Virtual Interinstitutional Palliative Care Consultation during the COVID-19 Pandemic in New York City

Technology to Support Older Adults in Home Palliative Care: A Scoping Review

BACKGROUND

Today, many older adults use health technologies, approach their final days with laptops, smartphones, and tablets. Telepalliative care is a service that remotely delivers palliative care through videoconferencing, telephonic communication, or remote symptom monitoring. The service meets the needs of patients who want to die at home and reducing unnecessary hospitalizations. The objective of this study is to map the literature on the use of technology by the terminally ill older adult population being cared for at home, to identify which technology systems are in use, to determine how technology can change communication between palliative care professionals and patients, and to explore the strengths or weaknesses patients perceive regarding the use of technology.

METHODS

We conducted a scoping review following the methodology of Arksey and O'Malley. A literature search was conducted in the MEDLINE, Embase, Web of Science, SCOPUS, PsycINFO, CINAHL, Ilisi and Google Scholar databases.

RESULTS

Fourteen eligible papers identified various tools available in clinical practice and found that most older adults are comfortable and satisfied using them. Despite being physically distanced from clinicians, patients felt cared for even though eye contact was lacking. Being unfamiliar with technology emerged as a barrier to telepalliative care in addition to difficulties caused by screen size and internet connection problems.

CONCLUSIONS

Older adults in palliative care at home perceive technology as a means of receiving efficient care. However, future research is needed to investigate what they look for in a technological tool and to develop more suitable technologies for them.

CLINICAL TRIAL REGISTRATION

The protocol of this study has been published in the Open Science Framework (OSF) preregistrations at https://osf.io/acv7q to enhance replicability and transparency and reduce any publication or reporting bias.

Application of Virtual Reality Technology in Clinical Practice, Teaching, and Research in Complementary and Alternative Medicine

Background

The application of virtual reality (VR) in clinical settings is growing rapidly, with encouraging results. As VR has been introduced into complementary and alternative medicine (CAM), a systematic review must be undertaken to understand its current status.

Aim

This review aims to evaluate and summarize the current applications of VR in CAM, as well as to explore potential directions for future research and development.

Methods

After a brief description of VR technology, we discuss the past 20 years of clinical VR applications in the medical field. Then, we discuss the theoretical basis of the combination of VR technology and CAM, the research thus far, and practical factors regarding usability, etc., from the following three main aspects: clinical application, teaching, and scientific research. Finally, we summarize and propose hypotheses on the application of VR in CAM and its limitations.

Results

Our review of the theoretical underpinnings and research findings to date leads to the prediction that VR and CAM will have a significant impact on future research and practice.

Conclusion

Although there is still much research needed to advance the science in this area, we strongly believe that VR applications will become indispensable tools in the toolbox of CAM researchers and practitioners and will only grow in relevance and popularity in the era of digital health.

Choices and Outcomes of the Oldest Old Admitted During the First Wave of COVID-19 in New York City

Objectives: Morbidity and mortality are higher in older adults with COVID-19, but their decisions about aggressive care, severity of disease, and outcomes during the first surge in New York City are not well characterized. We sought to determine if the oldest patients chose intubation and comfort care at different rates compared to younger geriatric patients. We also studied outcomes among patients admitted with severe disease and those who chose aggressive versus comfort care. Methods: This retrospective analysis used electronic health record data from patients 65 years and older at two medical centers in New York City admitted between 3/5/2020 and 5/15/2020. The primary outcome was comfort care orders, and secondary outcomes included death, palliative care consultation, goals of care discussion, code status, and ventilator weaning. Results: Of the 854 patients, 214 were in the oldest old (OO, age > = 85) group, 269 middle old (MO, age 75-84), and 371 young old (YO, age 65-74). Among those with serious disease, the OO were more likely to choose comfort care (45% vs. 21% MO and 6.8% YO), less likely to be intubated (17% vs. 37% MO and 44% YO), more likely to have a palliative care consult, more likely to be DNR/DNI on admission (60% vs. 17% MO and 9.3%% YO), and more likely to die during admission (65% vs. 42% MO and 21% YO) (all p-values < 0.001). Of all 216 intubated patients, 78% of the OO died, versus 66% of the MO and 36% of the YO (p = <0.001). Conclusions: Adults 85 and above admitted with COVID-19 were more likely to forego intubation and die with comfort-based care. Irrespective of intubation choice, patients 85 and older had a markedly poorer prognosis than other cohorts over 65.

Perspectives of Remote Volunteer Palliative Care Consultants During COVID: A Qualitative Study

CONTEXT

A novel remote volunteer program was implemented in response to the initial COVID-19 surge in New York City, allowing out-of-state palliative care specialists to serve patients and families in need. No study has detailed the perceptions of these consultants.

OBJECTIVES

To understand the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge.

METHODS

This qualitative study utilized a thematic analysis approach. During January and February 2021, we conducted one-on-one semi-structured interviews with 15 board-certified palliative care physicians who participated in the program. Codes and emerging themes were identified through iterative discussion and comparison.

RESULTS

Five overarching themes (with sub-themes in parentheses) were identified: 1) motivations for participating in the program, 2) logistical evaluation of the program (integration, telehealth model, dyad structure and debriefing sessions), 3) barriers to delivery (language and cultural differences, culture of high-intensity care, legal and administrative differences), 4) emotional burden (moral distress, burnout), and 5) ideas for improvements. Notably, participants observed institutional and cultural differences that posed challenges to delivery of care. Many expressed feelings of distress related to the uncertainty and scarcity caused by the pandemic, although volunteering may have been protective against burnout.

CONCLUSION

This study provides an in-depth look at the experiences of remote volunteer palliative care consultants during the initial COVID-19 surge from the unique perspectives of the consultants themselves. Participants expressed overall positive and meaningful experiences and felt that the model was appropriate given the circumstances. Additionally, participants provided recommendations that could guide future implementations of similar programs.