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Besides DNACPR, can we do more?

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Dr MA Hing Man
Consultant, KWH, A&E

In the midst of this COVID-19 pandemic crisis, every square inch of Accident and Emergency Department (AED) is overwhelmed by the sick and the dying. As the number of cases continues to mount, hundreds of elderly patients in need of treatment have no alternative but to wait in AED.

Whilst every painstaking second counts, Emergency physicians are fighting hard to try and save dozens of critically ill lives in the resuscitation room every day.  However, many of these elderly patients are, undoubtedly, in their final days or hours of life. The focus of emergency care is on diagnosis and treatment of acute illnesses and injuries, and stabilization of the immediate needs to ensure a smooth transition for ongoing treatment. However, from our professional judgement and hand-on experiences, we believe that many of these patients would unlikely benefit from cardiopulmonary resuscitation amid this unprecedented and prolonged world-wide chaos. Issuance of the “Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR)” order thus becomes a widely-seen practice. Consequently, acceleration of heart-wrenching deaths in AED is inevitable.

 

The current situation at AED is disheartening as we operate under severe manpower and resource constraint. The standard of professional care might be unavoidably compromised.  In such daunting environment, the very sick elderly patients could not be resuscitated but to fade away in a cold and lonely state without appropriate palliative care nor any tender loving family support. Emergency physicians would then be naturally assigned with a role of utmost importance - be the first and the only contact to notify family the sad news over phone. While traditional acute care services concentrate on the management of physical consequences resulting from COVID-19, integrating palliative care service into the treatment plan can work in a complementary fashion to address patients’ immediate corporeal concern as well as psychosocial, emotional and spiritual needs.

 

End-of-life Care (EOLC) refers to the care of terminally and critically ill patients in their final journey of life.  Traditionally, provision of EOLC in AED is challenging owing to minimal resources, lack of staff specialty-training as well as conflicting beliefs amongst staff in the arrangement of palliative care under emergency service setting. By initiating liaison with the palliative care team, a modified EOLC protocol can be established, which can then be safely and appropriately implemented, predominantly by AED frontline staff, to optimize the needs and comfort for this vulnerable patient group and their families. 

 

As part of a more holistic approach, the pertinent issue on minimizing unnecessary medications for the very sick and dying should be timely addressed.  Though there is little evidence or guidance on modifying the medication package for chronic illnesses in EOLC, patient comfort can be enhanced by minimizing maintenance medications that have little to no short-term benefit.  Symptom management for adult patients with COVID-19 receiving EOLC outside intensive care unit includes the use of opioids, such as morphine, which may help to alleviate acute respiratory distress and agitation, contributing to energy conservation.  All opioids are also helpful in controlling coughs.  Lorazepam or midazolam can be given to relieve anxiety on a need-basis.  Hyoscine butylbromide (buscopan) and furosemide can be considered for patients with severe respiratory secretion and congestion due to weakness or inability to effectively clear the accumulated secretions.

 

In response to COVID-19, hospitals have implemented policy on visitation restriction.  Limited visiting is granted upon assessment of each individual situation to enable family to accompany patient’s last journey of life. However, more often, patient may suddenly deteriorate drastically without any usual warning signs before family’s arrival. In fact, far too many patients, with or without COVID-19, have sadly passed away not having family bidding farewell at their bedside due to hospital regulations on infection control and social distancing. 

 

EOLC is a patient- and family-centered care approach and their wishes must be respected. Being able to spend the last hours with their loved ones and for the dying to leave this world peacefully without pain would be the ultimate wishes of patients and families. A more flexible approach, such as longer daily visiting hours in divided sessions, should be taken into consideration whilst continue to abide by hospital’s policy on infection control and avoidance of frequent visitor-cycling.  Even though most of these patients are minimally responsive and unable to interact with their family, measures adopted would be essential and invaluable for their final precious moments. These small acts of kindness will certainly help to ease family’s grief and sorrow. Furthermore, with modern technologies, many AED may be able to provide audio-visual equipment to facilitate virtual rendezvous for the loving goodbyes. 

 

AED would need to be better prepared in managing crises and disasters in both short and long term. This 5th wave of the COVID-19 pandemic has necessitated a rapid restructuring and overhaul of several aspects of AED operations in preparation for a more sustainable service provision.  It has also drastically changed how patients receive medical care and the pathway leading to the last days of patients’ lives.  Attitudinal and structural barriers will need to be overcome to improve EOLC in the AED. Liaison with palliative team for AED staff training, frontline colleagues will be better equipped in dealing with these unfamiliar situations, thus be able to provide more appropriate care to patients and families. In order to guide future development, establishing clinical trials and prospective data collection to elucidate the outcomes of EOLC in AED would be a crucial step forward.

 

End-of-Life Care is not a luxury; it is a human right and dignity must be respected!