Palliative Care in a Pandemic: Lessons Learned and Shared
At the peak of the COVID-19 pandemic, requests for palliative care consultations increased nearly sevenfold across the 10 campuses of NewYork-Presbyterian. “Palliative care seeks to meet a patient’s underlying values and goals in the face of a serious illness, however, many of our patients were intubated and sedated,” says Craig D. Blinderman, MD, MA, Director, Adult Palliative Care Service, NewYork-Presbyterian/Columbia University Irving Medical Center. “We were wearing protective gear, which posed a literal physical barrier to family members if they were in the hospital and most were not. And so, the normal kinds of difficult conversations that we would have with loved ones where we might bring them into another room, sit down with them, maybe hold their hand or touch their shoulder before discussing the difficult issues of life and death, could not happen. There is a major difference that we all felt when providing palliative care in this context.”
To address the need for atypical services within the throes of a pandemic, Dr. Blinderman and his colleagues developed a comprehensive response through multiple creative care models, expanding the reach of palliative care to outpatient and inpatient services. “We pivoted and reacted and responded to the increased need,” says Dr. Blinderman. “The new care models included virtual outpatient management of existing patients, multidisciplinary family support, hospice units that allowed for family visitation, team expansion through training other disciplines, and deploying an ePalliative Care service staffed by out-of-state volunteers.”
Blinderman CD, Adelman R, Kumaraiah D, Pan CX, Palathra BC, Kaley K, Trongone N, Spillane K. A Comprehensive Approach to Palliative Care During the Coronavirus Pandemic. Journal of Palliative Medicine. 2020 Dec 1.
Creation of a Psychiatry-Palliative Care Liaison Team
As the number of COVID-19 cases surged during March and April 2020, the Adult Palliative Care Service and the Department of Psychiatry at NewYork-Presbyterian/Columbia collaborated with Columbia’s Graduate Medical Education Program to form and rapidly train a psychiatry-palliative care liaison team under the supervision of consultation-liaison psychiatrists. In an article published in the June 2020 issue of the Journal of Pain and Symptom Management, Columbia faculty detail the teams’ training and function that included providing palliative care services to patients and their families through goals-of-care discussions and psychosocial support.
Palliative care physicians were available to team members for more advanced and specialized supervision. “The liaison teams provided palliative care services during the early phase of the COVID-19 crisis managing up to 16 new cases a day,” says Dr. Blinderman. “Their support enabled palliative care specialists to focus on providing services that required specialist-level palliative care expertise. The psychiatry-palliative care liaison team can serve as a model for rapidly increasing a palliative care workforce in future healthcare crises.”
Shalev D, Nakagawa S, Stroeh OM, Arbuckle MR, Rendleman R, Blinderman CD, Shapiro PA. The Creation of a Psychiatry-Palliative Care Liaison Team: Using Psychiatrists to Extend Palliative Care Delivery and Access During the COVID-19 Crisis. Journal of Pain Symptom and Management. 2020 Jun 13:S0885-3924(20)30441-3.
Palliative Care Specialists Cross Borders via Telehealth
As the unprecedented increase in demand for palliative care services surpassed the Columbia palliative care team’s ability to respond, physician volunteers were recruited from the University of California San Francisco, Stanford University, and Dartmouth-Hitchcock. Under Governor Andrew Cuomo’s executive order, NewYork-Presbyterian facilitated a fast-track licensing and credentialing process for out-of-state palliative care specialists within a few days.
Once credentialed, the physicians underwent a rapid orientation process, including use of NewYork-Presbyterian’s electronic medical record and palliative consultative workflow procedures. Their cases were selected based on several criteria. The remote consultants generally were assigned high-complexity cases with patients who were primarily intubated and sedated or otherwise unable to converse with the clinicians. This allowed for the consultant to speak with family members who themselves were not able to visit the hospital due to COVID-19 restrictions. “Consultations were based on clarification of goals of care, as opposed to symptom management or transition planning that would require an in-person assessment and management by clinicians who were familiar with local resources,” notes Dr. Blinderman.
An article published in the August 2020 issue of the Journal of the American Geriatrics Society describe the strategies used by Columbia faculty and those at the participating institutions and valuable lessons learned for those wanting to emulate this model.
Nakagawa S, Berlin A, Widera E, Periyakoil VS, Smith AK, Blinderman CD. Pandemic Palliative Care Consultations Spanning State Institutional Borders. Journal of the American Geriatrics Society. 2020 Aug;68(8):1683-1685.
Establishing a Virtual Support System for Palliative Care
How to extend palliative care services globally to underserved populations has also been the focus of Dr. Blinderman and his colleagues at Columbia. “In the setting where we are all thinking more globally due to the pandemic, we are seeing disparities in how palliative care has been implemented in healthcare systems around the world and in some areas, not at all,” says Dr. Blinderman. “We’ve been asking ourselves how we can improve access to desperately needed palliative care services? One way we found that could be helpful is through a telehealth system, whereby healthcare providers in programs that have adequate resources would either volunteer or provide additional services to those who don’t have those resources.”
Dr. Blinderman acknowledges that infrastructure issues, including Internet and telephonic access in more remote areas, could pose a barrier. “But by and large, if we can connect with folks through a telehealth type of portal, there could be a way in which we could leverage some of the programs that have the available resources to help those programs that don’t, and this can also be done in non-pandemic times as well.”
At the request of Columbia University’s Columbia World Projects, which seeks to generate, refine and select projects that have the potential to improve people’s lives in a significant way, the team submitted its proposal for the group’s World Projects Forum. To that end, they developed a proposal built upon the Hospital’s experience with the palliative medicine volunteer providers during the COVID-19 surge.
“This project seeks to build upon a two-tiered model of specialist and generalist-level palliative care support we developed at Columbia during the height of the pandemic and to pilot the model at additional hospitals in the U.S. in collaboration with the Center to Advance Palliative Care,” says Dr. Blinderman. “The dual approach would consist of developing an online platform to provide specialist palliative care remotely, while simultaneously developing a training for generalist palliative care to be given to individuals within a given hospital system. This project could help respond swiftly to the increased need for palliative care due to the COVID-19 pandemic and future emergencies, while reducing the disparities in palliative care services accessible to underserved communities.”