Where Is Palliative Care Now in the “Post-COVID” Landscape?
In the early days of the COVID pandemic, some palliative care and hospice programs found themselves pushed to the sidelines of the national crisis response. Patients “crashed” fast; doors closed to all-but essential facility staff; some patients put off seeking care for preexisting serious conditions and thus failed to get connected with hospice and palliative care.
At the same time, established palliative care programs at major medical centers in places like New York City, the epicenter for COVID cases in this country’s first wave, were pulled into a variety of demanding new roles, some of which were done virtually by phone or Zoom. Other palliative care professionals took their place in all-hands-on-deck responses on the hospital floors. Craig Blinderman, MD, MA, director of the adult palliative care service at New York-Presbyterian-Columbia University Irving Medical Center, says his team had embedded palliative care in the hospital emergency department within a week or two of the first surge in New York City.
Many hospitals were discovering—or rediscovering—how important palliative care could be in a crisis such as the COVID pandemic—especially when needing to confront the possibility of implementing triage or crisis standards of care. Volunteers from other departments—and from other states—were mobilized to help out in varied palliative care roles, including being the primary point of contact with shut-out families of seriously ill or dying COVID patients quarantined in the hospital.
Now, several surges and ebbs later, what is the news from palliative care professionals and their role within a healthcare system that is emerging utterly transformed by the past two years of a pandemic that killed more than a million Americans?
Better Handle on the Science?
In some places, caseload demands during the initial Omicron surge felt as bad as during the first COVID surge in March of 2020. “Some hospital organizations [were] overwhelmed—with the need to put up tents in their parking lots and ask for help from the National Guard, just like we did back in 2020,” Dr. Blinderman reports.
But in New York City, it didn’t seem as overwhelming because staff felt better prepared in their ability to respond, with more experience and more treatments to offer. Vaccinations meant the disease wasn’t as severe for many patients. The Omicron surge arrived after professionals had achieved a better handle on the science.
“Our challenge now is different—we have to respond and show up and hold our personal judgments aside when patients come in who are not vaccinated,” he says. “To say these words causes me pain. In 2020 we had no choice but to respond when we were all of a sudden confronted with a crisis. Now, the fact that some hospitals are still dealing with a preventable problem at that level is heartbreaking. It speaks to the failure of our country to do the right thing and take this pandemic seriously. We shouldn’t have to be that way.”
A colleague told Dr. Blinderman that she is finding it more difficult to run family meetings, and feels sick to her stomach because she is so angry about the unvaccinated. Clinicians are burned out, he says. “They are saying ‘I don’t know if I can do this work anymore.’”
Much of the work of palliative care teams is still being done remotely, by phone or Zoom, in 2022, he says. “We also have a busy inpatient service that carries a census of 40 or more patients. And we’re operating new components, such as trying to see patients earlier when they are still in the emergency department.” He is working with the ED’s chief of operations to strategize how to identify patients sooner and developing clinical decision tools that could help guide these interactions.
A Sense of Déjà Vu
Laura Schoenherr, MD, associate chief of inpatient palliative care services at the University of California San Francisco Division of Palliative Medicine, says it sometimes feels like déjà vu responding to the latest COVID surge. “What we’re now dealing with in palliative care is the burnout. This is not the first time our resources of resiliency have gotten low, but this time there isn’t the same sense of our community rallying behind medical providers like we saw in the first surge.”
Initially, health professionals were running on adrenaline. But it’s hard to operate indefinitely on adrenaline, she says. “The country’s great resignation also applies to healthcare and to palliative care, which makes it harder for those of us left behind.” A lot of experienced professionals have decided to retire earlier than they planned. “For right now, staffing for our program is okay. But we’re a small group, and it doesn’t take many people out sick to really stretch us.”
Early last winter, UCSF reached a Hospital Surge Status of Red—the highest of its color-coded levels. “But it [didn’t] seem like the Red Surge Status of a year ago, when they were asking the palliative care consult team to be the primary medical service for end-of-life patients,” Dr. Schoenherr says.
“In a lot of ways, COVID has advanced our ability to see patients in the outpatient setting who used to have trouble coming long distances to visit their providers,” she adds. “We’ve made significant improvements in our use of telemedicine. But there are still some things that require periodic in-person visits for us to adequately address, and to fully integrate our interventions and interactions with patients, loved ones, and other providers.”
Dr. Blinderman believes that physicians, including palliative care physicians, need to become more involved in the public discourse about COVID. “We need to share what we have learned about the precariousness of life, and about the disparities in health care that we are seeing,” he says. “Palliative care professionals should be speaking out on how we think about these issues of life and death and decision-making in a pandemic. We have important perspectives to share.”
