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VOLUME 24 , ISSUE 6 ( June, 2020 ) > List of Articles

REVIEW ARTICLE

Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India

Naveen Salins, Roop Gursahani, Srinagesh Simha, Sushma Bhatnagar

Citation Information : Salins N, Gursahani R, Simha S, Bhatnagar S. Symptom Management and Supportive Care of Serious COVID-19 Patients and their Families in India. Indian J Crit Care Med 2020; 24 (6):435-444.

DOI: 10.5005/jp-journals-10071-23400

License: CC BY-NC 4.0

Published Online: 30-07-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Coronavirus disease-19 (COVID-19) pandemic is causing a worldwide humanitarian crisis. Old age, comorbid conditions, end-stage organ impairment, and advanced cancer, increase the risk of mortality in serious COVID-19. A subset of serious COVID-19 patients with serious acute respiratory illness may be triaged not to receive aggressive intensive care unit (ICU) treatment and ventilation or may be discontinued from ventilation due to their underlying conditions. Those not eligible for aggressive ICU measures should receive appropriate symptom management. Early warning scores (EWS), oxygen saturation, and respiratory rate, can facilitate categorizing COVID-19 patients as stable, unstable, and end of life. Breathlessness, delirium, respiratory secretions, and pain, are the key symptoms that need to be assessed and palliated. Palliative sedation measures are needed to manage intractable symptoms. Goals of care should be discussed, and advance care plan should be made in patients who are unlikely to benefit from aggressive ICU measures and ventilation. For patients who are already in an ICU, either ventilated or needing ventilation, a futility assessment is made. If there is a consensus on futility, a family meeting is conducted either virtually or face to face depending on the infection risk and infection control protocol. The family should be sensitively communicated about the futility of ICU measures and foregoing life-sustaining treatment. Family meeting outcomes are documented, and consent for foregoing life-sustaining treatment is obtained. Appropriate symptom management enables comfort at the end of life to all serious COVID-19 patients not receiving or not eligible to receive ICU measures and ventilation.


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  1. Lee TH. Creating the new normal: the clinician response to COVID-19. NEJM Catal Innovat Care Deliv 2020;1(2).
  2. Wu Z, McGoogan JM. Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in china: summary of a report of 72 314 cases from the Chinese center for disease control and prevention. JAMA 2020(13). DOI: 10.1001/jama.2020.2648.
  3. Ñamendys-Silva SA. Respiratory support for patients with COVID-19 infection. The Lancet Respirat Med 2020;8(4). DOI: 10.1016/S2213-2600(20)30110-7.
  4. Truog RD, Mitchell C, Daley GQ. The toughest triage—allocating ventilators in a pandemic. New England J Med 2020. DOI: 10.1056/NEJMp2005689.
  5. White DB, Lo B. A framework for rationing ventilators and critical care beds during the COVID-19 pandemic. JAMA 2020. DOI: 10.1001/jama.2020.5046.
  6. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? The Lancet 2020;395(10228):931–934. DOI: 10.1016/S0140-6736(20)30567-5.
  7. Sohrabi C, Alsafi Z, O'Neill N, Khan M, Kerwan A, Al-Jabir A, et al. World Health Organization declares global emergency: a review of the 2019 novel coronavirus (COVID-19). Int J Surg 2020;76:71–76. DOI: 10.1016/j.ijsu.2020.02.034.
  8. Mahase E. Coronavirus: COVID-19 has killed more people than SARS and MERS combined, despite lower case fatality rate. Br Med J Pub Group 2020;368:m641. DOI: 10.1136/bmj.m641.
  9. Novel CPERE. The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China. Zhonghua Liu Xing Bing Xue Za Zhi 2020;41(2):145–151.
  10. Onder G, Rezza G, Brusaferro S. Case-fatality rate and characteristics of patients dying in relation to COVID-19 in Italy. JAMA 2020. DOI: 10.1001/jama.2020.4683.
  11. Porcheddu R, Serra C, Kelvin D, Kelvin N, Rubino S. Similarity in case fatality rates (CFR) of COVID-19/SARS-COV-2 in Italy and China. The J Infect Develop Countr 2020;14(02):125–128. DOI: 10.3855/jidc.12600.
  12. Wang D, Hu B, Hu C, Zhu F, Liu X, Zhang J, et al. Clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in Wuhan, China. JAMA 2020;323(11):1061–1069. DOI: 10.1001/jama.2020.1585.
  13. Costantini M, Sleeman KE, Peruselli C, Higginson IJ. Response and role of palliative care during the COVID-19 pandemic: a national telephone survey of hospices in Italy. medRxiv 2020.
  14. World Health Organization, Integrating palliative care and symptom relief into responses to humanitarian emergencies and crises: a WHO guide. 2018.
  15. Tanja F-S, Nancy P, Keller N, Claudia G. Conservative management of COVID-19 patients–emergency palliative care in action. J Pain Symptom Manage 2020. DOI: 10.1016/j.jpainsymman.2020.03.030.
  16. World Health Organization., Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: interim guidance, 13 March 2020. World Health Organization; 2020.
  17. Williams B, Alberti G, Ball C, Ball D, Binks R, Durham L, Royal College of Physicians, National Early Warning Score (NEWS), Standardising the assessment of acute-illness severity in the NHS, London. 2012.
  18. Abbott TEF, Vaid N, Ip D, Cron N, Wells M, Torrance HDT, et al. A single-centre observational cohort study of admission national early warning score (NEWS). Resuscitation 2015;92:89–93. DOI: 10.1016/j.resuscitation.2015.04.020.
  19. Xu Z, Shi L, Wang Y, Zhang J, Huang L, Zhang C, et al. Pathological findings of COVID-19 associated with acute respiratory distress syndrome. Lancet Respir Med 2020;8(4):420–422. DOI: 10.1016/S2213-2600(20)30076-X.
  20. Wysham NG, Miriovsky BJ, Currow DC, Herndon JE, Samsa GP, Wilcock A, et al. Practical dyspnea assessment: relationship between the 0-10 numerical rating scale and the four-level categorical verbal descriptor scale of dyspnea intensity. J Pain Symptom Manage 2015;50(4):480–487. DOI: 10.1016/j.jpainsymman.2015.04.015.
  21. Davidson P, Currow D. Management of refractory dyspnoea: evidence-based interventions. Cancer Forum. Australian Cancer Society; 2010.
  22. Rocker GM, Simpson AC, Joanne Young B, Horton R, Sinuff T, Demmons J, et al. Opioid therapy for refractory dyspnea in patients with advanced chronic obstructive pulmonary disease: patients’ experiences and outcomes. CMAJ Open 2013;1(1):E27. DOI: 10.9778/cmajo.20120031.
  23. Matsuda Y, Maeda I, Tachibana K, Nakao K, Sasaki Y, Sugimoto C, et al. Low-dose morphine for dyspnea in terminally ill patients with idiopathic interstitial pneumonias. J Palliat Med 2017;20(8):879–883. DOI: 10.1089/jpm.2016.0432.
  24. Navigante AH, Cerchietti LC, Castro MA, Lutteral MA, Cabalar ME. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 2006;31(1):38–47. DOI: 10.1016/j.jpainsymman.2005. 06.009.
  25. Ouimet S, Kavanagh BP, Gottfried SB, Skrobik Y. Incidence, risk factors and consequences of ICU delirium. Intensive Care Med 2007;33(1):66–73. DOI: 10.1007/s00134-006-0399-8.
  26. Girard TD, Thompson JL, Pandharipande PP, Brummel NE, Jackson JC, Patel MB, et al. Clinical phenotypes of delirium during critical illness and severity of subsequent long-term cognitive impairment: a prospective cohort study. Lancet Respir Med 2018;6(3):213–222. DOI: 10.1016/S2213-2600(18)30062-6.
  27. Inouye SK. Delirium in older persons. New England journal of medicine 2006;354(11):1157–1165. DOI: 10.1056/NEJMra052321.
  28. Bellelli G, Morandi A, Davis DHJ, Mazzola P, Turco R, Gentile S, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing 2014;43(4): 496–502. DOI: 10.1093/ageing/afu021.
  29. Arumugam S, El-Menyar A, Al-Hassani A, Strandvik G, Asim M, Mekkodithal A, et al. Delirium in the intensive care unit. J Emerg Trauma Shock 2017;10(1):37–46. DOI: 10.4103/0974-2700.199520.
  30. Seneff MG, Mathews RA. Use of haloperidol infusions to control delirium in critically ill adults. Ann Pharmacother 1995;29(7-8): 690–693. DOI: 10.1177/106002809502907-806.
  31. Abraha I, Trotta F, Rimland JM, Cruz-Jentoft A, Lozano-Montoya I, Soiza RL, et al. Efficacy of non-pharmacological interventions to prevent and treat delirium in older patients: a systematic overview. the SENATOR project ONTOP series. PLoS ONE 2015;10(6):e0123090. DOI: 10.1371/journal.pone.0123090.
  32. Wildiers H, Menten J. Death rattle: prevalence, prevention and treatment. J Pain Symptom Manage 2002;23(4):310–317. DOI: 10.1016/s0885-3924(01)00421-3.
  33. Clark K, Butler M. Noisy respiratory secretions at the end of life. Curr Opin Support Palliat Care 2009;3(2):120–124. DOI: 10.1097/SPC.0b013e32832af251.
  34. Lanuke K, Fainsinger RL, DeMoissac D. Hydration management at the end of life. J Palliat Med 2004;7(2):257–263. DOI: 10.1089/109662104773709378.
  35. Arcuri JF, Abarshi E, Preston NJ, Brine J, Di Lorenzo VAP. Benefits of interventions for respiratory secretion management in adult palliative care patients—a systematic review. BMC Palliat Care 2016;15(1):74. DOI: 10.1186/s12904-016-0147-y.
  36. Nunn C. It's not just about pain: symptom management in palliative care. Nurse Prescribing 2014;12(7):338–344. DOI: 10.12968/npre.2014.12.7.338.
  37. Freire AX, Afessa B, Cawley P, Phelps S, Bridges L. Characteristics associated with analgesia ordering in the intensive care unit and relationships with outcome. Crit Care Med 2002;30(11):2468–2472. DOI: 10.1097/00003246-200211000-00011.
  38. Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, et al. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41(1):263–306. DOI: 10.1097/CCM.0b013e3182783b72.
  39. Young J, Siffleet J, Nikoletti S, Shaw T. Use of a behavioural pain scale to assess pain in ventilated, unconscious and/or sedated patients. intensive and critical care. Nursing 2006;22(1):32–39. DOI: 10.1016/j.iccn.2005.04.004.
  40. Hajiesmaeili MR, Safari S. Pain management in the intensive care unit: do we need special protocols? Anesth Pain Med 2012;1(4):237–238. DOI: 10.5812/aapm.4523.
  41. Day M. COVID-19: ibuprofen should not be used for managing symptoms, say doctors and scientists. Br Med J Publish Group 2020. DOI: 10.1136/bmj.m1086.
  42. Pasero C, Puntillo K, Li D, Mularski RA, Grap MJ, Erstad BL, et al. Structured approaches to pain management in the ICU. Chest 2009;135(6):1665–1672. DOI: 10.1378/chest.08-2333.
  43. Cherny NI, Radbruch L, BotEAfP Care. European association for palliative care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med 2009;23(7):581–593. DOI: 10.1177/0269216309107024.
  44. Cherny NI. ESMO clinical practice guidelines for the management of refractory symptoms at the end of life and the use of palliative sedation. Ann Oncol 2014;25(suppl_3):iii143–iii152. DOI: 10.1093/annonc/mdu238.
  45. Schildmann EK, Schildmann J, Kiesewetter I. Medication and monitoring in palliative sedation therapy: a systematic review and quality assessment of published guidelines. J Pain Symptom Manage 2015;49(4):734–746. DOI: 10.1016/j.jpainsymman.2014.08.013.
  46. Duan L, Zhu G. Psychological interventions for people affected by the COVID-19 epidemic. The Lancet Psychiatry 2020;7(4):300–302. DOI: 10.1016/S2215-0366(20)30073-0.
  47. You JJ, Fowler RA, Heyland DK. Just ask: discussing goals of care with patients in hospital with serious illness. CMAJ 2014;186(6):425–432. DOI: 10.1503/cmaj.121274.
  48. Curtis JR, Downey L, Back AL, Nielsen EL, Paul S, Lahdya AZ, et al. Effect of a patient and clinician communication-priming intervention on patient-reported goals-of-care discussions between patients with serious illness and clinicians: a randomized clinical trial. JAMA Int Med 2018;178(7):930–940. DOI: 10.1001/jamainternmed.2018.2317.
  49. Borasio GD, Gamondi C, Obrist M, Jox R. COVID-19: decision making and palliative care. Swiss Med Wkly 2020;150(1314). DOI: 10.4414/smw.2020.20233.
  50. Lesage P, Portenoy RK. Ethical challenges in the care of patients with serious illness. Pain Medicine 2001;2(2):121–130. DOI: 10.1046/j.1526-4637.2001.002002121.x.
  51. Singer AJ, Ng J, Thode JrHC, Spiegel R, Weingart S. Quick SOFA scores predict mortality in adult emergency department patients with and without suspected infection. Ann Emerg Med 2017;69(4):475–479. DOI: 10.1016/j.annemergmed.2016.10.007.
  52. Melltorp G, Nilstun T. Decisions to forego life-sustaining treatment and the duty of documentation. Intens Care Med 1996;22(10): 1015–1019. DOI: 10.1007/bf01699221.
  53. Curtis JR, Rubenfeld GD. “No escalation of treatment” as a routine strategy for decision-making in the ICU: con. Intensive Care Med 2014;40(9):1374–1376. DOI: 10.1007/s00134-014-3421-6.
  54. Machare Delgado E, Callahan A, Paganelli G, Reville B, Parks SM, Marik PE. Multidisciplinary family meetings in the ICU facilitate end-of-life decision making. Am J Hosp Palliat Med 2009;26(4):295–302. DOI: 10.1177/1049909109333934.
  55. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: a systematic review. PLoS ONE 2012;7(4). DOI: 10.1371/journal.pone.0035797.
  56. Almutairi AF, Adlan AA, Balkhy HH, Abbas OA, Clark AM. “It feels like I'm the dirtiest person in the world.”: Exploring the experiences of healthcare providers who survived MERS-CoV in Saudi Arabia. J Inf Public Health 2018;11(2):187–191. DOI: 10.1016/j.jiph.2017.06.011.
  57. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Network Open 2020;3(3). DOI: 10.1001/jamanetworkopen.2020.3976 e203976-e.
  58. Chen Q, Liang M, Li Y, Guo J, Fei D, Wang L, et al. Mental health care for medical staff in china during the COVID-19 outbreak. The Lancet Psychiatry 2020;7(4):e15–e16. DOI: 10.1016/S2215-0366(20)30078-X.
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