End-of-life decisions and care in the midst of a global coronavirus (COVID-19) pandemic

"I couldn't": A phenomenological exploration of ethical tensions experienced by bereaved family members during the pandemic

INTRODUCTION

The COVID-19 pandemic entailed significant changes in accompaniment, end-of-life, and bereavement experiences. In some countries, public health measures prevented or restricted family caregivers from visiting their dying loved ones in residences, long-term care institutions, and hospitals. As a result, family members were faced with critical decisions that could easily lead to ethical dilemmas and moral distress.

AIM

This study aimed to understand better the experience of ethical dilemmas among family caregivers who lost a loved one.

METHDS

We interviewed twenty bereaved family caregivers and analysed their narratives using Interpretative phenomenological analysis.

RESULTS

Our analysis suggests that family caregivers struggled with their multiple responsibilities (collective, relational, and personal) and had to deal with the emotional cost of their choices. Results display three emerging themes describing the experience of ethical struggles: (1) Flight or fight: Struggling with collective responsibility; (2) Being torn apart: Assuming relational responsibility and (3) "Choosing" oneself: The cost of personal responsibility.

DISCUSSION/CONCLUSION

Results are discussed and interpreted using an ethical, humanistic, and existential conceptual framework.

Effects of awake-prone positioning on oxygenation and physiological outcomes in non-intubated patients with COVID-19: A randomized controlled trial

BACKGROUND

Prone positioning is a well-known supportive approach for increasing oxygenation and reducing mortality in non-COVID-19 patients with moderate to severe acute respiratory distress syndrome. However, studies highlighting the effects of proning in patients with COVID-19 are limited.

AIM

To investigate the effects of awake-prone positioning (APP) on oxygenation and physiological outcomes in non-intubated patients with COVID-19.

STUDY DESIGN

A randomized controlled trial was carried out with two parallel groups at 1:1 ratio. Adult awake non-intubated patients with confirmed COVID-19, non-rebreathing face mask or continuous positive airway pressure, PaO2 /FiO2 ratio ≤150 mmHg were randomly assigned to the APP group or control group. The control group was subjected to conventional positioning interventions. Outcome measures were PaO2 /FiO2 ratio, ROX index, PaO2 , PaCO2 , SaO2 , respiratory rate, blood pressure, and shock index. These parameters were recorded immediately before positioning, 10 min after patient positioning, and 1 h after patient positioning.

RESULTS

Of 115 patients assessed for eligibility, 82 were randomized to the APP group or control group (41 patients in each group). The use of APP for non-intubated patients with COVID-19 resulted in statistically significant improvements in oxygenation parameters, that is, SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 , at the three study time points (p = .000, .007, .000, .011, and .000 respectively). The SpO2 was increased to 92.15 ± 2.735 mmHg for the APP group versus 88.17 ± 4.847 for the control group after 1 h of patients' positioning. The PaO2 /FiO2 ratio increased in the APP group before proning compared with 1 h after proning (79.95 ± 22.508 vs. 98.91 ± 34.44) respectively. APP improved the SpO2 , PaO2 /FiO2 , ROX index, PaO2 , and SaO2 values for the APP group, representing an increase of 5.85%, 23.71%, 30.79%, 22.59%, and 5.26%, respectively.

CONCLUSION

Awake proning in non-intubated patients with COVID-19 showed marked improvement in oxygenation and physiological parameters.

RELEVANCE TO CLINICAL PRACTICE

This study provides evidence for critical care nurses to implement APP in non-intubated patients with COVID-19 to improve oxygenation and physiological parameters, as it was tolerated by most of the patients without serious adverse events.

Surprising pandemic experiences: A confrontation between principle-based and virtue ethics, and a plea for virtue ethics training for medical students and residents. A rudimentary outline of a four-step model

BACKGROUND

In past years, physicians have, with a certain continuity, reported increasing numbers of burnout, depression and compassion fatigue in their daily practice. These problems were attributed, not only but also, to a loss of public trust and an increase in violent behaviour of patients and family members towards medical professionals in all walks of life. Recently, however, during the breakout of the coronavirus disease 2019 (COVID-19) pandemic in 2020, there were public expressions of appreciation and respect for health care workers that almost universally have been assessed as indications of a re-establishment of public trust in physicians and appreciation for the medical professions' commitments. In other words, shared experiences of what society was in need of: the experience of a 'common good'. Those responses during the COVID-19 pandemic increased positive feelings among practicing physicians, such as commitment, solidarity, competency, and experiences concerning obligations for the common good and a sense of belonging to one and the same community for all. Essentially, these responses of raised self-awareness of commitment and solidarity between (potential) patients and medical personal point towards the social importance and power of these values and virtues. This shared domain in ethical sources of behaviour seems to hold a promise of overcoming gaps between the different spheres of doctors and patients. That promise justifies stressing the relevance of this shared domain of Virtue Ethics in the training of physicians.

METHODS

In this article, therefore, we shall make a plea for the relevance of Virtue Ethics before proposing an outline of an educational programme for Virtue Ethics training for medical students and residents. Let us start by very briefly presenting on Aristotelian virtues and its relevance to modern medicine in general, and during the current pandemic in particular.

RESULTS

We shall follow up this short presentation by a Virtue Ethics Training Model and the respective settings in which it takes place. This model has four steps as follows: (a) include moral character literacy in the formal curriculum; (b) provide ethics role modelling and informal training in moral character in the healthcare setting by senior staff; (c) create and apply regulatory guidelines regarding virtues and rules; and (d) assess success of training by evaluation of moral character of physicians.

CONCLUSION

Applying the four-step model may contribute to strengthening the development of moral character in medical students and residents, and decrease the negative consequences of moral distress, burnout and compassion fatigue in health care personnel. In the future, this model should be empirically studied.

ICU stays that are judged to be non-beneficial: A qualitative study of the perception of nursing staff

INTRODUCTION

Non-beneficial stays in the intensive care unit (ICU) may have repercussions for patients and their families, but can also cause suffering among the nursing staff. We aimed explore the perceptions of nursing staff in the ICU about patient stays that are deemed to be "non-beneficial" for the patient, to identify areas amenable to intervention, with a view to improving how the nursing staff perceive the patient pathway before, during and after intensive care.

METHODS

Multicentre, qualitative study using individual, semi-structured interviews. All qualified nurses and nurses' aides who were full-time employees in the ICU of three participating centres were invited to participate. Interviews were recorded, transcribed and analyzed using textual content analysis.

RESULTS

A total of 21 interviews were performed from February 2020 to October 2021, at which point saturation was reached in the data. Average age of participants was 38.5±7.5 years, and they had an average of 10.7±7.4 years of experience working in the ICU. Four major themes emerged from the interviews, namely: (1) the work is oriented towards life-threatening emergencies, technical procedures and burdensome care; (2) a range of specific criteria and circumstances influence the decisions to admit patients to ICU; (3) there are significant organisational, physical and psychological repercussions associated with a non-beneficial stay in the ICU; (4) respondents made some proposals for improvements to the patient care pathway.

CONCLUSION

Nursing staff have a similar perception to physicians regarding admission decisions and non-beneficial ICU stays. The possibility of future ICU admission needs to be anticipated, discussed systematically with patients and integrated into healthcare goals that are consistent with the patient's wishes and preferences, in multi-professional collaboration including nursing and medical staff.

A Retrospective Review of the Characteristics and Outcomes of Patients through an Integrated Palliative Care Model during the First Wave of the SARS-COV-2 Pandemic

Background: The COVID-19 pandemic created surges of rapidly deteriorating patients straining health care necessitating the evaluation of novel models of palliative care (PC) integration to reduce patient suffering and hospital strain. Objective: To evaluate an integrated PC model's effect on code status change. Design: This is an observational retrospective study. Setting: Urban quaternary referral center in the southeastern United States from April 6th to August 20th, 2020. Patients: All patients admitted to our medical intensive care unit and stepdown unit were diagnosed with COVID-19. Measurements: Code status change, multivariate regression on patient characteristics. Results: In total, 79.7% (98/123) patients were full code at admission. After PC consultation, 33.3% (41/123) patients remained full code, 13.0% (16/123) were do not resuscitate (DNR), and 53.6% (66/123) changed to DNR/do not intubate (DNI). An ordinal logistic model determined that consultation location (odds ratio [OR] 3.35, p = 0.017) and patient age (OR 1.09, p < 0.001) were predictive of code status change to DNR/DNI. Conclusion: Within an integrated PC model, PC consultation was associated with code status change. The effect of an integrated PC model warrants further study in comparison with a traditional PC model in a similar patient cohort.

Standardized High-Quality Processes for End-of-Life-Decision Making in the Intensive Care Unit Remain Robust during an Unprecedented New Pandemic-A Single-Center Experience

Due to the global COVID-19 pandemic, a concomitant increase in awareness for end-of-life decisions (EOLDs) and advance care planning has been noted. Whether the dynamic pandemic situation impacted EOLD-processes on the intensive care unit (ICU) and patient-sided advance care planning in Germany is unknown. This is a retrospective analysis of all deceased patients of surgical ICUs of a university medical center from March 2020 to July 2021. All included ICUs had established standardized protocols and documentation for EOLD-related aspects of ICU therapy. The frequency of EOLDs and advance directives and the process of EOLDs were analyzed (No. of ethical approval EA2/308/20). A total number of 319 (85.5%) of all deceased patients received an EOLD. Advance directives were possessed by 83 (22.3%) of the patients and a precautionary power of attorney by 92 (24.7%) of the patients. There was no difference in the frequency of EOLDs and patient-sided advance care planning between patients with COVID-19 and non-COVID-19 patients. In addition, no differences in frequencies of do-not-resuscitate orders, withholding or withdrawing of intensive care medicine therapeutic approaches, timing of EOLDs, and participation of senior ICU attendings in EOLDs were noted between patients with COVID-19 and non-COVID-19 patients. Documentation of family conferences occurred more often in deceased patients with COVID-19 compared to non-COVID-19 patients (COVID-19: 80.0% vs. non-COVID-19: 56.8, p = 0.001). Frequency of EOLDs and completion rates of advance directives remained unchanged during the pandemic compared to pre-pandemic years. The EOLD process did not differ between patients with COVID-19 and non-COVID-19 patients. Institutional standard procedures might contribute to support the robustness of EOLD-making processes during unprecedented medical emergencies, such as new pandemic diseases.

Managing Covid-19 in patients with heart failure: current status and future prospects

INTRODUCTION

COVID-19 may contribute to decompensation of previously stable chronic HF or cause a de-novo heart failure, which may come from the hyperinflammatory response and subsequent increase in metabolic demand.

AREAS COVERED

Two independent investigators searched MEDLINE (via PubMed), Europe PMC, and ScienceDirect databases with the following search terms: COVID-19, heart failure, COVID-19 drugs, heart failure drugs, and device therapy. All of the included full-text articles were rigorously evaluated by both authors in case there was disagreement about whether research should be included or not. In total, 157 studies were included and underwent extensive reading by the authors.

EXPERT OPINION

The World Health Organization (WHO) and the National Institute of Health (NIH) have published COVID-19 drug recommendations, although recommendations for HF-specific drug choices in COVID-19 are still lacking. We hope that this review can answer the void of comprehensive research data regarding the management options of HF in the COVID-19 condition so that clinicians can at least choose a more beneficial therapy or avoid combination therapies that have a high burden of side effects on HF; thus, morbidity and mortality in COVID-19 patients with HF may be reduced.

Providing palliative and end of life care for people with advanced disease

All nurses and healthcare workers have a vital role in caring for people with a life-limiting prognosis. The importance of this role was accentuated during the widespread loss of life resulting from the coronavirus disease 2019 (COVID-19) pandemic. This article revisits the crucial role of nurses in the care of people with advanced disease, while outlining how nurses can provide evidence-based palliative and end of life care. The author explores some of the essential elements of symptom management in advanced disease and presents a series of short case studies to support nurses' critical reflection.

Risk factors for complicated grief among family members bereaved in intensive care unit settings: A systematic review

Background

Families of intensive care unit (ICU) decedents are at increased risk of experiencing complicated grief. However, factors associated with complicated grief in ICU and bereavement needs assessment are not available routinely. We aimed to conduct a systematic review identifying risk factors associated with complicated grief among family members of ICU decedents.

Materials and methods

MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Library and Web of Science were searched to identify relevant articles. Observational studies and randomised and non-randomised controlled trials were included. Studies were screened and quality appraised in duplicate. Risk of bias was assessed using Newcastle-Ottawa Scale. A narrative synthesis was undertaken.

Results

Seven studies conducted across three continents were eligible. Four studies were of high quality. 61 risk factors were investigated across the studies. Factors associated with a decreased risk of complicated grief included age, patient declining treatment and involvement in decision-making. Factors associated with increased risk included living alone, partner, dying while intubated, problematic communication, and not having the opportunity to say goodbye.

Conclusion

This systematic review has identified risk factors which may help identify family members at increased risk of complicated grief. Many of the studies has small sample sizes increasing the risk of erroneously reporting no effect due to type II error. Some factors are specific to the ICU setting and are potentially modifiable. Bereavement services tailored to the needs of bereaved family members in ICU settings are required. (PROSPERO registration ID 209503)

Conflict Sources and Management in the ICU Setting before and during COVID-19: A Scoping Review of the Literature

Introduction. Conflicts are an inherent part of work within any organisation. They can arise between members of an interdisciplinary team (or between teams representing different departments), between patients and team members/family members, and patients’ families and team members. Various conflict situations among employees may occur, therefore it is very important to identify their causes and take preventive or targeted corrective measures. The aim of this study was to review the available literature concerning conflicts arising in ICUs—their types, methods of expression as well as their management and mitigation. In addition, we reviewed the available literature on the impact of the pandemic on the ICU environment caring for COVID-19 patients. Methods. The databases were searched. Single key words or their combinations using AND or OR operators were entered. Eventually, 15 articles were included in our review, which included two identical papers. Results. Conflicts occurred occasionally or rarely; researchers describing ethical conflicts demonstrated a moderate level of exposure to conflicts. The pandemic created many challenges and ethical dilemmas that are a source of ethical conflict. Conclusions. As conflict by nature remains inevitable, adequate procedures in conflict management should be developed and the leadership of managing personnel should be reinforced, because team members frequently expect guidance from their supervisors. The importance of training in interpersonal communication and crisis situation management in healthcare should therefore be emphasised.

Shifting Nursing Care Models as a Solution for the Increasing Demand on Intensive Care Unit Beds During a Pandemic: A Case Study

AIM

An option appraisal of different nursing care delivery models was presented, which were made in between the first and second COVID-19 waves. The authors wanted to inform colleagues on involving nursing care delivery models in the problem-solving process during a pandemic.

LOCAL PROBLEM

In the pre-COVID-19 hospital practice, the nursing care delivery model of primary nursing was applied in the intensive care unit (ICU). However, during the COVID-19 pandemic, this situation could not be upheld because of the increased need for ICU beds and the shortages of available ICU nurses.

METHODS

This study used the literature of an ongoing systematic review on nursing care delivery models and expert meetings between the authors and nursing staff.

RESULTS

One standard nursing care delivery model and 3 alternative nursing care delivery models were discussed and compared in this case study. Theoretically, a modular system of team nursing seemed the better model to use during a pandemic. This model leads to an equal distribution of expertise and social distancing between experts. Compared with the other models, a strategic reserve can be created.

CONCLUSION

This case study should be primarily considered as an example on how rethinking and reorganizing the nursing care delivery model could contribute to an enlarged, qualitative capacity, which needs to be organized in a short time span.

Exploring variables related to medical surrogate decision-making accuracy during the COVID-19 pandemic

OBJECTIVE

Surrogate medical decision making is common in the United States healthcare system. Variables that may influence surrogate decision making have been proposed. Little work has examined relations between these variables and outcomes of surrogate decision making. This study investigated whether surrogates' characteristics, including their knowledge of treatment options, and interpersonal factors predicted surrogates' accuracy and intervention selections. Specifically, predictor variables included: trust in the medical profession, trait-level anxiety, depression, anxiety about COVID-19, religiosity, perceived emotional support, understanding of treatment options, empathy, willingness to accept responsibility for medical decisions, reluctance to burden others, and perceived similarity between oneself and the patient.

METHODS

154 pairs of patients and their surrogates completed an online survey. Patients indicated preferred treatments in hypothetical decision scenarios. Surrogates indicated the treatment that they thought the patient would prefer.

RESULTS

When taken all together in a predictive model, the variables significantly predicted surrogates' accuracy, F (6) = 3.03, R² = .12, p = .008. Variables also predicted selection of intensive interventions, F (4) = 5.95, R² = .14, p = .00. Surrogates reporting greater anxiety about COVID-19 selected more intensive interventions.

CONCLUSIONS

Consistent with prior research, this study found that surrogates' characteristics influence the interventions they choose, with anxiety about COVID-19 having considerable bearing on their chosen interventions.

PRACTICE IMPLICATIONS

These findings can inform development of decision-making interventions to improve surrogates' accuracy. Providers may attend to variables highlighted by this study to support surrogates, particularly within the stressful context of COVID-19 and possible future pandemics.

Hospice palliative care professionals' opinions, emotions, skills and ethical reflections during the first phase of the COVID-19 pandemic

BACKGROUND

The COVID-19 pandemic presented an extraordinary challenge for palliative care in Italy.

AIM

To investigate the opinions, emotions, skills, resources, critical issues and ethical aspects of palliative care encountered by hospice palliative care professionals in Italy.

METHODS

Content analysis was performed on the answers to a survey distributed by e-mail.

FINDINGS

A sample of 42 professionals completed the survey. They commonly experienced the pandemic as a challenging situation that highlighted the need for an upgrade to the Servizio Sanitario Nazionale (SSN). Conflicting emotions emerged, namely fear, frustration and sadness, but also hope and solidarity. The lack of adequate personal protective equipment and the fact that caregivers were unable to access their patients due to concerns of infection were the most critical problems. The need for greater training on communication skills and training on end-of-life issues were emphasised by the participants of the survey. Regarding ethical aspects of providing palliative care during the COVID-19 pandemic, the importance of guaranteeing humane care and patients' dignity was mentioned.

CONCLUSION

The importance of specific training regarding end-of-life care and the central role of empathic communication were confirmed.

COVID-19 palliative care toolkit development and military health system deployment

BACKGROUND

During the initial phase of the pandemic, we identified a critical gap in the Military Health System's access to palliative care. Our team of nurse scientists and evidence-based practice (EBP) facilitators aimed to develop and implement an evidence-based point of care palliative care toolkit for frontline workers in inpatient settings lacking established palliative care specialists.

METHODOLOGY

We utilized Melnyk and Fineout-Overholt's (2018) seven-step EBP process. Six central themes were derived from 17 publications providing an evidence-base for toolkit resource selection and development. Our practice change implementation was piloted at a large West Coast military treatment facility. We included iPads in the toolkit for patient communication and palliative mobile application use.

RESULTS

The most significant finding was the critical and continued need for basic palliative care education and training. Integrating the palliative care toolkit into daily practice was promising yet challenging due to the high volume of deployed medical staff.

Communicating with patients and families about illness progression and end of life: a review of studies using direct observation of clinical practice

BACKGROUND

There is growing recognition that a diverse range of healthcare professionals need competence in palliative approaches to care. Effective communication is a core component of such practice. This article informs evidence-based communication about illness progression and end of life through a rapid review of studies that directly observe how experienced clinicians manage such discussions.

METHODS

The current rapid review updates findings of a 2014 systematic review, focussing more specifically on evidence related to illness progression and end-of-life conversations. Literature searches were conducted in nine bibliographic databases. Studies using conversation analysis or discourse analysis to examine recordings of actual conversations about illness progression or end of life were eligible for inclusion in the review. An aggregative approach was used to synthesise the findings of included studies.

RESULTS

Following screening, 26 sources were deemed to meet eligibility criteria. Synthesis of study findings identified the structure and functioning of ten communication practices used in discussions about illness progression and end-of-life.

CONCLUSION

The ten practices identified underpin five evidence-based recommendations for communicating with patients or family members about illness progression and end of life.

Addressing Acute Stress among Professionals Caring for COVID-19 Patients: Lessons Learned during the First Outbreak in Spain (March-April 2020)

Objectives: To describe lessons learned during the first COVID-19 outbreak in developing urgent interventions to strengthen healthcare workers' capacity to cope with acute stress caused by health care pressure, concern about becoming infected, despair of witnessing patients' suffering, and critical decision-making requirements of the SARS-CoV-2 pandemic during the first outbreak in Spain. Methods: A task force integrated by healthcare professionals and academics was activated following the first observations of acute stress reactions starting to compromise the professionals' capacity for caring COVID-19 patients. Literature review and qualitative approach (consensus techniques) were applied. The target population included health professionals in primary care, hospitals, emergencies, and nursing homes. Interventions designed for addressing acute stress were agreed and disseminated. Findings: There are similarities in stressors to previous outbreaks, and the solutions devised then may work now. A set of issues, interventions to cope with, and their levels of evidence were defined. Issues and interventions were classified as: adequate communication initiative to strengthen work morale (avoiding information blackouts, uniformity of criteria, access to updated information, mentoring new professionals); resilience and recovery from physical and mental fatigue (briefings, protecting the family, regulated recovery time during the day, psychological first aid, humanizing care); reinforce leadership of intermediate commands (informative leadership, transparency, realism, and positive messages, the current state of emergency has not allowed for an empirical analysis of the effectiveness of proposed interventions. Sharing information to gauge expectations, listening to what professionals need, feeling protected from threats, organizational flexibility, encouraging teamwork, and leadership that promotes psychological safety have led to more positive responses. Attention to the needs of individuals must be combined with caring for the teams responsible for patient care. Conclusions: Although the COVID-19 pandemic has a more devastating effect than other recent outbreaks, there are common stressors and lessons learned in all of them that we must draw on to increase our capacity to respond to future healthcare crises.

Changes in intensive care unit nurse involvement in end of life decision making between 1999 and 2016: Descriptive comparative study

OBJECTIVE

Comparison of nurse involvement in end of life decision making in European countries participating in ETHICUS I- 1999 and ETHICUS II- 2015.

METHODOLOGY

This was a prospective observational study of 22 European ICUs included in the ETHICUS-II and I. Data were collected as per the ETHICUS-I and ETHICUS-II protocols. Four questions within the ETHICUS protocols related to nurse involvement in end of life decision making were analyzed. This is a comparison of changes in nurse involvement in end of life decisions from 1999 to 2015.

SETTING

International e-based questionnaire completed by an intensive care clinician when an end of life decision was performed on any patient.

SUBJECTS

Intensive care physicians and nurses, no interventions were performed.

MEASUREMENTS

A 20 question survey was used to describe the decision making process, on what basis was the decision made, who was involved in the decision making process, and what precise decisions were made.

RESULTS

A total of 4592 cases from 22 centres are included. While there was more agreement between nurses and physicians in ETHICUS-I compared to ETHICUS-I, fewer discussions with nurses occurred in ETHICUS-II. The frequency of end of life decisions that were discussed with nurses decreased in all three regions between ETHICUS-I and ETHICUS-II.

CONCLUSION

Based on the results of the current study, nurses should be further encouraged to increase their involvement in end of life decision-making, especially those in southern Europe.

Expressing grief through metaphors: family caregivers' experience of care and grief during the Covid-19 pandemic

Purpose: The COVID-19 pandemic has disrupted thousands of individuals’ experience of caregiving and grief. This qualitative study aimed to gain in-dept understanding of family caregivers’ lived experiences of caregiving and bereavement in the context of the COVID-19 pandemic in Quebec, Canada. The study also aimed at providing new insight about caregiving and bereavement by analysing the metaphors family caregivers use to report their experiences. Methods: The design of this study was guided by an interpretative phenomenological approach. In-depth interviews were conducted with twenty bereaved family caregivers who had lost a loved one during the first waves of the pandemic. Results: Results indicate that bereaved family caregivers lived and understood their experience in terms of metaphoric cut-offs, obstructions and shockwaves. These three metaphors represented the grief process and the bereaved’s quest for social connection, narrative coherence and recognition. Conclusion: By identifying the meaning of the bereaved’s metaphors and the quest they reveal, our study underlines the singularity of pandemic grief and points to the value and meaning of caregiving with regard to the grieving process.

The impact of providing end-of-life care during a pandemic on the mental health and wellbeing of health and social care staff: Systematic review and meta-synthesis

Background

Disease outbreaks and disasters can result in excess deaths and severe disruption of usual end-of-life care processes. We aimed to: i) synthesise evidence describing the experiences of health and social care staff providing end-of-life care during a disease outbreak or humanitarian disaster, ii) understand the impact on their mental health and wellbeing and, iii) identify means of support.

Methods

A systematic review with meta-synthesis was conducted including studies of health and social care staff providing end-of-life care during disease outbreaks (Ebola, COVID-19, SARs, MERs) or humanitarian disasters (2001–2020). MEDLINE (Ovid), Embase, PsycInfo, Web of Science, and grey literature databases were searched systematically, with forward and backward citation searching of included studies. Any research study designs, in any care settings, were included. Study quality was assessed using an appraisal tool relevant to each study design. Qualitative meta-synthesis was used to analyse the findings, which were then reported narratively. PROSPERO registration: CRD42020181444.

Results

Nineteen studies were included, including 10 Ebola studies and two COVID-19 studies. The analysis generated two superordinate themes: individual experience and organisational responsibilities. Individual experience comprised four themes: dignity in death, positive experiences, negative experience and support for staff. Organisational responsibilities comprised four themes: preparation, adaption, resources, and Personal Protective Equipment (PPE).

Discussion

No studies quantitively measured the impact of providing end-of-life care on staff mental health and wellbeing, however qualitative studies described experiences in varied settings. Serious disease outbreaks and disasters can expose care staff to abnormally high levels of mortality and suffering. Health and social care systems need to proactively prepare for future events and enable peer support mechanisms that may help mitigate experiences of psychological distress in humanitarian crises.

'Saying goodbye' during the COVID-19 pandemic: A document analysis of online newspapers with implications for end of life care

BACKGROUND

News media create a sense-making narrative, shaping, reflecting and enforcing cultural ideas and experiences. Reportage of COVID-related death and bereavement illuminates public perceptions of, and responses to, the COVID-19 pandemic.

AIM

We aimed to explore British newspaper representations of 'saying goodbye' before and after a COVID-related death and consider clinical implications.

DESIGN

Document analysis of UK online newspaper articles published during 2 week-long periods in March-April 2020.

DATA SOURCES

The seven most-read online newspapers were searched: The Guardian, The Daily Mail, The Telegraph, The Mirror, The Sun, The Times and The Metro. Fifty-five articles discussed bereavement after a human death from COVID-19, published during 18/03-24/03/2020 (the UK's transition into lockdown) or 08/04-14/04/2020 (the UK peak of the pandemic's first wave).

RESULTS

The act of 'saying goodbye' (before, during and after death) was central to media representations of COVID bereavement, represented as inherently important and profoundly disrupted. Bedside access was portrayed as restricted, variable and uncertain, with families begging or bargaining for contact. Video-link goodbyes were described with ambivalence. Patients were portrayed as 'dying alone' regardless of clinician presence. Funerals were portrayed as travesties and grieving alone as unnatural. Articles focused on what was forbidden and offered little practical guidance.

CONCLUSION

Newspapers portrayed COVID-19 as disruptive to rituals of 'saying goodbye' before, during and after death. Adaptations were presented as insufficient attempts to ameliorate tragic situations. More nuanced and supportive reporting is recommended. Clinicians and other professionals supporting the bereaved can play an important role in offering alternative narratives.

Sadness, despair and anger when a patient dies alone from COVID-19: A thematic content analysis of Twitter data from bereaved family members and friends

BACKGROUND

To inform clinical practice and policy, it is essential to understand the lived experience of health and social care policies, including restricted visitation policies towards the end of life.

AIM

To explore the views and experiences of Twitter social media users who reported that a relative, friend or acquaintance died of COVID-19 without a family member/friend present.

DESIGN

Qualitative content analysis of English-language tweets.

DATA SOURCES

Twitter data collected 7-20th April 2020. A bespoke software system harvested selected publicly-available tweets from the Twitter application programming interface. After filtering we hand-screened tweets to include only those referring to a relative, friend or acquaintance who died alone of COVID-19. Data were analysed using thematic content analysis.

RESULTS

9328 tweets were hand-screened; 196 were included. Twitter users expressed sadness, despair, hopelessness and anger about their experience and loss. Saying goodbye via video-conferencing technology was viewed ambivalently. Clinicians' presence during a death was little consolation. Anger, frustration and blame were directed at governments' inaction/policies or the public. The sadness of not being able to say goodbye as wished was compounded by lack of social support and disrupted after-death rituals. Users expressed a sense of political neglect/mistreatment alongside calls for action. They also used the platform to reinforce public health messages, express condolences and pay tribute.

CONCLUSION

Twitter was used for collective mourning and support and to promote public health messaging. End-of-life care providers should facilitate and optimise contact with loved ones, even when strict visitation policies are necessary, and provide proactive bereavement support.

Facing Death: Attitudes toward Physician-Assisted End of Life among Physicians Working at a Tertiary-Care-Hospital in Israel

The demand for medical assistance in dying remains high and controversial with a large knowledge gap to support optimal patient care. The study aimed to explore physicians’ attitudes regarding euthanasia and examine the factors that related to these attitudes. We surveyed 135 physicians working at a tertiary-care hospital in Israel. The questionnaire was comprised of demographic and background information, DNR procedure information, encounters with terminally ill patients, familiarity with the law regarding end-of-life questions, and Attitudes toward Euthanasia. About 61% agreed that a person has the right to decide whether to expedite their own death, 54% agreed that euthanasia should be allowed, while 29% thought that physicians should preserve a patients’ life even when they expressed the wish to die. A negative statistically significant relationship was found between the level of religiosity and attitudes toward euthanasia. The physicians’ attitudes towards euthanasia are quite positive when compared to other countries. The data shows a conflict of values: the sacredness of human life versus the desire to alleviate patients’ suffering. The Coronavirus-19 outbreak reinforces the importance of supporting physicians’ efforts to provide ethical and empathic communication for terminally ill patients. Future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to end-of-life requests.

End of Life Decision-Making Challenges in a Latino Patient with COVID-19: Facing Barriers

COVID-19 pandemic brought difficult scenarios that patients and families are facing about end- of-life decisions. This exposed some weak areas in the healthcare system where we can continue improve in reducing disparities and emphasizing advance care planning from a primary level of care. We present a case of challenges in end-of-life decision-making in a Latino patient.

Practical Considerations in Providing End-of-Life Care for Dying Patients and Their Family in the Era of COVID-19

In the era of coronavirus disease 2019 (COVID-19), social distancing and strict visitation policies at hospitals have made it difficult for medical staff to provide high-quality end-of-life (EOL) care to dying patients and their families. There are various issues related to EOL care, including psychological problems of patients and their families, difficulties in EOL decision-making, the complicated grief of the bereaved family, moral distress, and exhaustion of medical staff. In relation to these issues, we aimed to discuss practical considerations in providing high-quality EOL care in the COVID-19 pandemic. First, medical staff should discuss advance care planning as early as possible and use the parallel planning strategy. Second, medical staff should play a role in facilitating patient-family communication. Third, medical staff should actively and proactively evaluate and alleviate dying patients' symptoms using non-verbal communication. Lastly, medical staff should provide care for family members of the dying patient, who may be particularly vulnerable to post-bereavement problems in the COVID-19 era. Establishing a system of screening high-risk individuals for complicated grief and connecting them to bereavement support services might be considered. Despite the challenging and limited environment, providing EOL care is essential for patients to die with dignity in peace and for the remaining family to return to life after the loved one's death. Efforts considering the practical issues faced by all medical staff and healthcare institutions caring for dying patients should be made.

Missing the human connection: A rapid appraisal of healthcare workers' perceptions and experiences of providing palliative care during the COVID-19 pandemic

BACKGROUND

During infectious epidemics, healthcare workers are required to deliver traditional care while facing new pressures. Time and resource restrictions, a focus on saving lives and new safety measures can lead to traditional aspects of care delivery being neglected.

AIM

Identify barriers to delivering end-of-life care, describe attempts to deliver care during the COVID-19 pandemic, and understand the impact this had on staff.

DESIGN

A rapid appraisal was conducted incorporating a rapid review of policies from the United Kingdom, semi-structured telephone interviews with healthcare workers, and a review of mass print media news stories and social media posts describing healthcare worker's experiences of delivering care during the pandemic. Data were coded and analysed using framework analysis.

SETTING/PARTICIPANTS

From a larger ongoing study, 22 interviews which mentioned death or caring for patients at end-of-life, eight government and National Health Service policies affecting end-of-life care delivery, eight international news media stories and 3440 publicly available social media posts were identified. The social media analysis centred around 274 original tweets with the highest reach, engagement and relevance. Incorporating multiple workstreams provided a broad perspective of end-of-life care during the COVID-19 pandemic in the United Kingdom.

RESULTS

Three themes were developed: (1) restrictions to traditional care, (2) striving for new forms of care and (3) establishing identity and resilience.

CONCLUSIONS

The COVID-19 pandemic prohibited the delivery of traditional care as practical barriers restricted human connections. Staff prioritised communication and comfort orientated tasks to re-establish compassion at end-of-life and displayed resilience by adjusting their goals.

[Evidence of the validity of a Brazilian version of the Fear of COVID-19 Scale]

This study sought to analyze the evidence of the validity of a Brazilian version of the Fear of COVID-19 Scale (FCV-19S), based on indicators relating to: (1) the internal structure; (2) the internal consistency; (3) the relation with external variables; and (4) the content. The instrument was culturally adapted, focusing on semantic and specifically Brazilian linguistic aspects. The Brazilian version of the FCV-19S was then applied, in a virtual environment, to 211 participants (72.98% female) with an average age of 37.07 years (SD=13.03), together with the Self-Perception Questionnaire on Mental Health in Pandemics and the Sociodemographic and Functional Questionnaire. The confirmatory factor analysis revealed one-dimensionality. The internal consistency indices obtained (Cronbach's alpha =0.921; McDonald's omega =0.926) can be considered high. The correlation between fear and obsessive thinking of the disease, generalized anxiety, generalized stress, phobic-avoidant behavior and bereavement due to the pandemic was found to be statistically significant. Evidence of the validity related to content, derived from a qualitative approach, were satisfactory. The conclusion drawn is that the Brazilian version of the FCV-19S proved to be adequate regarding the evidence of the expected validity.

The Long Shadow: Collateral Impact and Finding Resilience Amidst a Global Pandemic Pediatric Palliative Care Social Work During COVID-19

This manuscript illuminates the nuanced ways in which the COVID-19 pandemic has impacted the pediatric palliative care social work role and clinical care in caring for children with life-limiting illnesses and their families throughout the country. The authors discuss memorable moments, logistical impacts, telehealth usage, decision-making experiences, end of life care, bereavement practices, specialized interventions, and self-care. The paper concludes with lessons learned and practical recommendations for the future.

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.

Anxiety among front-line health-care workers supporting patients with COVID-19: A global survey

OBJECTIVE

We aimed to explore anxiety status across a broad range of HCWs supporting patients with COVID-19 in different global regions.

METHOD

This was an international online survey in which participation was on voluntary basis and data were submitted via Google Drive, across a two-week period starting from March 18, 2020. The Beck Anxiety Inventory was used to quantify the level of anxiety.

RESULTS

1416 HCWs (70.8% medical doctors, 26.2% nurses) responded to the survey from 75 countries. The distribution of anxiety levels was: normal/minimal (n = 503, 35.5%), low (n = 390, 27.5%); moderate (n = 287, 20.3%), and severe (n = 236, 16.7%). According to multiple generalized linear model, female gender (p = 0.001), occupation (ie, being a nurse dealing directly with patients with COVID-19 [p = 0.017]), being younger (p = 0.001), reporting inadequate knowledge on COVID-19 (p = 0.005), having insufficient personal protective equipment (p = 0.001) and poor access to hand sanitizers or liquid soaps (p = 0.008), coexisting chronic disorders (p = 0.001) and existing mental health problems (p = 0.001), and higher income of countries where HCWs lived (p = 0.048) were significantly associated with increased anxiety.

CONCLUSIONS

Front-line HCWs, regardless of the levels of COVID-19 transmission in their country, are anxious when they do not feel protected. Our findings suggest that anxiety could be mitigated ensuring sufficient levels of protective personal equipment alongside greater education and information.

Ethical conflict during COVID-19 pandemic: the case of Spanish and Italian intensive care units

AIM

To identify factors underlying ethical conflict occurring during the current COVID-19 pandemic in the critical care setting.

BACKGROUND

During the first wave of the COVID-19 outbreak, Spanish and Italian intensive care units were overwhelmed by the demand for admissions. This fact revealed a crucial problem of shortage of health resources and rendered that decision-making was highly complex.

SOURCES OF EVIDENCE

Applying a nominal group technique this manuscript identifies a series of factors that may have played a role in the emergence of the ethical conflicts in critical care units during the COVID-19 pandemic, considering ethical principles and responsibilities included in the International Council of Nurses Code of Ethics. The five factors identified were the availability of resources; the protection of healthcare workers; the circumstances surrounding decision-making, end-of-life care, and communication.

DISCUSSION

The impact of COVID-19 on health care will be long-lasting and nurses are playing a central role in overcoming this crisis. Identifying these five factors and the conflicts that have arisen during the COVID-19 pandemic can help to guide future policies and research.

CONCLUSIONS

Understanding these five factors and recognizing the conflicts, they may create can help to focus our efforts on minimizing the impact of the ethical consequences of a crisis of this magnitude and on developing new plans and guidelines for future pandemics.

IMPLICATIONS FOR NURSING PRACTICE AND POLICY

Learning more about these factors can help nurses, other health professionals, and policymakers to focus their efforts on minimizing the impact of the ethical consequences of a crisis of this scale. This will enable changes in organizational policies, improvement in clinical competencies, and development of the scope of practice.

Communication Tools to Support Advance Care Planning and Hospital Care During the COVID-19 Pandemic: A Design Process

The COVID-19 pandemic has exposed the medical and social vulnerability of an unprecedented number of people. Consequently, there has never been a more important time for clinicians to engage patients in advance care planning (ACP) discussions about their goals, values, and preferences in the event of critical illness. An evidence-based communication tool-the Serious Illness Conversation Guide-was adapted to address COVID-related ACP challenges using a user-centered design process: convening relevant experts to propose initial guide adaptations; soliciting feedback from key clinical stakeholders from multiple disciplines and geographic regions; and iteratively testing language with patient actors. With feedback focused on sharing risk about COVID-19-related critical illness, recommendations for treatment decisions, and use of person-centered language, the team also developed conversation guides for inpatient and outpatient use. These tools consist of open-ended questions to elicit perception of risk, goals, and care preferences in the event of critical illness, and language to convey prognostic uncertainty. To support use of these tools, publicly available implementation materials were also developed for clinicians to effectively engage high-risk patients and overcome challenges related to the changed communication context, including video demonstrations, telehealth communication tips, and step-by-step approaches to identifying high-risk patients and documenting conversation findings in the electronic health record. Well-designed communication tools and implementation strategies can equip clinicians to foster connection with patients and promote shared decision making. Although not an antidote to this crisis, such high-quality ACP may be one of the most powerful tools we have to prevent or ameliorate suffering due to COVID-19.

Attitudes of Front-Line Nurses Toward Hospice Care During the COVID-19 Pandemic

OBJECTIVE

The aim of this study was to understand the attitudes of front-line clinical nurses toward hospice care in the fight against the COVID-19 pandemic, to provide a source of reference for hospice care education and training in hospitals treating patients with COVID-19.

METHOD

Front-line nurses from a designated COVID-19 hospital in Wuhan, China, participated. Participants completed the Chinese versions of the General Information Questionnaire, the Frommelt Attitudes Toward Care of the Dying Scale, the Jefferson Scale of Empathy, and the General Self-Efficacy Scale.

RESULTS

A total of 149 questionnaires were included in the analysis. The median total hospice care attitudes score was median 102.00(interquartile range, 95.5-120.50). The nurses' attitudes toward hospice care were significantly associated with their age, knowledge of hospice care, level of empathy, and self-efficacy.

CONCLUSION

The attitudes of front-line nurses toward hospice care need to be improved. Hospital departments should establish an effective public health emergency strategy, provide training to increase front-line nurses' knowledge and practical experience of hospice care, cultivate nurses' empathy, and enhance their sense of self-efficacy, in order to improve the quality of hospice care for patients and their families.

The effects of regional climatic condition on the spread of COVID-19 at global scale

The pandemic outbreak of the novel coronavirus epidemic disease (COVID-19) is spreading like a diffusion-reaction in the world and almost 208 countries and territories are being affected around the globe. It became a sever health and socio-economic problem, while the world has no vaccine to combat this virus. This research aims to analyze the connection between the fast spread of COVID-19 and regional climate parameters over a global scale. In this research, we collected the data of COVID-19 cases from the time of 1st reported case to the 5th June 2020 in different affected countries and regional climatic parameters data from January 2020 to 5th June 2020. It was found that most of the countries located in the relatively lower temperature region show a rapid increase in the COVID-19 cases than the countries locating in the warmer climatic regions despite their better socio-economic conditions. A correlation between metrological parameters and COVID-19 cases was observed. Average daylight hours are correlated to total the COVID-19 cases with a coefficient of determination of 0.42, while average high-temperature shows a correlation of 0.59 and 0.42 with total COVID-19 cases and death cases respectively. The finding of the study will help international health organizations and local administrations to combat and well manage the spread of COVID-19.

Dying From COVID-19: Loneliness, End-of-Life Discussions, and Support for Patients and Their Families in Nursing Homes and Hospitals. A National Register Study

CONTEXT

Preparation for an impending death through end-of-life (EOL) discussions and human presence when a person is dying is important for both patients and families.

OBJECTIVES

The aim was to study whether EOL discussions were offered and to what degree patients were alone at time of death when dying from coronavirus disease 2019 (COVID-19), comparing deaths in nursing homes and hospitals.

METHODS

The national Swedish Register of Palliative Care was used. All expected deaths from COVID-19 in nursing homes and hospitals were compared with, and contrasted to, deaths in a reference population (deaths in 2019).

RESULTS

A total of 1346 expected COVID-19 deaths in nursing homes (n = 908) and hospitals (n = 438) were analyzed. Those who died were of a more advanced age in nursing homes (mean 86.4 years) and of a lower age in hospitals (mean 80.7 years) (P < 0.0001). Fewer EOL discussions with patients were held compared with deaths in 2019 (74% vs. 79%, P < 0.001), and dying with someone present was much more uncommon (59% vs. 83%, P < 0.0001). In comparisons between nursing homes and hospital deaths, more patients dying in nursing homes were women (56% vs. 37%, P < 0.0001), and significantly fewer had a retained ability to express their will during the last week of life (54% vs. 89%, P < 0.0001). Relatives were present at time of death in only 13% and 24% of the cases in nursing homes and hospitals, respectively (P < 0.001). The corresponding figures for staff were 52% and 38% (P < 0.0001).

CONCLUSION

Dying from COVID-19 negatively affects the possibility of holding an EOL discussion and the chances of dying with someone present. This has considerable social and existential consequences for both patients and families.

A comparison of 3 frailty measures and adverse outcomes in the intake home care population: a retrospective cohort study

BACKGROUND

In Ontario, Canada, nearly all home care patients are assessed with a brief clinical assessment (interRAI Contact Assessment [interRAI CA]) on admission. Our objective was to compare 3 frailty measures that can be operationalized using the interRAI CA.

METHODS

We conducted a retrospective cohort study using linked patient-level assessment and administrative data for all Ontario adult (≥ 18 yr) home care patients assessed with the interRAI CA in 2014. We employed multivariable logistic models to compare the Changes in Health, End-stage disease and Signs and Symptoms Scale for the Contact Assessment (CHESS-CA), Assessment Urgency Algorithm (AUA) and the Frailty Index for the Contact Assessment (FI-CA) that was created for this study. Our outcomes of interest were death, hospital admission and emergency department visits within 90 days, and assessor-rated need for comprehensive geriatric assessment (CGA).

RESULTS

In 2014, there were 228 679 unique adult home care patients in Ontario assessed with the interRAI CA. Controlling for age, sex and health region, being in a higher frailty level defined by any measure increased the likelihood of experiencing adverse outcomes. Among all assessments, CHESS-CA was best suited for predicting death and hospital admission, and either AUA or FI-CA for predicting perceived need for CGA. Previous emergency department visits were more predictive of future visits than frailty. Model fit was independent of whether the assessment was completed over the phone or in person.

INTERPRETATION

Frailty measures from the interRAI CA identified patients at higher risk for death, hospital admission and perceived need for CGA. In jurisdictions where the CHESS-CA and AUA are already built into the electronic home care platform, such as Ontario, patients identified as high risk should be prioritized for proactive referral and care planning, and may benefit from greater involvement of primary care and other health professionals in the circle of care.

Comment on "Response of a comprehensive cancer center to the COVID-19 pandemic: the experience of the Fondazione IRCCS-Istituto Nazionale dei Tumori di Milano"

Although European governments have launched the so-called phase 2 in the coronavirus disease 2019 (COVID-19) pandemic (a transitional phase of beginning to downsize containment measures), intensive care units are not COVID-19-free and this restricts our therapeutic strategies. Moreover, minimally invasive surgery and general anesthesia are under debate as they are both aerosol-generating procedures and may contribute to contamination spread inside operating theatres. During this pandemic, 13 fragile patients needing abdominal surgery underwent awake open surgery under locoregional anesthesia at our department. This approach was feasible, safe, and, in specific cases, the only viable option. In the COVID-19 era, this approach could allow surgeons to carry out undeferrable surgeries, preventing viral transmission inside the operating room.

Psychological stress among health care professionals during the 2019 novel coronavirus disease Outbreak: Cases from online consulting customers

Background

During the 2019 novel coronavirus disease (COVID-19) outbreak, online consulting has been widely used to address mental health problems, including health care professionals (HCPs) caring for COVID-19 patients who experienced substantial psychological distress.

Aim

To explore the severity of perceived stress and potential correlates among the HCPs seeking online mental health services during the COVID-19 outbreak.

Methods

A descriptive study was conducted among 34 HCPs to assess levels of psychological distress using the Perceived Stress Scale (PSS-10), Patient Health Questionnaire (PHQ-9), and Generalized Anxiety Disorder (GAD-7) questionnaire. The HCPs working in different departments were compared using χ²-test for categorized variables and t-test for continuous ones, followed by the analysis of covariate (ANCOVA) to compare the perceived stress. Linear regression for the PSS-10 score was performed to identify potential correlates of stress.

Results

The sample overall (n = 34) showed a relatively moderate level of perceived stress (PSS mean = 15.71 ± 4.02) with 38% identified as depressed (PHQ-9 ≥ 5) and 24% as suffering from anxiety (GAD-7 ≥ 5). Those working at intensive care units (ICUs) or in departments of respiratory medicine (RM) demonstrated significantly higher perceived stress than those at other departments (adjusted mean: 17.48 ± 0.96 vs. 13.06 ± 1.25, p = .018, partial η² = 0.173). High perceived stress was most strongly associated with being depressed (beta = 0.486, p = .002) and working at ICUs/RM (beta = 0.345, p = .023).

Conclusions

The psychological health status of frontline health care professionals during the 2019 novel coronavirus outbreak warrants clinical attention. Online mental health services has played a major role although its effectiveness and barriers to its utilisation require further evaluation.

COVID-19 in a young man with hypertension: A case study of missed opportunities in intensive progression

We report the case of a young patient diagnosed with coronavirus disease 2019 with a history of hypertension. The patient improved after antiviral treatment but eventually developed severe respiratory distress syndrome and cardiac insufficiency. His respiratory secretions were tested for nucleic acids and returned negative twice. Computed tomography imaging of the patient showed evidence of viral pneumonia on the 11th day of onset and continued to worsen. The patient was finally intubated and transferred to a higher-level care centre for further treatment. We were very focused on infectious disease protection throughout the treatment, however, suboptimal treatment was provided due to the switch in antihypertensive medication, lack of early nutritional support and fluid restriction management.