Effects of the COVID-19 pandemic on the activity of a palliative care unit

Dear Editor:

The COVID-19 infection constitutes a pandemic, with 72,172,270 confirmed infections and 1,612,932 deaths worldwide (as of 13th December 2020).¹

In just a few months, this has challenged health systems around the world, which have had to cope with a huge healthcare burden. The crisis has forced clinicians to make difficult triage decisions about what types of care are of high immediate value and essential for optimal results. The most challenging are the situations in which a delay in care has a significant adverse influence on the quality of life or a dignified death according to the wishes of the patient, such as the case at hand.

Patients in need of palliative care are a particularly vulnerable group in the face of the situation imposed by the current pandemic, with a worse prognosis due to their underlying disease and the loss of continuity of care during this period, when emergency and primary care services have been overloaded.

The COVID-19 disease called for an organisational readjustment of all hospital centres and their different departments, including the palliative care units (PCU). This situation posed a major challenge for the multidisciplinary team at the Red Cross Central Hospital in Madrid. Despite this readjustment of care during the pandemic (addition of new beds and conversion of units for the exclusive care of Covid-19 patients), the 7-bed inpatient PCU unit has been the only one in the centre that has maintained its specific care activity.

So, the objective of this study was to analyse the changes in the activity parameters and the profile of hospitalized palliative patients who did not suffer from COVID infection during the pandemic period.

A prospective cohort study of all patients admitted to the PCU was conducted from its opening on 12th December 2019 to 1st June 2020. Care activity parameters of two time periods were compared: pre-pandemic period of 90 days (from opening on 12th December 2019 to 13th March 2020) and pandemic period of 70 days (14th March 2020 to 1st June 2020).

Frequencies are compared using the Chi-square and Fisher's exact methods and the means using Student's t and Mann–Whitney U. Confidence intervals and significance level >95%.

A sample size of 101 patients was obtained (with 42 [42%)] being women, with a mean age of 80.2 ± 12.66 years).

During the pandemic there was an increase in admissions (56 vs. 45 admissions) from home (36 [64%] vs. 13 [29%]; p < 0.001%), younger (76.69 ± 13.2 vs. 84.62 ± 10.33; p < 0.001), more men (39 [70%] vs. 20 [44%]; p = 0.01) and with a shorter mean stay (7.18 ± 9.91 vs. 13.06 ± 17.49; p < 0.001).

The need for symptomatic control in the final days of life increased (survival less than 3 days) with 12 patients (27%) vs. 28 patients (51%); p = 0.01.

There were no differences in the admission disease, with cancer being the most common in both periods (86 vs. 71%; p: 0.07).

Family support during COVID admission was maintained (75 vs. 85%; p: ns) despite the required restrictions, with no COVID outbreak in the unit (2 imported patients). Furthermore, when analysing the subgroup of patients who came from home in both periods, we found no differences in family support, both of which were optimal (Fig. 1).

Fig. 1.

Care activity results: (A) Comparison between non-COVID period (12-12-2019 to 13-3-2020) and COVID (14-3-2020 to 1-6-2020): increase in number of admissions from home (p < 0.001) from 13 patients in the non-COVID period to 36 patients during the pandemic. The age of the patients (p < 0.001) admitted during the pandemic decreased by 8 years (from 85 to 77). The mean stay decreases by 6 days (p < 0.001) from 13 to 7 days. The cancer patient continued to be the most common profile and the family presence during admission was preserved. (B) Comparative survival (p: 0.01): during the pandemic, patients with survival of less than 3 days increased (28 patients compared to 13), the stay between 4–7 days was similar and the stay longer than 7 days decreased (13 patients in the COVID period compared to 23). (C) Differences with respect to the reason for admission (p: 0.1742): in the COVID period, the percentage of patients in the final days of life increased (68.7% compared to the previous 46%). Both poor symptom control and functional worsening were the most common reasons for admission during the non-COVID period.

As conclusions, it can be seen that the need for admission to hospital PCUs increased especially for cancer patients undergoing home follow-up.

Activity increased during the pandemic, with younger patients coming from home where the unstable situation of the final days of life was conducive to admission.

Bearing in mind that, in end-of-life situations, the needs of family members increase as death approaches, the participation of loved ones in family support was maintained, adapting the activity to the application of established end-of-life hospital protocols for prevention and care of patients and families.

All of the above reflects the need to ensure proper continuity of care in patients needing palliative care, who have been especially vulnerable during the pandemic.