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COVID-19: Prognosis and Palliative Care

COVID-19: Prognosis and Palliative Care

INTRODUCTION:

The reality is that COVID-19 is associated with mortality and that it is vitally important to identify those patients that might not survive and have discussions regarding goals of care, early in your management strategy. In British Columbia we use the MOST form that can be used effectively to discuss goals of care regarding CPR, ventilation, dialysis and nutrition. Every person deserves care and as physicians we can reduce suffering and play an integral role in managing symptoms and patient expectations and fears effectively.

CASE FATALITY RATE:

  • Case fatality rate in Canada 1.0%
  • Case fatality rate in world 5.0%
    • REMAINS A MOVING TARGET
  • Median interval to death – Wuhan – 16 days
  • 2 peaks regarding fatality
    • 14 days
    • 22 days
  • Causes of death
    • Respiratory failure
    • Myocardial Injury
  • ICU rates
    • 75% mortality rate of patient over the age of 60
    • Higher mortality rates for patients who is intubated and with associated comorbidities
  • No benefit of invasive techniques in this disease

PROGNOSIS:

Risk factors for severe disease:

  • Older Age (> 60 years)
  • Male sex
  • Medical comorbidities
  • Chronic pulmonary diseases (COPD…)
  • Cardiovascular disease (HTN, CAD)
  • Chronic kidney disease
  • Diabetes
  • HIV
  • Organ Transplant or immunosuppressants
  • Cancer
  • Smoking (Small increase risk)

Poor Prognostic Indicators:

  • Clinical Frailty Score
    • 5 = Poor Prognosis
  • Vital Signs
    • Respiratory rate >24 breaths/min
    • Heart rate > 125 b/m
    • Oxygen saturation <90% on room air
  • Labs
    • D-dimer > 1000 ng/ml
    • Ferritin >300 ug/L
    • LDH >245 IU/?L
    • Absolute lymphocyte count < 0.8
    • C-reactive protein >100

DISCUSSION:

PRINCIPLES:

  1. Person Centered and Purpose-orientated
  2. Patients want the truth
  3. Anxiety is normal (Physician and Patient – get support)

HOW TO APPROACH IT:

  • What matter most to them?
  • Set up the conversation. Ask permission.
  • Access understanding and information preferences
  • Share prognosis
    • “wish/worry”
    • “hope/worry”
  • Explore key topics
    • Goals
    • Fears
    • Sources of strength
    • Family
  • Close the conversation
    • “I’ve heard you say…”
  • Communicate and document care plan

MANAGEMENT:

PRINCIPLES:

  • Ensure all patients receive care
  • Avoid Harm
  • Reduce suffering by providing appropriate symptom control
  • Protect Health Care Staff
  • Support Families
  • Conserve Resources (Medications, PPE)

SYMPTOMS:

  1. DYSPNEA
    • Oxygen up to 6L without generating aerosols
    • Avoid use of fans
    • Avoid Nebulizers
    • No evidence to use bronchodilators or ICS unless known with COPD/Asthma
    • Opioids
      • Opioid Naive
        • Morphine 2.5mg – 5mg po q1H PRN
        • Morphine 1-2mg IV/SC q30 min PRN (Consider pump or device administrating as don and doff can deplete PPE)
        • OR
        • Hydromorphone 0.5 – 1mg PO Q1H PRN
        • Hydromorphone 0.25mg – 0.5mg IV/SC Q30 MIN PRN
        • Review often, start Q4H scheduled if using frequent PRN’s
      • Opioid Tolerant

Morphine Equivalence Table

DRUG SQ/IV PO COMMENTS
Morphine
10mg
30mg
Morphine
Codeien
120 (SC Only)
200mg
Metabolized to Morphine
Fentanyl Patch
-
Fentanyl
100mcg
N/A
Usually dosed prn less than 1 hour effect
Hydromorphone
2mg
4mg
Oxycodone
Not available in Canada
20mg
        • Give breakthrough dose as 10% of the total daily dose, IV/SQ Q30 min PRN
      • Consider transition to opioid continious IV/SQ infusion if still taking frequent PRNs on top of regular dosing
      • Palliative Sedation
        • Consider in patients with refractory dyspnea with patient distress
          • Midazolam 1 – 4mg/hr CSCI
          • Methotrimeprazine 5 – 25mg Q8H and Q3H PRN
  1. RESPIRATORY CONGESTION
    • Copious airway secretions
      • Glycopyrolate 0.4mg IV/SC Q4H PRN
      • Atropine 0.6mg SC Q6H PRN
      • Atropine 1% (ophthalmic drops) 1 – 2 drops SL Q4H PRN

REFERENCES:

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