Palliative Care Collaboration With Oncology Amplifies During COVID-19 Pandemic

For the treatment of patients with cancer during the ongoing corona virus disease 2019 (COVID-19) pandemic, Aberdeen Mehta, MD, MPH, says, “Palliative care is not a luxury; it is a necessity.” Mehta’s statement is based on first-hand experience of working in a COVID-19 palliative care service established to provide better and safer care for inpatients who are positive for COVID-19 and to protect patients and providers who do not have COVID-19.

In a paper published in JAMA Oncology, Mehta et al. revealed that early research on COVID-19 suggested that patients with active cancer are at high risk, but there are ways to minimize the impact and reduce the spread of the disease, including consulting with palliative care specialists who can balance the burden placed on oncologists and other members of a multidisciplinary care team.

The issue with the heightened need for palliative care specialists during the pandemic is that palliative care specialists are experiencing challenges of their own, including trying to understand the changes in their role, how to collaborate with other care teams, prescribing medications, communicating with caregivers, and having limited personal protective equipment.

In an interview with Targeted Oncology, Mehta, associate clinical professor, Palliative Care Program, Department of Medicine, UCLA Medical Center, discussed his experiences practicing palliative care in patients with cancer during the COVID-19 pandemic and how new care plans may continue even after the curve flattens.

TARGETED ONCOLOGY: We know that patients are highly susceptible to COVID-19. How is this different or even amplified in the palliative care setting?

Mehta: Even before COVID-19 happened, a lot of oncology patients in palliative care were matched very closely. At our hospital, for example, we have a specific cancer-related service for palliative care because the burden of cancer from people regarding how it affects their quality of life that they have is impacted by the disease itself and so do the treatments on top of that. Already, these patients were at high risk of distress and of being connected with palliative care for those services. COVID-19 amplified some of those needs and a lot of the barriers that patients had of getting to cancer-related treatments; having to protect themselves against the COVID-19 just amplified traditional palliative care.

TARGETED ONCOLOGY: Can you discuss the changes in recommendation that have been introduce in palliative care recently? Has it been challenging to adhere to these changes during this time?

Mehta: Every institution has been finding their way of coping, managing, and using the workforce that they have available to them. Every palliative care team at institutions is slightly different, but the core team is often similar in the sense that it's interdisciplinary. There’s a physician, social worker, or case manager, and a chaplain. All of those parties are still involved in the care of patients after COVID-19 began. The challenge has been trying to figure out how the team will work together while still having to be physically separated.

One way that we’ve adjusted, in our hospital, is we're no longer able to see patients as a multidisciplinary unit at the same time. Instead, we have team phone calls, and the physician is usually the one who is going to the patient’s bedside, or the physician’s assistant or the nurse practitioner. We've been trying to maximize the use of those services and keep our other teammates safe by just having them make more phone calls or conduct video meetings. For patients and caregivers, we've adjusted our structure in that way also.

Another way that we’ve adjusted is by having a COVID-19-related palliative care service specifically.We have 1 provider dedicated only to the COVID-19 patients and consults so that they can stay more isolated, and we're not spreading the risk to our other patients who don't have COVID-19.

TARGETED ONCOLOGY: What are the key challenges and questions that palliative care professionals have? What are some potential solutions to these problems?

Mehta: We have had a lot of questions about ourselves as providers about how our roles will evolve. As consultants, a lot of times we tried to minimize the amount of burden on patients and the primary care teams. As a field, we’ve trying to understand how much exposure to patients with COVID-19 [we] should be having so that we don't harm our patients by spreading disease and that we don't contract it ourselves.

We expect this disease to be around for a while, so we ultimately want to know how we can provide the best palliative while COVID-19 is still around. We know that as palliative care professionals, we're still essential. In fact, [we are] more essential. People have heard the phrase palliative care more recently than ever before.

As we explored some of these questions, I think that provided opportunities for developing these different kinds of care. We are still supporting our patients even though we can’t see them in person. The ability to conduct video visits with patients is also helpful.

TARGETED ONCOLOGY: What advice can you give to community oncologists about dealing with her teammates from multiple disciplines during this time?

Mehta: We must continue to advocate for interdisciplinary practice. As a community oncologist, it can often feel like you’re doing a lot of extra work. Some patients need palliative care or advanced care service and being able to provide resources sometimes falls on the oncologists themselves. I think it's really important to recognize that the primary care services that oncologists provide are important and very much in parallel to what specialty palliative care provider would do. In this time of COVID-19, having some of those early emergency plans in place with your patient is key.

I've spoken to a few of our patients in the clinic, and we talked about an emergency plan. We also need a secondary plan. I think that's very important. I would encourage that even with the scope of practice that oncologists have to do to manage their patients that they do early emergency planning for their patients related to the treatments they need and applications for those treatments.

TARGETED ONCOLOGY: As the COVID-19 curve flattens and practices and hospitals fully reopen, what lasting impact would you say this experience will have on the way the palliative care field works with patients?

Mehta: We’ve all been talking about this. I certainly know I found a number of silver linings to the new practice. Recently, while I was on the COVID-19 service, I had several patients, who had previous admissions to the hospital, tell me that this was the most communication they had had throughout their care. I think some of those opportunities to communicate a little more regularly and a little more closely with patients will be valuable. That’s something I would like to continue and see continued [by my peers].

In the pandemic emergency, there were a lot of laws that got passed quickly that impacted the ability for providers to bill for services like telephone visits and video visits as well as being able to do prescription refills or new patient visits using video. I think if those laws remain, they will be a huge advantage, [especially] for patients who are quite isolated from health care services.

_Reference:

_{Mehta AK, and Smith TJ. Palliative Care for Patients With Cancer in the COVID-19 Era. JAMA Oncol. Published online May 7, 2020. doi:10.1001/jamaoncol.2020.1938}