Palliative Care Program Response to COVID-19: Duke Health

The palliative care program at Duke Health in Durham, North Carolina covers three hospitals and includes an outpatient program.

This is a snapshot of the palliative care program's involvement in Duke Health's COVID-19 response, based on an interview with Jennifer Gentry, DNP, ANP-BC, GNP, ACHPN, FPCN, Palliative Nurse Practitioner at the Duke University Hospital Palliative Care Consult Service, and Clinical Associate at the Duke School of Nursing, from April 5, 2020. At the time of the interview, Duke Health was in the early stages of the COVID-19 crisis.

• Preparations began March 1 and included developing ethics, communication, and documentation strategies
• Collaborating with health system-wide ethics board and state around scarce resource allocation
• Response developed based on SARS response, and involves state health officials, legal, and ethics professionals, and the use of SOFA scores and triage officer
• Community support for patient care
  • Able to get hospice patients to inpatient unit
  • Challenges with discharging patients to other facilities due to COVID-19 outbreaks

• Palliative care leadership is part of the command center of the Duke response
• Education of non-palliative care colleagues including guidance on symptom management
  • Creating communication scripts for resident teaching
  • Providing clinical coaching to residents over the phone and having them practice script
• Provision of care planning and goals of care conversations
  • North Carolina has witness requirement, which means that trying to do verbal advance care planning (ACP) is challenging
  • Using EPIC “dot phrases” to document goals of care discussions
  • Palliative care team is reaching out to existing palliative care patients to do ACP
  • Nurses who have not previously had ACP conversations as part of their scope on the team need scripts to do so during crisis
• Focus of clinical partnerships changes daily according to need; palliative care is assessing the need for care management across teams
• Telehealth is playing a key role:
  • All clinic visits are now done via telehealth
  • Community palliative care house calls program is also doing telehealth
  • The palliative care interdisciplinary team does daily WebEx rounds for team check-in and to run the team list
• Palliative care social worker has set up twice-weekly support rounds and is calling patients and families to do virtual support

Note: Because referring partners are focused on Duke's COVID-19 response, the palliative care census has been lower during COVID-19.

Preparation

• Wished they had used the 2-3 weeks of time prior to crisis to prepare policies and procedures for patient care
• Expect the unexpected; be nimble and prepared to make changes in “real time” on a daily basis
• Consider medication shortages
• Care delivery for patients who live out of state is challenging due to provider licensing for their state (result is nurse navigator checking in, but care is difficult)

Scheduling

• Need to be considerate of how each hospital is staffed (e.g., larger academic hospital needs an onsite team as virtual did not work)
• Consider how to schedule due to control of quarantine
  • Performing a system-wide daily staff symptom check after team members tested positive for COVID-19
  • Leadership is encouraging honesty about symptoms and testing

Care Delivery

• Consider what it means to deliver palliative care with social distancing
• Everyone is now wearing scrubs, which are left at work

Team Wellness

• Acknowledge lack of respite from COVID; issues affect team members professionally and personally
• Many team members do not have 'down time' at home, because they are coping with family members who have lost jobs or with caring for children or family members with disabilities without normal support structures

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