relief, end-of-life care decisions, information, support, and human presence at death.

RESULTS

Breakthrough of breathlessness was more common in the hospital patients compared to the SPC patients (61% and 39%, respectively; p < .001), while pain was less common (65% and 78%, respectively; p < .001). Breakthrough of nausea, anxiety, respiratory secretions, or confusion did not differ. All 6 symptoms, except for confusion, were more often completely relieved in SPC (p = .014 to p < .001 in different comparisons). In SPC, a documented decision about the goal being end-of-life care and information about this were more common than in hospitals (p < .001). Also, to have family members present at the time of death and for family members to be offered a follow-up talk afterward was more common in SPC (p < .001).

CONCLUSION

More systematic palliative care routines may be an important factor for better symptom control and higher quality of end-of-life care in hospitals.

Clinical expressions, characteristics and treatments of confirmed COVID-19 in nursing home residents: a systematic review

BACKGROUND

The coronavirus 2019 (COVID-19) pandemic has led to a high rate of infections, frequent outbreaks, and high mortality rates in nursing homes (NH) worldwide. To protect and improve the treatment and care of the vulnerable NH population, it is pivotal to systematise and synthesise data from cases of COVID-19 among NH residents. In our systematic review, we therefore aimed to describe the clinical expressions, characteristics, and treatments of NH residents confirmed to have COVID-19.

METHODS

We conducted two comprehensive literature searches in several electronic databases: (1) PubMed, (2) CINAHL, (3) AgeLine, (4) Embase, and (5) PsycINFO in April and July 2021. Of the 438 articles screened, 19 were included in our sample, and we used the Newcastle-Ottawa Assessment Scale to assess the quality of the reported studies. A weighted mean (M_weighted), was calculated to account for the large variation in sample sizes of the studies, and due to heterogeneity among the studies, we report our findings in a narrative synthesis.

RESULTS

According to the mean weights (M_weighted), common symptoms and signs in NH residents confirmed to have COVID-19 were fever (53.7%), cough (56.5%), hypoxia (32.3%), and delirium or confusion (31.2%). Common comorbidities were hypertension (78.6%), dementia or cognitive impairment (55.3%), and cardiovascular diseases (52.0%). Six studies presented data concerning medical and pharmacological treatments, such as inhalers, oxygen supplementation, anticoagulation, and parenteral/enteral fluids or nutrition. The treatments were used to improve outcomes, as part of palliative care, or as end-of-life treatment. Transfers to hospital for NH residents with confirmed COVID-19 were reported in six of the included studies, and the rate of hospital transfers ranged from 6.9% to 50% in this population. In the 17 studies reporting mortality, 40.2% of the NH residents died during the studies' observation periods.

CONCLUSIONS

Our systematic review allowed us to summarise important clinical findings about COVID-19 among NH residents and to identify the population's risk factors for serious illness and death caused by the disease. However, the treatment and care of NH residents with severe COVID-19 warrant further investigation.

Use, usability, and impact of a card-based conversation tool to support communication about end-of-life preferences in residential elder care – a qualitative study of staff experiences

Background

Proactive conversations about individual preferences between residents, relatives, and staff can support person-centred, value-concordant end-of-life (EOL) care. Nevertheless, prevalence of such conversations is still low in residential care homes (RCHs), often relating to staff’s perceived lack of skills and confidence. Using tools may help staff to facilitate EOL conversations. While many EOL-specific tools are script-based and focus on identifying and documenting treatment priorities, the DöBra card tool is developed to stimulate reflection and conversation about EOL care values and preferences. In this study, we explore staff’s experiences of use, usability, and perceived impact of the DöBra cards in supporting discussion about EOL care in RCH settings.

Methods

This qualitative study was based on data from two participatory action research processes in which RCH staff tested and evaluated use of DöBra cards in EOL conversations. Data comprise 6 interviews and 8 group meetings with a total of 13 participants from 7 facilities. Qualitative content analysis was performed to identify key concepts in relation to use, usability, and impact of the DöBra cards in RCH practice.

Results

Based on participants’ experiences of using the DöBra cards as an EOL conversation tool in RCHs, we identified three main categories in relation to its usefulness. Outcomes of using the cards (1) included the outlining of content of conversations and supporting connection and development of rapport. Perceived impact (2) related to enabling openings for future communication and aligning care goals between stakeholders. Use and usability of the cards (3) were influenced by supporting and limiting factors on the personal and contextual level.

Conclusions

This study demonstrates how the DöBra cards was found to be useful by staff for facilitating conversations about EOL values, influencing both the content of discussion and interactions between those present. The tool encouraged reflection and interaction, which staff perceived as potentially helpful in building preparedness for future care-decision making. The combination of providing a shared framework and being adaptable in use appeared to be key features for the DöBra cards usability in the RCH setting.

Terminal care in oldest old dying from COVID-19 in the acute hospital : A multicenter study describing pharmacological treatment in the last 24 h

Background

Coronavirus disease 2019 (COVID-19) has a high mortality, especially in the oldest old. Dying from COVID-19 is often characterized by symptoms such as breathlessness and agitation but data concerning medical treatment in the dying phase are limited.

Objective

This study describes the administration of oxygen, opioids and benzodiazepines in the last 24 h before death in patients 80 years or older dying from COVID-19 on acute hospital wards.

Material and methods

In this multi-centric retrospective study, patients, 80 years and older, admitted to the acute hospital in March and April 2020 were recruited from 10 acute Belgian hospitals. They all were diagnosed with COVID-19 and died on non-ICU wards with COVID-19. Administration of oxygen, opioids and benzodiazepines in the last 24 h before death was registered.

Results

Eighty-five percent of patients received oxygen, half of them even by means of a mask providing at least 10l oxygen per minute. The majority (84.3%) of patients were treated with opioids (morphine). Mean dosage of SC morphine equivalent was 31.3 mg/24 h (range 2–120 mg; SD 21.6 mg). More than half of patients (52.8%) received benzodiazepines, mostly midazolam. Mean dosage of midazolam was 20.4 mg/24 h (range 1–100 mg; SD 15.4 mg). Dosages of morphine and midazolam did not differ depending on frailty or comorbidities. Older COVID-19 patients dying with respiratory failure had higher midazolam dosage (p 0.002) but not morphine dosage (p 0.11).

Conclusion

A high proportion of patients 80 years and older and dying with COVID-19 in the hospital, were treated with oxygen, opioids and benzodiazepines in the last 24 h before death. With this descriptive study, we hope to contribute to the discussion and further research on the optimization of symptom control in an older population dying from/with COVID-19.

Interventions for palliative symptom control in COVID-19 patients

BACKGROUND

Individuals dying of coronavirus disease 2019 (COVID-19) may experience distressing symptoms such as breathlessness or delirium. Palliative symptom management can alleviate symptoms and improve the quality of life of patients. Various treatment options such as opioids or breathing techniques have been discussed for use in COVID-19 patients. However, guidance on symptom management of COVID-19 patients in palliative care has often been derived from clinical experiences and guidelines for the treatment of patients with other illnesses. An understanding of the effectiveness of pharmacological and non-pharmacological palliative interventions to manage specific symptoms of COVID-19 patients is required.

OBJECTIVES

To assess the efficacy and safety of pharmacological and non-pharmacological interventions for palliative symptom control in individuals with COVID-19.

SEARCH METHODS

We searched the Cochrane COVID-19 Study Register (including Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (PubMed), Embase, ClinicalTrials.gov, World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), medRxiv); Web of Science Core Collection (Science Citation Index Expanded, Emerging Sources); CINAHL; WHO COVID-19 Global literature on coronavirus disease; and COAP Living Evidence on COVID-19 to identify completed and ongoing studies without language restrictions until 23 March 2021. We screened the reference lists of relevant review articles and current treatment guidelines for further literature.

SELECTION CRITERIA

We followed standard Cochrane methodology as outlined in the Cochrane Handbook for Systematic Reviews of Interventions. We included studies evaluating palliative symptom management for individuals with a confirmed diagnosis of COVID-19 receiving interventions for palliative symptom control, with no restrictions regarding comorbidities, age, gender, or ethnicity. Interventions comprised pharmacological as well as non-pharmacological treatment (e.g. acupressure, physical therapy, relaxation, or breathing techniques). We searched for the following types of studies: randomized controlled trials (RCT), quasi-RCTs, controlled clinical trials, controlled before-after studies, interrupted time series (with comparison group), prospective cohort studies, retrospective cohort studies, (nested) case-control studies, and cross-sectional studies. We searched for studies comparing pharmacological and non-pharmacological interventions for palliative symptom control with standard care. We excluded studies evaluating palliative interventions for symptoms caused by other terminal illnesses. If studies enrolled populations with or exposed to multiple diseases, we would only include these if the authors provided subgroup data for individuals with COVID-19. We excluded studies investigating interventions for symptom control in a curative setting, for example patients receiving life-prolonging therapies such as invasive ventilation.  DATA COLLECTION AND ANALYSIS: We used a modified version of the Newcastle Ottawa Scale for non-randomized studies of interventions (NRSIs) to assess bias in the included studies. We included the following outcomes: symptom relief (primary outcome); quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We rated the certainty of evidence using the GRADE approach.  As meta-analysis was not possible, we used tabulation to synthesize the studies and histograms to display the outcomes.  MAIN RESULTS: Overall, we identified four uncontrolled retrospective cohort studies investigating pharmacological interventions for palliative symptom control in hospitalized patients and patients in nursing homes. None of the studies included a comparator. We rated the risk of bias high across all studies. We rated the certainty of the evidence as very low for the primary outcome symptom relief, downgrading mainly for high risk of bias due to confounding and unblinded outcome assessors. Pharmacological interventions for palliative symptom control We identified four uncontrolled retrospective cohort studies (five references) investigating pharmacological interventions for palliative symptom control. Two references used the same register to form their cohorts, and study investigators confirmed a partial overlap of participants. We therefore do not know the exact number of participants, but individual reports included 61 to 2105 participants. Participants received multimodal pharmacological interventions: opioids, neuroleptics, anticholinergics, and benzodiazepines for relieving dyspnea (breathlessness), delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms.  Primary outcome: symptom relief All identified studies reported this outcome. For all symptoms (dyspnea, delirium, anxiety, pain, audible upper airway secretions, respiratory secretions, nausea, cough, and unspecified symptoms), a majority of interventions were rated as completely or partially effective by outcome assessors (treating clinicians or nursing staff). Interventions used in the studies were opioids, neuroleptics, anticholinergics, and benzodiazepines.  We are very uncertain about the effect of pharmacological interventions on symptom relief (very low-certainty evidence). The initial rating of the certainty of evidence was low since we only identified uncontrolled NRSIs. Our main reason for downgrading the certainty of evidence was high risk of bias due to confounding and unblinded outcome assessors. We therefore did not find evidence to confidently support or refute whether pharmacological interventions may be effective for palliative symptom relief in COVID-19 patients. Secondary outcomes We planned to include the following outcomes: quality of life; symptom burden; satisfaction of patients, caregivers, and relatives; serious adverse events; and grade 3 to 4 adverse events. We did not find any data for these outcomes, or any other information on the efficacy and safety of used interventions. Non-pharmacological interventions for palliative symptom control None of the identified studies used non-pharmacological interventions for palliative symptom control.

AUTHORS' CONCLUSIONS

We found very low certainty evidence for the efficacy of pharmacological interventions for palliative symptom relief in COVID-19 patients. We found no evidence on the safety of pharmacological interventions or efficacy and safety of non-pharmacological interventions for palliative symptom control in COVID-19 patients. The evidence presented here has no specific implications for palliative symptom control in COVID-19 patients because we cannot draw any conclusions about the effectiveness or safety based on the identified evidence. More evidence is needed to guide clinicians, nursing staff, and caregivers when treating symptoms of COVID-19 patients at the end of life. Specifically, future studies ought to investigate palliative symptom control in prospectively registered studies, using an active-controlled setting, assess patient-reported outcomes, and clearly define interventions. The publication of the results of ongoing studies will necessitate an update of this review. The conclusions of an updated review could differ from those of the present review and may allow for a better judgement regarding pharmacological and non-pharmacological interventions for palliative symptom control in COVID-19 patients.

Everyday life in a Swedish nursing home during the COVID-19 pandemic: a qualitative interview study with persons 85 to 100 years

OBJECTIVE

To understand and report on the impact of the COVID-19 pandemic on the everyday lives of frail older persons living in nursing homes by exploring their experiences of how the pandemic-related restrictions had influenced them and in what way.

DESIGN

Empirical qualitative interview study.

SETTING

A publicly run nursing home in an urban area in Sweden in June 2020. The nursing home had visitor restrictions, cancelled activities and physical distancing requirements since March 2020.

PARTICIPANTS

A total of 10 persons, 85-100 years, living in a Swedish nursing home during the COVID-19 pandemic, were recruited through nursing home management and interviewed in June 2020 using medically approved visors and physical distancing.

ANALYSIS

Interviews were analysed using thematic analysis, which involves familiarisation, coding and definition of themes. Transcripts were coded into data-driven categories before being organised into categories that described and explained the data.

RESULTS

The analysis resulted in the main theme 'It is like living in a bubble', that describes everyday life in the nursing home during the pandemic as a world of its own in which the older persons felt both protected and isolated. This is described in four subthemes: living 1 day at a time, without fear of the virus; feeling taken care of; having limited freedom and missing out on the little extras.

CONCLUSIONS

Contributing to the growing area of COVID-19-related research, our findings provide novel insights into how pandemic-related restrictions in nursing homes represent a risk of isolating older people from the outside world and diminishing their freedom. Put in relation to the previous research, these findings could be applied beyond the pandemic, to develop research and practice that puts focus on how to support older people to decide for themselves how to spend the rest of their lives.

Dying from COVID-19 in nursing homes-sex differences in symptom occurrence

Background

Coronavirus disease 2019 (COVID-19), is a disease with diverse presentation. Several studies have shown different occurrence of symptoms for women and men, but no studies have been found examining sex differences in clinical presentation for nursing home residents dying from COVID-19.

The objective of this study was to describe sex and age differences and the impact of a dementia diagnosis on symptom occurrence during the last week in life for persons dying from COVID-19 in nursing homes.

Methods

This is a population-based retrospective study based on data from the Swedish Register of Palliative Care. A total of 1994 residents aged 65 or older who died from COVID-19 in nursing homes were identified. The impact of sex, age and a dementia diagnosis on six different symptoms was analysed using chi2-test and multivariate logistic regression.

Results

Residents dying from COVID-19 were more often men (p < .002). Men more often had dyspnoea and death rattles (p < .001). Nausea was more common in women (p < .001). No sex differences in the occurrence of pain, anxiety or confusion were seen. Dyspnoea and nausea were less commonly reported in residents with dementia (p < .001).

Conclusions

We found sex differences in symptom presentation for fatal COVID-19 in nursing home settings which remained after adjusting for age. Residents with a dementia diagnosis had fewer symptoms reported before death compared to those without dementia.

Clinical presentation of fatal COVID-19 differs between women and men in nursing homes. Residents with fatal COVID-19 present with more unspecific and less prominent symptoms when also suffering from dementia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12877-021-02228-4.

Dying in times of the coronavirus: An online survey among healthcare professionals about end-of-life care for patients dying with and without COVID-19 (the CO-LIVE study)

BACKGROUND

During the COVID-19 outbreak restricting measures may have affected the provision of good end-of-life care for patients with and without COVID-19.

AIM

To describe characteristics of patients who died and the care they received, and to examine how patient characteristics, setting and visiting restrictions are related to provided care and evaluation of the dying process.

DESIGN

An open observational online survey among healthcare professionals about their experience of end-of-life care that was provided to a patient with or without COVID-19 who died between March and July 2020.

SETTING/PARTICIPANTS

Healthcare professionals (nurses, physicians and others) in the Netherlands from all settings: home (n = 163), hospital (n = 249), nursing home (n = 192), hospice (n = 89) or elsewhere (n = 68).

RESULTS

Of patients reported on, 56% had COVID-19. Among these patients, 358 (84.4%) also had a serious chronic illness. Having COVID-19 was negatively, and having a serious chronic illness was positively associated with healthcare staff's favourable appreciation of end-of-life care. Often there had been visiting restrictions in the last 2 days of life (75.8%). This was negatively associated with appreciation of care at the end of life and the dying process. Finally, care at the end of life was less favourably appreciated in hospitals and especially nursing homes, and more favourably in home settings and especially hospices.

CONCLUSIONS

Our study suggests that end-of-life care during the COVID-19 pandemic may be further optimised, especially in nursing homes and hospitals. Allowing at least some level of visits of relatives seems a key component.

Dying at home of Covid-19: Meeting the need for home-based care

Despite the increased burden of Covid-19 on older adults, ethical and public health frameworks lack adequate guidance for elderly patients who manage severe, even fatal, illness at home. The U.S. Centers for Disease Control and Prevention (CDC) and World Health Organization (WHO) recognize the heightened risks of Covid-19 for older adults; however, both organizations presuppose that most cases of Covid-19 will be mild to moderate and recoverable at home. Yet, older adults are least likely to follow this trajectory. Older patients are more susceptible to experiencing severe illness at home from which they may not recover; and if they do seek medical care, they tend to suffer worse outcomes than younger patients in intensive care settings. Given their likelihood of severe illness, worse outcomes in intensive care settings, and potential difficulty accessing resources, frail, disabled, and otherwise vulnerable older patients may face Covid-19 at home without adequate resources, information, or support for home-based care. This editorial proposes three approaches to prevent needless suffering and ensure that this vulnerable population continues to receive needed care.

COVID-19: Symptoms in Dying Residents of Nursing Homes and in Those Admitted to Hospitals

Objective: To compare symptom prevalence and relief in residents who died in nursing homes with residents who were acutely referred to hospitals. Design: Data on symptoms during the last week of life from the Swedish Register of Palliative Care (SRPC). Setting and Subjects: Nursing homes (n = 1903 deaths) and hospitals in Sweden (n = 202 nursing home residents who were admitted to hospital before death). Data were retrieved on August 24, 2020. Results: Residents who died in hospitals had more breakthrough symptoms of breathlessness (60% vs. 31%, p < 0.0001) and delirium (41% vs. 25%, p < 0.0001) than those who died in nursing homes. When symptoms were present, complete symptom relief was seen less often in hospitals compared with nursing homes (breathlessness, 28% vs. 47%, p < 0.001; delirium, 10% vs. 35%, p < 0.0001; respiratory secretions, 30% vs. 55%, p < 0.0001). Conclusion: Despite access to oxygen and pharmacologic/nonpharmacologic therapies in hospitals, symptom relief in dying nursing home residents acutely admitted to hospitals was lower compared with those who died in nursing homes, possibly because of differences in patient characteristics.

Leveraging epidemiological principles to evaluate Sweden's COVID-19 response

In the response to COVID-19, countries have implemented response strategies along a continuum of population- and venue-level specificity ranging from suppression to mitigation strategies. Suppression strategies generally include population-wide shelter-in-place mandates or lockdowns, closure of nonessential physical venues, travel bans, testing and contact tracing, and quarantines. Sweden followed a mitigation strategy focused on risk-tailored approaches to mitigate specific acquisition risks among the elderly, minimizing the disruption to education and the delivery of other health care services, and recommendations for social distancing to minimize the disease burden. To date, Sweden has reported higher case counts and attributable mortality than other Scandinavian countries and lower than other Northern European countries. However, there are several limitations with comparison given heterogeneity in testing strategies, suspected and confirmed case definitions, and assessment of attributable mortality. The decisions in Sweden also reflect social priorities such as equity being a foundational principle of Swedish social systems. Consistently, in-person education for those aged less than 16 years continued throughout. Notably, the mitigation strategy did not eliminate the inequitable impacts of COVID-19 cases and mortality in Sweden with higher-exposure and generally lower-income occupations being associated with higher risks intersecting with these communities often residing in more dense multigenerational households. From January 1 to November 15, there has been a 1.8% increase in all-cause mortality in 2020 compared with the average of 2015-2019, representing an excess of 14.3 deaths per 100,000 population. However, the final assessment of excess deaths in Sweden in 2020 including stratification by age and integration of secular trends can only be calculated in the coming years. In response to increasing cases in the fall of 2020, Sweden has continued to leverage business-oriented regulations and public-oriented guidelines for social distancing rather than police-enforced mandates. Ultimately, pandemics present no winners. Countries have implemented a range of different COVID-19 prevention and mitigation strategies responsive to their own priorities and legal systems including equity and the balancing of competing health priorities. Given these varied approaches, countries that pursued elimination, suppression, or mitigation strategies can collaboratively learn from both successes and challenges of the different strategies to inform COVID-19 and future pandemic responses.