Palliative Care Program Response to COVID-19: Northwestern Memorial Hospital

The palliative care program at Northwestern Memorial Hospital (NMH) in Chicago, Illinois is an inpatient program but also has a small outpatient practice.

This is a snapshot of the palliative care program's involvement in NMH's COVID-19 response, based on an interview with Eytan Szmuilowicz, MD, Director, Palliative Medicine at Northwestern Hospital, and Joshua Hauser, MD, Associate Professor at Northwestern Feinberg School of Medicine, on April 10, 2020. At the time of the interview, NMH was preparing for an expected COVID-19 surge in one to two weeks.

• Palliative care is not on NMH's COVID-19 Task Force, but is working closely with Ethics on resource allocation and potential limitation of life-sustaining therapies
• Community planning:
  • Many local hospices and home health agencies do not have enough PPE (case by case)
  • Long-term care facilities have become more stringent about which patients they will take back
  • Hospital is renting hotel rooms in the event that they are needed for stable patients to receive ongoing care
  • Working with medical student groups who are obtaining PPE for Northwestern and multiple other Chicago-area facilities
• Palliative care team is addressing advance care planning (ACP) with two areas of focus:
  • Decision-making support and proactive ACP for patients with COVID-19 who do not want to go to the ICU
  • Reaching out to existing palliative care patients to do ACP, especially with potential for COVID-19 infection (especially for those who want to avoid unwanted hospital admission and life-sustaining therapies)
• Palliative care providing support for families and patients where possible; learning that providing a source of continuity is particularly helpful as other teams, providers, and sites of care change quickly
• All visits are done by telehealth unless a physical exam is warranted
• Case finding:
  • Palliative care participates in twice-daily COVID rounds with hospitalists, ethics, and ICU to review complex patients
  • Developing a new screening process with the ED to identify patients at high risk earlier in their trajectory (this also helps the team to build rapport early in a hospitalization)
• Education: Because many fellow clinicians are too busy to call palliative care, the team is facilitating access to palliative care clinical information and tools to do their work
  • Adapted CAPC and Vital Talk communication resources, and decision-making aides from Colorado
• Staffing:
  • Blended inpatient and outpatient teams to prevent gaps in care
  • Outpatient holds separate daily meeting to make sure no issues or patients are missed
  • Interdisciplinary team members are deployed according to patient and referrer needs

Note: Inpatient (non-COVID) palliative care census is lower since attention is on COVID care. Outpatient volume and work remains similar or slightly increased with telephone management.

Scheduling

• Be flexible and nimble; restructure early to limit on-campus exposure (i.e., maximize telehealth, minimize PPE use)
  • Consider skeletal inpatient team on-site and one outpatient member on-site with multiple team members available remotely for phone support and clinician coaching
  • Within two weeks, increased inpatient team to three teams on site (two COVID, one non-COVID)
• Plan for two to three layers of back-up (if possible) since clinicians may get sick, have other roles (e.g., serving through the local VA, local hospices), or have other needs

Medication Management

• Consider what is necessary for medication management; have become more liberal in medication prescriptions and refills for those who don’t absolutely need an in-person visit per DEA emergency flexibilities

Collaboration and Relationship-Building

• Be present for other medical teams’ rounds through proactive contact (What are that team's urgent issues? Who are you most worried about? How can palliative care help?)

Teamwork

• Work as a team to identify ways to build in some “normalcy” (e.g., weekly virtual educational conference, journal club, case study reviews, poetry)
• Proactively support one another and recognize varying levels of comfort in the event that team members are redeployed to unfamiliar areas/duties
• Hold weekly COVID-19 meeting for the extended palliative care team (inpatient, outpatient, on-service, off-service) to plan

Leadership

• Biggest challenge for the team is figuring out how to be most helpful in a rapidly-evolving and uncertain environment when the pace, needs, and practice are all different than usual
• Equal challenge: balancing effort and increased availability of team members with need for self-care, especially in setting of heightened, constant anxiety and stress

This snapshot was consolidated, edited, and condensed by Constance Dahlin, MSN, ANP-BC, ACHPN, FPCN, FAAN, Consultant, Center to Advance Palliative Care.