The palliative care program at Ochsner Health in New Orleans, Louisiana is an inpatient program that also has a small outpatient practice.

This is a snapshot of the palliative care program's involvement in Ochsner Health's COVID-19 response, based on an interview with Susan Nelson, MD, System Chair, Palliative Medicine, on March 27, 2020. At the time of the interview, Ochsner Health had moved from conventional to contingency level of care.

Organizational Context for COVID-19

  • Louisiana State Hospital Crisis Standard of Care Guidelines in Disasters written in 2011, revised in 2019 based on lessons from Hurricanes Katrina and Rita (2005) and H1N1 pandemic planning (2009); plan developed and vetted by 136 different stakeholders including consumers
  • Only the Louisiana governor has authority to authorize “Crisis Standards of Care”, based on nine specific criteria
  • Ochsner's system-wide crisis strategy was developed in collaboration with emergency services, intensivists, surgical specialties, pediatrics, hospital medicine, ethics, legal, and palliative care
  • Community Planning
    • Hospice and home health services limited by lack of PPE, although more PPE is expected to arrive shortly
    • Due to past experience with crisis care, very collaborative approach statewide
    • Working to increase capacity in post-acute settings and move patients who are stable
    • Working with post-acute partners to develop COVID-only facilities
    • Moving hospitalized transplant service to an alternate, but appropriate, location to protect those patients

Role of Palliative Care in COVID-19

  • Palliative care staff review all COVID-positive patients or Patients Under Investigation (PUI) in the hospital from oldest (most at risk) to youngest
    • Ensure a contact number for someone to call for updates and review advance care planning (ACP) documents, if filed (chart reviews)
    • Work with inpatient teams regarding symptom management
  • Provide just-in-time learning with information, education, and CAPC resources (CAPC's clinical tools have been put on Ochsner's COVID SharePoint)
  • Facilitating completion of ACP documents and goals of care
    • ACP coordinator is directing Respecting Choices educational initiatives, and working with high-risk patients to clarify their goals of care
    • Palliative care team offering front line communication with families
    • Helping patients who are stable get out of the hospital to a safe environment
  • Real time consultants
    • Daily rounds to divide the work and be useful
    • Providing algorithm for care and improving comfort-focused treatment order sets
      • Dyspnea – dosing of opioids
      • Cough – dosing of useful medications
  • Staffing and teamwork
    • Palliative care workload has increased, so the team recruited other people to help (e.g., neurology, primary care, and pediatrics)
    • Other Ochsner physicians who have palliative care training have been redeployed to help inpatient teams with symptom management and goals of care discussions

Note: Palliative care census is higher than usual given COVID-positive patients, though the team is seeing a lower volume of “typical” patients because referring partners are focused on COVID-19 response. The children’s team does not have their normal volume or intensity, so they are helping with adults.

Advice from Palliative Care Leadership

Messaging

  • Words matter; develop a script and messaging so all clinicians are consistent (e.g., withdrawal of life-sustaining treatments vs. withdrawal of life sustaining care; comfort-focused treatments vs. comfort-focused care)
  • Coach all health care team members and mentor new learners with scripting and common sense

Preparation

  • Review crisis standards of care from other states and institutions
  • Review current patients, and clear the hospital of stable patients to prepare for COVID-19 patients
  • Plan for COVID+ post-acute facilities; it is unknown what the rehabilitation of survivors will look like

Collaboration

  • Be present for other teams' morning huddles; let them know palliative care is willing to help


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