Palliative Care for the COVID-19 Patient

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“This video is aimed at healthcare workers caring for patients dying with suspected or proven COVID-19 infection.” Recommended dosages for all drugs are listed on the final slide on this presentation.

• COVID-19 can cause severe disease. Some people, of all ages, will become very sick with COVID-19.

• Patients with chronic conditions such as heart and lung disease, and the elderly are most at risk of dying. But it is important to remember that most will still recover. Patients over 70 years have had a fatality rate of 8%, so 92% survive.

• Deterioration may occur rapidly and is most likely during the second week of the illness.

• If someone is severely ill, you need to consider whether admission is appropriate. It may not improve outcome for the patient who may be more comfortable in their own home. Admission also increases the risk of infecting others. Who should you consider for palliative care? Palliative care should be considered in patients who are unable to walk, who are semi-comatose or not taking food or fluids orally.

Ask yourself the question – “Would I be surprised if this patient died in the next day or two?” If you would not be surprised, you should consider what management strategies are required? And whether a focus on symptom relief should be considered? Some patients, particularly those who were frail before getting sick, may not have distressing symptoms and may not need medications.

So treat people based on their symptoms. Common symptoms in the patient dying with COVID-19 Common symptoms in the dying COVID-19 patient include • Breathlessness • Pain • Fever • Agitation or distress, and • Inability to manage day to day tasks such as washing, dressing or eating. • Patients may not be too unwell to take medications orally, so may require subcutaneous or rectal administration.

Symptom control: Breathlessness • Oxygen may be considered for breathlessness, but is only of benefit if oxygen saturations are low. And if you have adequate supply for other patient groups. A fan blowing over the face will ease the sense of breathlessness. • Opioids, including morphine sulphate, will relieve breathlessness, pain or severe cough. • Benzodiazepines, including diazepam or midazolam, can help with agitation and breathlessness. Symptom control: Pain, nausea and agitation • Opioids, as prescribed for breathlessness, or rectal NSAIDs may be useful for pain. • Antiemetics like prochlorperazine or metoclopramide may be needed for side effects of opioids, or for nausea. • Haloperidol can help with nausea, and agitation. Other symptoms • If marked fever, consider rectal paracetamol or NSAID. • Marked respiratory secretions are uncommon with COVID-19. Hyoscine butylbromide (buscopan) can help • Antibiotics and intravenous or subcutaneous fluids are not of benefit in improving symptoms.

Care for guardians • Remember that guardians of patients with possible or proven COVID-19 are at risk of infection, whether in hospital or at home. If a guardian must remain with a COVID-19 patient then- • The patient should remain in one room if at home, or in isolation if in hospital. It should be well ventilated with open windows and door. • Guardians should be in good health with no underlying chronic or immunocompromising conditions. • Household members should maintain a distance of 1-2m from the ill patient. • Non-essential visitors should be discouraged. • Encourage hand washing, masks, appropriate disposal of tissues, dedicated plates and cups and regular cleaning of surfaces. • Patients should be encouraged to wear a mask to contain respiratory secretions. If this is not feasible or not tolerated, cover the mouth and nose with disposable paper tissue when coughing or sneezing, and discard immediately after use. If cloth is used, wash after each use with soap and water.

Recommended drug dosages Morphine sulphate 2.5mg subcutaneously (SC) or 5mg orally, 2-4 hourly PRN Diazepam 5mg orally or rectally, 2-4 hourly PRN Midazolam 2.5-5mg SC or via the buccal mucosa 2-4 hourly PRN Prochlorperazine, 12.5 mg SC 8 hourly Metoclopramide, 10 mg SC 8 hourly Haloperidol, 0.5 -1mg SC 12 hourly Hyoscine butylbromide (Buscopan) 20mg SC 4-6 hourly PRN (Max 120mg/24 hours) Paracetamol 1g rectally 4-6 hourly ( Max 2g/24hrs)

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Voice Over: Elias Phiri

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