The palliative care team at Knox Community Hospital in Mount Vernon, Ohio provides inpatient palliative care to a 99-bed critical access hospital and has a small home-based practice in a rural community.

This is a snapshot of the the palliative care program's involvement in Knox Community Hospital's COVID-19 response, based on an interview with Adonyah Whipple, MSN, AGCNS-BC, APRN, ACHPN, Palliative Care Coordinator and Palliative Clinical Nurse Specialist, on May 1, 2020. At the time of the interview, COVID-19 was present in the community, but the hospital had not encountered as many cases as expected and was considering the possibility of a delayed COVID-19 spread.

Organizational Context for COVID-19

  • The hospital convened a group to consider the ethical considerations of the incident command plan, including:
    • Collaborating with legal counsel and critical care physicians to develop a plan for scarce critical care and allocations
    • Using Truog et al. NEJM article, White et al. JAMA article, Ohio state guidelines, and Indiana state guidelines to frame the document
    • Planning for 3-4 times the hospital's normal capacity
  • Care in community settings:
    • Extended care facilities (ECFs) still accepting non-COVID-19-positive patients, even with restricted visitor policy (ECFs following a protocol of two negative COVID-19 tests before accepting a resident)
    • Community providers include one private hospice with limited PPE, and a larger corporate home health/hospice with more resources, which translates in variable ability to take palliative care and hospice patients on any given day

Role of Palliative Care

  • Palliative care leadership was involved in hospital planning as palliative program leader
    • Participated in Ohio Hospital Association meetings with other ethicists around the state to review Ohio’s guidelines for resources, which both provided a rural and palliative care perspective and allowed connection with the regional palliative care community and health care experts from whom to seek advice
  • Seeing all inpatients whether they have COVID-19 or not
  • Successfully working with the two local hospices in real-time communication about access
    • Lack of shared EHR meant using a centralized Google document
    • Palliative care leader enters daily discharge needs: diagnosis, COVID-19 positive or negative
    • Hospices enter their daily availability to take patients in real time
  • Palliative care team moved all home-based patients to telehealth (routine checks delegated from the APRN to the RN)
  • Clinical partnerships are flexible according to daily need; palliative care does daily inpatient rounding to be present and supportive for all patient care teams
  • Team focused on determining surrogate decision-makers for Knox patients
  • Disseminating just-in-time palliative care information (such as CAPC tools) to the hospital and community
  • Fostering proactive advance care planning skills in the PCPs

Note: the palliative care census has been lower than average during COVID-19.

Advice from Palliative Care Leadership


  • In a small community, collaboration and communication is essential due to lack of resources
    • In conventional times, able to tap into larger regional and state hospitals, but during the COVID-19 pandemic, this is not possible, and the critical access hospital can feel isolated
  • Understand regional and state guidelines, and get involved with planning groups
  • Consider emotional and physical exhaustion, and work together to support community and staff

Clinical Care

  • Be creative, because transfers to regional centers will not be able to happen
  • Knox Palliative Care's plan for a group of patients who need end-of-life care but cannot be discharged:
    • Convert a hospital conference room into a small COVID-19 unit
    • Use hospice nurses to provide care so that the small palliative care team is not overburdened
  • Expand capacity by forming a bank of volunteer nurses from the community to help as needed through the hospital

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

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