Reflections on the pandemic: Flexibility ‘a must’ for palliative care nurse practitioners
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The future held promise at the onset of 2020.
Then, the term “coronavirus” crept into our discussions over the following weeks.
As part of the supportive oncology and palliative care team at a cancer hospital that is part of an academic university health care system in Utah, I was cautiously aware of the novel coronavirus outbreak in China and associated deaths. At first, our team — which consists of seven nurse practitioners (NPs) and three MDs — did not worry about the pandemic becoming a reality here. However, once we started getting word of the presence of the virus in the U.S., and especially news of cruise ships with infected travelers, we began to consider the possibility.
Our team is strong and diverse. We provide inpatient consultations and outpatient clinic visits in multiple settings, including hospital clinics and outlying community clinics.
We generally have a robust palliative care hospital census that has been averaging 15 to 25 inpatients per day. In the outpatient setting, we attend 1-hour appointments and see four to eight patients per day per provider, depending on whether it is a full- or half-day clinic.
In mid-February, we received notice from our health care system that WHO had updated terminology related to the novel coronavirus, known as SARS-CoV-2, and that it was the causative agent for COVID-19. Our division of epidemiology reported 407 people under investigation had been tested in the U.S. — not including those evacuated from the Diamond Princess cruise ship — with 15 positive cases as of Feb. 17.
Our health care system began to discuss implementation of virtual visits to safely evaluate patients suspected of having COVID-19. We also had information about triage and identification, clinical care guidelines, diagnostic testing/restrictions and other precautions available for employees and medical staff.
Cancellations, anxiety mount
By March, we began to hear the terms “flattening the curve” and “social distancing” everywhere.
Things also were changing at work. Notices went out to our patients about how to protect themselves and prevent the spread of COVID-19. The visitor policy changed to allow only one visitor aged older than 18 years, and visitors with suspected or confirmed COVID-19 were prohibited. Use of hand sanitizer was required to enter the building. Valets would no longer be parking cars, but instead directing drivers to parking areas.
I had been working hard to plan monthly CME meetings for the advanced practice clinicians, which I had to cancel for March and April. All hospital meetings were canceled and moved to virtual platforms, if possible. Medical meetings around the country also were canceled, including the Annual Assembly of Hospice and Palliative Care, which many members of my team had planned to attend.
Talk of how overwhelmed the health care system in Italy had become caused anxiety on our team.
We heard cases of patients not receiving treatment because they were too old or too sick and that resources needed to be saved. No one liked the idea of not having enough resources to treat patients.
By March 16, elective surgeries began to be postponed and rescheduled. Our team, and all other clinic teams, started providing virtual/phone visits for most patients, canceling nonessential appointments and scheduling no new patient visits. We decided that, generally, we would only see patients in clinic if they were already there seeing other providers.
Three days later, the Management Council informed us that over 1,000 patients in our system had been tested for COVID-19 and 80 had tested positive. There were three COVID-19-positive patients in the hospital, including one in the ICU. We were told it would take about 8 to 12 weeks to get through the hump and, during that time, to anticipate a surge of COVID patients. Our hospital system also started promoting the saying “Physical distancing — not social distancing” to promote keeping physically distant while staying socially connected.
I learned on March 20 that one of our palliative fellows had been exposed to two other providers at a different facility that tested positive for COVID-19. He worked with four of our team members that day, but I was not one of them. Luckily, neither he nor any members of our team got symptoms or became COVID-positive. However, everyone was anxious.
‘An ever-changing schedule’
The next week we designed and implemented an alternate hospital and clinic coverage schedule for our team.
The schedule included assigning one of our NPs to the university hospital where most of the patients with COVID-19 would be placed. We reorganized our rotations so there would be two NPs in the hospital (one on a short-day schedule and one on a long-day schedule), with one NP doing virtual clinic visits from home and one on backup at home. This would be an ever-changing schedule, adjusted according to patient loads. The idea was to keep as many of us at home as possible, thus limiting exposure.
In April, the clinic and administration halls were eerily quiet. Most nonclinical workers had been sent home to work and most clinic visits were being done through virtual platforms or postponed to later dates. Nonessential surgeries were canceled.
Our team members worked an average of 2 days in the hospital seeing patients and 2 days from home doing virtual clinic visits or being on call. We were told the curve was flattening and the surge might not come until early- to mid-May.
Our nurse practitioners and other providers used a variety of virtual platforms for visits with clinic patients, trying to find what would work best for us and for patients. At first, we used Doxy.me and Doximity, sometimes resorting to FaceTime or a phone call, if necessary. We tried to use a video format as much as possible for help with billing. Later, we began using Canto, through MyChart, in our EPIC system.
Things were a little challenging, especially for nurses and medical assistants trying to help patients understand how to use the systems. It was a daily learning process that required humor, understanding and encouragement for patients, families and staff.
‘A big success’ in crazy times
We had our challenges with inpatients, as well. Visitors were now prohibited except in rare situations. One visitor was allowed for end-of-life patients who were actively dying. In the case of a dying ICU patient to whom I was assigned, the daughter was at her mother’s bedside, but the rest of the family lived 2 hours away and was distressed that they were not allowed to be there to comfort her, as well as each other. They wanted to take the patient home.
The 2-hour ride was risky and there was a lot to arrange. The patient needed a continuous infusion pump to maintain her IV drip medications. Pharmacy would have to ready her medications, hospice transport would need to be arranged, and equipment needed to be placed in the home. Family and friends would need to coordinate being at the home to make sure the patient could be moved safely up the stairs into the home.
A lot of calling and coordinating was quickly done, and I was apprehensive the patient might not make it out of the hospital. But with much relief, the pharmacy came just in time, the hospice nurse switched the IV drip over to the portable pump and off they went. I said a silent prayer as they left the unit that she would make it home to her family before she died.
The next morning, I was overjoyed to hear that she had made it home smoothly and died peacefully in the middle of the night, surrounded by her family. I counted this as a big success in otherwise crazy times of the coronavirus pandemic.
The COVID-19 pandemic has steadily increased across the nation and around the world. Meanwhile, guidelines and preventive practices have been adjusted as we learn new information. The past 6 months have been a real challenge, with change being the only constant and flexibility and adaptation being a must. Although uncertain times remain ahead, we have pulled together and learned a lot.
For instance, we found ways to minimize our exposure to the virus while still meeting the needs of patients. We learned to maintain a strong awareness of our own work-life balance to avoid stress and mental exhaustion.
We adjusted to the decreased ability to touch, communicate feelings and see expressions by connecting families using virtual formats on phones, iPads and computers, often calling patients in their rooms or at home and by using resources for palliative care teams from the Center to Advance Palliative Care.
We coped with the secondary effects of social and physical isolation on patients and their families and within our own team by holding even tighter to those we love and focusing on the positive aspects of every day.
Through it all, I’ve been stressed and saddened, but lucky enough to have an incredibly responsive employer, a wonderfully supportive team at work and a caring and supportive family at home. I hope all of you have found healthy ways to cope and remain safe in these unprecedented times.
References:
Center to Advance Palliative Care. COVID-10 Response Resources Hub: Palliative care team. Available at: www.capc.org/covid-19/palliative-care-team/. Accessed Sept. 28, 2020.
Vergano M, et al. Clinical ethics recommendations for admission to intensive treatments and for their suspension, in exceptional conditions of imbalance between needs and available resources. Available at: docs.google.com/document/d/1QZw6g-h5hkW8NWn47AwNN_edMLHceKp46Mx92raOMK8/edit. Accessed Sept. 15, 2020.
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