Introducing palliative care from the moment of diagnosis is an essential component of comprehensive care, but it becomes even more critical when patients contract the COVID-19 coronavirus during treatment.
In their article in the February 2020 issue of the Clinical Journal of Oncology Nursing, Rosa et al. outlined the enhanced primary palliative care skills that oncology nurses need to care for patients with cancer and COVID-19.
Palliative Care Needs for COVID-19
Patients with cancer are more susceptible to contracting COVID-19 and more likely to experience worse outcomes. They need comprehensive palliative care to manage those symptoms throughout the disease trajectory.
For primary palliative nursing care, some of the virus-related competencies that Rosa et al. described were:
- Understand patients’ risk for contracting COVID-19 and follow proper procedures to minimize the risk while maintaining patients’ dignity.
- Support patients through treatment interruptions.
- Adjust approaches to account for medication and supply shortages or shifts to telehealth.
- Provide advance care planning, goals of care, and culturally appropriate psychosocial support for patients and families in the context of higher risk for poor outcomes with COVID-19.
- Identify hospice and palliative services prepared to care for patients with COVID-19 and community-based resources.
- Address COVID-19–specific concerns, such as social isolation and lack of informational support from families during treatment. For specialty palliative nursing care, Rosa et al. recommended adding:
- Understand and educate patients about which cancers are associated with highest risk from COVID-19 and the implications for making treatment decisions, including the possibility of interruptions from social restrictions to resource availability.
- Manage complex symptoms that community care may not have the capacity to manage during COVID-19.
- Assess patients’ understanding of their care transition to end of life in the context of COVID-19. Help them organize a plan for death that considers setting, proactive pain and symptom management, potential challenges from COVID-19, options and resources if they chose death at home, and the risk for limited family access or social isolation if they chose death in an acute care facility.
- Manage all care transitions.
- Offer psychosocial and emotional support during social isolation or limited social access.
- Include culturally competent spiritual care.
Palliative Care Nursing Education
To prepare nurses to provide person-centered palliative care during COVID-19, institutions should provide conduct and training in communication around end-of-life care, Rosa et al. said. “Oncology nurses need coaching and mentoring around communication, common pain and symptom management, community resources, and planning within the confines of COVID-19.” That education should also include support for nurses to develop their own self-care and resiliency skills.
The End-of-Life Nursing Education Consortium developed a collection of palliative care resources for nurses to use during COVID-19. ONS has a Nurse Self-Care Learning Library.
Questions to Guide Conversations
Talking with patients and families about decisions and approaches when treatment turns from curative to comfort is never easy, but the uncertainty around COVID-19 adds another level of challenge. Rosa et al. provided a question guide that oncology nurses can use to facilitate patient discussions, assess learning needs and patient education opportunities, and inform the healthcare team about patient wishes for palliative and end-of-life care. The questions are organized according to the eight care domains that the National Consensus Project for Quality and Palliative Care identified for its Clinical Practice Guidelines for Quality Palliative Care.
Structure and Processes
- What is your understanding of the purpose of this visit and its relationship to your cancer treatment?
- What are your concerns about your hospitalization or treatment?
- Has the COVID-19 pandemic raised any worries or fears about your cancer care?
- Many of the providers on your interprofessional team are working virtually at this time. When would be the best time for social workers, chaplains, and volunteers to contact you?
- What is the best technology for you—landline telephone, mobile phone, or email?
- What are your usual treatment and visit schedules? Do you still have symptoms?
- Given your comfort level, what is the best way to have regular visits: in person or virtually?
- Do you have any changes in any symptoms, including fatigue and anxiety?
- What bothersome symptoms do you have?
- What treatments have you tried that are effective or ineffective?
- To family members: Have you observed any other symptoms?
Psychological and Psychiatric
- How is COVID-19 affecting your spirits and well-being?
- Have any loved ones developed COVID-19? How has that affected you?
- Have you lost any family members or loved ones during the pandemic?
- How do you cope? Where do you find support? Who do you turn to?
- Do you feel you would benefit from additional support from others on the cancer care team?
- For patients with existing mental health challenges: Has your mental health changed during this experience? How have you managed that? Who have you spoken to about it?
- To family members: Have you observed any other symptoms, such as change in mood or spirits?
- How is your social support network and community during the COVID-19 pandemic?
- Have you felt isolated? Has it affected your health and well-being?
- Do you have concerns about your social welfare once you are discharged?
- Are you able to fill your prescriptions? Do you have enough medications to manage your symptoms?
- Can we support any of your social needs or concerns (e.g., transportation, technology, financial)?
- To family members: How can we support you to take care of your loved one’s oncology needs?
Spiritual, Religious, and Existential
- How has your cancer diagnosis or the pandemic affected your faith beliefs, practices, and traditions?
- How has the pandemic changed how you find meaning in your life, particularly with a cancer diagnosis?
- How has the importance of religion or faith changed during the pandemic?
- Do you feel supported by your faith community right now? Do you have any spiritual concerns or needs?
- What name do you prefer we use? What is your gender identity? What pronouns do you use? Whom do you consider your family?
- To help us provide respectful care, is there anything you prefer or find problematic?
- With whom can we speak to or share the details of your care?
- How does your family make healthcare decisions? Do you make them alone or in consultation with your family or community?
- Who is in your support system? Are they aware of your situation? Can we help you talk with them?
Nearing End of Life
- Are you at peace?
- What are you most worried about?
- How do you best like to be comforted?
- To patients and family members: What is most important to you right now? What are you hoping for?
- To family members: What information do you need as your loved one nears the end of their life? How can we best support you?
Ethical and Legal
- Have you assigned someone to make medical decisions if you are unable to do so?
- If not, who would you want to make decisions for you in the event that you were unable to? Do they know you want them to do this?
- Have you ever thought about getting really sick? Have you thought about how much treatment you want?
- How can I help you document those wishes?
To learn more about the palliative care skills, competencies, and education needs for oncology nurses during COVID-19, including applying the skills and competencies to a patient case study, refer to the full article by Rosa et al.