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Palliative Care Consultation in Hospitalized Patients With COVID-19: A Retrospective Study of Characteristics, Outcomes, and Unmet Needs

  • Santiago Lopez
    Correspondence
    Address correspondence to: Santiago Lopez, MD, Site Director, Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, New York 11030, USA.
    Affiliations
    Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA
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  • Kayla D. Finuf
    Affiliations
    The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
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  • Allison Marziliano
    Affiliations
    The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
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  • Liron Sinvani
    Affiliations
    Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA

    The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
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  • Edith A. Burns
    Affiliations
    Division of Geriatrics and Palliative Medicine, Department of Medicine, Zucker School of Medicine at Hofstra Northwell, Manhasset, New York, USA

    The Feinstein Institute for Medical Research, Center for Health Innovation and Outcomes Research (CHIOR), Department of Medicine, Northwell Health, Manhasset, New York, USA
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      Abstract

      Context

      Few studies have described the characteristics and palliative care needs in hospitalized patients with coronavirus disease 2019 (COVID-19).

      Objectives

      Describing characteristics, consultation demands, patients’ needs, and outcomes of hospitalized patients with COVID-19 who received a palliative care evaluation.

      Methods

      Retrospective chart review of patients (aged 18+ years) with COVID-19 admitted to an academic quaternary center and seen by the geriatrics and palliative medicine team from March 1st to May 11th, 2020. Socio-demographics, operational metrics, severity of illness, goals of care-advanced care planning documentation, and outcomes were analyzed.

      Results

      Three hundred seventy-six (17.6%) out of 2138 COVID-19 admissions were seen by the consultation team. Compared with prepandemic situation (September 1st, 2019, to February 29th, 2020), overall new consults (205 vs. 371, P < 0.001) significantly increased, particularly in the intensive care unit (ICU; 9.5% vs. 36.9%, P < 0.001). For the COVID-19 population, median age was 78 years (interquartile range, 70-87; range, 36-102); 56% were male. LACE score, D-dimer, and C-reactive protein suggested severe disease and increased risk of mortality. Seventy-five percent of consults were for goals of care-advanced care planning, and 9.6% for symptoms. During the index admission, 7.1% had documented advanced directives, and 69.7% became do not resuscitate. Of all deaths, 55.5% were in the ICU, and 87.2% were aged ≥65 years. Underserved minority patients had a disproportionate mortality. Overall consultation mortality (38.3% vs. 70.4%, P < 0.001) and ICU mortality (55.2% vs. 78.1%, P < 0.001) significantly increased compared with those before COVID-19.

      Conclusion

      During this pandemic, understanding inpatient specialized palliative care needs and the vulnerable populations driving these causes may encourage health-care agencies and local, state, and federal governments to support the dedicated palliative care workforce.

      Key Words

      Key Message

      This study reports one of the largest retrospective studies of coronavirus disease 2019 (COVID-19) patients seen by an inpatient palliative care team. We describe the characteristics of this population, the surge and unsustainable demand for specialized palliative care resources (particularly in the ICU), and the social disparities among these patients.

      Introduction

      In 2010, James Downar and Seccareccia described the basic needs for “Palliating a Pandemic.” In his article, he described strategies for having providers, locations, and medications available to deliver palliative care for patients that may become critically ill or that were to die because of a pandemic.
      • Downar J.
      • Seccareccia D.
      Associated medical services Inc. Educational Fellows in care at the end of life
      Palliating a pandemic: “all patients must be cared for”.
      Although the field of palliative care has grown during the last decade, “with teams present in 85% of medium/large hospitals in the US,” there is still a great imbalance between patients in need of palliative care services and the available specialized palliative care work force.
      • Kamal A.H.
      • Bull J.H.
      • Swetz K.M.
      • Wolf S.P.
      • Shanafelt T.D.
      • Myers E.R.
      Future of the palliative care workforce: Preview to an Impending crisis.
      Experts in the area have estimated the ratio of patients in need of palliative care to palliative physicians in the U.S. is 808:1. The current coronavirus disease 2019 (COVID-19) pandemic has highlighted and magnified the imbalance in need-to-workforce ratio.
      On March 18, 2020, there were 7038 cases of COVID-19 in the U.S. and up to 97 deaths. By July 1st, 2020, this number had increased to 2,624,873 confirmed cases and 127,299 deaths.
      CDC COVID Data Tracker
      Centers for disease control and prevention.
      ,
      COVID-19 Map. Johns Hopkins Coronavirus Resource Cent.
      This left no time for creating a “Palliating a Pandemic” plan, and palliative care teams in this country needed to quickly respond with spur-of-the-moment strategies to provide attention for patients significantly affected by this pandemic. Mortality rates have been especially high among hospitalized patients with certain risk factors: older age, cardiovascular disease, diabetes, chronic respiratory illness, hypertension, cancer—especially when they require ventilator support.
      • Richardson S.
      • Hirsch J.S.
      • Narasimhan M.
      • et al.
      Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area [published correction appears in JAMA. 2020 May 26;323(20):2098].
      • Wu Z.
      • McGoogan J.M.
      Characteristics of and important Lessons from the coronavirus disease 2019 (COVID-19) Outbreak in China: summary of a report of 72 314 cases from the Chinese center for disease control and prevention.
      • Cummings M.J.
      • Baldwin M.R.
      • Abrams D.
      • et al.
      Epidemiology, clinical course, and outcomes of critically ill adults with COVID-19 in New York City: a prospective cohort study.
      Death rates for patients requiring mechanical ventilation have been reported as high as 76.4% for those aged 18 to 65 years and up to 97.2% for those aged 65 years and older,
      • Richardson S.
      • Hirsch J.S.
      • Narasimhan M.
      • et al.
      Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area [published correction appears in JAMA. 2020 May 26;323(20):2098].
      ,
      • Auld S.C.
      • Caridi-Scheible M.
      • Blum J.M.
      • et al.
      ICU and ventilator mortality among critically ill adults with coronavirus disease 2019.
      ,
      • Twigg 3rd, H.L.
      • Khan S.H.
      • Perkins A.J.
      • et al.
      Mortality rates in a diverse cohort of mechanically ventilated patients with Novel coronavirus in the Urban Midwest.
      although these reports did not control for confounding factors such as functional status among older adults.
      Owing to these high mortality rates, patients with COVID-19–associated complications would benefit from complex symptom management, dedicated goals of care discussions (GOC), and psychosocial and spiritual support not only for themselves but also for family members and caregivers.
      • Richardson S.
      • Hirsch J.S.
      • Narasimhan M.
      • et al.
      Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City area [published correction appears in JAMA. 2020 May 26;323(20):2098].
      Specialized palliative care focuses on these complex needs and should be considered a fundamental part of managing these patients. However, most of the current literature describing palliative care and COVID-19 has focused on the development of a framework to respond to the pandemic, rather than directly addressing actual patient needs and the impact palliative care may have during this crisis.
      • Etkind S.N.
      • Bone A.E.
      • Lovell N.
      • et al.
      The role and response of palliative care and Hospice services in Epidemics and pandemics: a rapid review to Inform Practice during the COVID-19 pandemic.
      • Radbruch L.
      • Knaul F.M.
      • de Lima L.
      • de Joncheere C.
      • Bhadelia A.
      The key role of palliative care in response to the COVID-19 tsunami of suffering.
      • Ting R.
      • Edmonds P.
      • Higginson I.J.
      • Sleeman K.E.
      Palliative care for patients with severe covid-19.
      • Keeley P.
      • Buchanan D.
      • Carolan C.
      • Pivodic L.
      • Tavabie S.
      • Noble S.
      Symptom burden and clinical profile of COVID-19 deaths: a rapid systematic review and evidence summary.
      • Petriceks A.H.
      • Schwartz A.W.
      Goals of care and COVID-19: a GOOD framework for dealing with uncertainty [published correction appears in Palliat Support Care. 2020 Aug;18(4):510].
      There are few studies describing the population of COVID-19 inpatients seen by palliative care teams, the demand for services, or how palliative care resources have been able to meet these needs.
      • Lovell N.
      • Maddocks M.
      • Etkind S.N.
      • et al.
      Characteristics, symptom management, and outcomes of 101 patients with COVID-19 referred for hospital palliative care.
      ,
      • Lee J.
      • Abrukin L.
      • Flores S.
      • et al.
      Early intervention of palliative care in the emergency department during the COVID-19 pandemic.
      Drawing from a large series of COVID-positive adults admitted to an inpatient medical service at an academic, quaternary care hospital in New York State, we describe the complexity of patients seen by palliative care teams: demographics, comorbid conditions, severity of illness (e.g., LACE score, C-reactive protein [CRP] and D-dimer, intensive care usage), mortality, and requests for and services provided by the inpatient palliative care consult team.

      Methods

      Population and Timeframe

      A retrospective chart review was conducted of COVID-19 patients seen by the geriatrics and palliative medicine (GAP) consult service at the highest admitting center of the largest health-care system in New York State.
      • Dyrda L.
      100 of the largest hospitals and health systems in America: 2019: Becker's Hospital Review compiled 40 large health systems by number of hospitals and 60 large hospitals by bed count.
      The work was approved by the COVID-19 Research Consortium, and the institutional review board judged it to be of minimal risk and exempt from informed consent.
      Electronic medical records from March 1st to May 11th, 2020, corresponding to the first surge of the COVID-19 pandemic in this geographic area, were accessed.
      COVID-19: Data
      COVID-19: data main - NYC health.
      Patients aged ≥18 years with a positive nasopharyngeal polymerase chain reaction test for COVID-19, hospitalized, and seen by the GAP team were included. Clinical course and end results were monitored until August 5th, 2020. Electronic medical record from a comparison group of patients seen by the palliative team during the pre-COVID-19 period, September 1st, 2019, to February 29th, 2020, were accessed to compare operational metrics and outcomes (e.g., clinical load, illness severity, and mortality). Data were collected from the enterprise electronic health record (Sunrise Clinical Manager; Allscripts).

      GAP Consultation Team

      The GAP consult team included 5 fulltime equivalent (FTE) board-certified palliative care specialized M.D.s, 2 FTE nurse practitioners, a dedicated social worker and a chaplain.

      Data Elements

      Demographic and clinical data included age, gender, race, and medical comorbidities. ZIP code was used as a surrogate marker of underserved population status. Data elements related to palliative care included prior documentation of GOC and advanced care planning (ACP) before index admission, code status, orders for palliative care consultation and follow-up notes, and dedicated palliative care social work/chaplaincy referrals. Illness severity was assessed with the LACE index (calculated with length of stay [LOS] during the index admission, acuity of admission [emergency room vs. elective], Charlson Comorbidity Index, and the number of emergency department visits within the last 6 months).
      • Heppleston E.
      • Fry C.H.
      • Kelly K.
      • et al.
      LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge.
      LACE score predicts readmission and mortality within 30 days of discharge, with a score ≥10 increasing the risk of death within 6 months of discharge by 6.8-fold among all ages.
      • Heppleston E.
      • Fry C.H.
      • Kelly K.
      • et al.
      LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge.
      Additional laboratory data including CRP and D-dimer levels were collected. CRP values above 4.38 mg/dL were considered a marker of severe disease,
      • Wang L.
      C-reactive protein levels in the early stage of COVID-19.
      ,
      • Wang G.
      • Wu C.
      • Zhang Q.
      • et al.
      C-reactive protein level may predict the risk of COVID-19 Aggravation.
      and a D-dimer level >1000 ng/mL is associated with increased mortality.
      • Zhou F.
      • Yu T.
      • Du R.
      • et al.
      Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study [published correction appears in Lancet. 2020 Mar 28;395(10229):1038] [published correction appears in Lancet. 2020 Mar 28;395(10229):1038].
      Owing to difficulty verifying the fidelity of data, no other laboratory values were collected. Orders for mechanical ventilation and pressors were also analyzed. Operational metrics (e.g., volume and timing of service delivery) including LOS, time from admission to palliative consult (order logged; date of first consult note), time from consult to discharge, and mortality were examined.

      Analysis

      Frequencies were calculated for categorical data, and descriptive statistics (average, standard deviation, median, interquartile range [IQR], range) were used for continuous variables. Outcomes/operational metrics categories were compared between consults seen during the peak of COVID-19 (i.e., April 2020) and six months before COVID-19. Student's t-test or Mann-Whitney U for continuous data and χ2 or z-ratios for proportions for categorical data were used to compare. Analyses were performed using jamovi (version 1.2), a program that works in tandem with R Statistical Software (The jamovi project, 2020).

      Results

      Overall COVID-19 vs. Palliative Care Consultation Metrics

      During the period between March 1st and May 5th, 2138 patients were admitted with a diagnosis of COVID-19. Of these, 435 (20.3%) were admitted to the intensive care unit (ICU). The GAP team was consulted on 376 cases out of the 2138 total admitted (17.6%). Over 76% of these initial consults (n = 288) and 395 follow-up visits were completed during the month of April (peak of COVID-19 in New York State; Figs. 1 and 2).
      COVID-19: Data
      COVID-19: data main - NYC health.
      A large number, 184, were seen in the ICU (48.9% of the total number of consults seen by the GAP team). Up to the study's end, median time from admission to consult was 5 days (IQR, 2-12), and from consult to discharge, 5 days (IQR, 2-11). Median LOS was 10.5 (IQR, 7-21) days for patients seen by the GAP team, and overall median ICU LOS was 14 days (IQR, 5.3-22). For comparison, monthly operational metrics and main outcomes for COVID-19 and non–COVID-19 cases seen during this study time frame are presented in Table 1. As noted in the methods, at the end of the study period, LOS, consult-to-discharge, and disposition were not available for 58 patients (40 were still in the ICU). However, their poststudy outcomes are presented in Table 2.
      Figure thumbnail gr1
      Fig. 1Relative frequency of COVID-19 metrics comparing New York State with study site. Relative frequencies were calculated as the ratio between the number of cases per day and the total number of cases during the study period. The month of April represents the highest increase in relative frequencies for COVID-19 new consults, follow-up visits, and ICU admissions which correlates with the highest increase in relative frequencies for COVID-19 cases and hospitalization in New York State. Notice also that when the curve for New York State cases drops, the operational metrics for the study site also decrease.
      Figure thumbnail gr2
      Fig. 2Relative frequency of COVID-19 metrics comparing New York State with study site. Relative frequencies were calculated as the ratio between the number of cases per day and the total number of cases during the study period. As also seen in , case frequencies for mortality data reach its peak during the month of April for both New York State and the study site.
      Table 1Operational Metrics/Outcomes for COVID-19 and Non–COVID-19 Cases Seen by the GAP Team (March 1st to May 11th, 2020)
      Up to May 11th, for 58 patients, from which 40 were still in the ICU, outcomes such as consult to discharge, disposition, and LOS were not available because they had not completed their hospital course. However, their outcomes were followed up to August 5th, 2020, and they are presented on Table 2.
      Operational Metrics/OutcomesMarch 2020, No. (%)April 2020,
      Peak of COVID-19 in NYC.19
      No. (%)
      May 1st–May 11th, 2020, No. (%)
      No. of consults/mo18737151
      No. of COVID-19 consults/mo53 (28.3)288 (77.6)35 (68.6)
      No. of follow-up visits/mo41050656
      No. of COVID-19 follow-up visits/mo91 (22.2)395 (78)36 (64.3)
      Overall admission to consult, median355
      COVID-19 admission to consult, median457.5
      Overall consult to discharge544
      COVID-19 consult to discharge55.74
      Overall LOS
      LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      11129
      Overall COVID-19 LOS
      LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      101210.5
      Overall ICU LOS
      LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      111316
      ICU COVID-19 LOS
      LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      101417.5
      Any ICU stay37 (19.8)136 (36.7)19 (37.3)
      Any COVID-19 ICU stay30 (16)136 (36.7)18 (35.3)
      All mortality102 (54.5)243 (65.5)31 (60.7)
      Any COVID-19 mortality44 (23.5)197 (53)24 (47)
      All ICU mortality30 (16)105 (28.3)18 (35.3)
      Any COVID-19 ICU mortality25 (13.4)105 (28.3)17 (33.3)
      Abbreviations: COVID-19 = coronavirus disease 2019; GAP = geriatrics and palliative medicine; LOS = length of Stay.
      a Up to May 11th, for 58 patients, from which 40 were still in the ICU, outcomes such as consult to discharge, disposition, and LOS were not available because they had not completed their hospital course. However, their outcomes were followed up to August 5th, 2020, and they are presented on Table 2.
      b LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      c Peak of COVID-19 in NYC.
      COVID-19: Data
      COVID-19: data main - NYC health.
      Table 2Outcomes up to August 5th, 2020, for Patients With COVID-19 Seen by the GAP Team that Were Still Hospitalized at the End of the Study Period
      Operational Metric/OutcomesNo (%)
      No.58
      No. of follow-up visits44
      Consult to discharge average31
      LOS,
      For this study, hospice, refers to an insurance benefit provided in the U.S. for patients believed to have a terminal illness process (with a possible life expectancy of less than 6 months) and where disease-modifying treatments are not possible or looked for by the patient. This benefit provides support services that are delivered by a multidisciplinary team and that focus on improving quality of life. Hospice care is provided wherever a patient resides.
      average
      41.9
      Any ICU stay40 (69)
      All mortality22 (37.9)
      All ICU mortality17 (29.3)
      Discharge disposition
       Home7 (12.1)
       Rehabilitation center22 (37.9)
       Nursing home0
       Expired22 (37.9)
       Home with hospice
      For this study, hospice, refers to an insurance benefit provided in the U.S. for patients believed to have a terminal illness process (with a possible life expectancy of less than 6 months) and where disease-modifying treatments are not possible or looked for by the patient. This benefit provides support services that are delivered by a multidisciplinary team and that focus on improving quality of life. Hospice care is provided wherever a patient resides.
      3 (5.2)
       Inpatient hospice
      Inpatient hospice care refers to services provided by this insurance program, in a specialized facility, for patients having intractable symptoms that otherwise cannot be provided wherever they reside.
      1 (1.7)
       Other1 (1.7)
       Admitted2 (3.4)
      Abbreviations: COVID-19 = coronavirus disease 2019; GAP = geriatrics and palliative medicine; LOS = length of stay; ICU = intensive care unit.
      LOS begins with admission time and ends with discharge time, time of death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      a For this study, hospice, refers to an insurance benefit provided in the U.S. for patients believed to have a terminal illness process (with a possible life expectancy of less than 6 months) and where disease-modifying treatments are not possible or looked for by the patient. This benefit provides support services that are delivered by a multidisciplinary team and that focus on improving quality of life. Hospice care is provided wherever a patient resides.
      b Inpatient hospice care refers to services provided by this insurance program, in a specialized facility, for patients having intractable symptoms that otherwise cannot be provided wherever they reside.

      Demographics and Outcomes

      Demographic and medical characteristics of COVID-19 patients seen by the GAP team are presented in Table 3. Median age was 78 years (IQR, 70-87; range, 36-102), 56% were male, 47.3% were white, 17.8% Hispanic or Latino, and 13% were African American. Most patients were English-speaking; however, up to 10% were Spanish speakers, and over 20% of these patients resided in underserved areas.
      • Wang G.
      • Wu C.
      • Zhang Q.
      • et al.
      C-reactive protein level may predict the risk of COVID-19 Aggravation.
      Median LACE score was 11 (IQR, 9-13), and median D-dimer and CRP at the time of consult were 1832 ng/mL and 12.9 mg/dL, respectively. Mechanical ventilation and pressor support were common among these patients (Table 3).
      Table 3Demographic Characteristics and Illness Severity Markers of Patients Hospitalized With COVID-19 Seen by the GAP Consult Team
      Demographic InformationNo. (%)
      Total no.376
      Age, median (IQR) [range]78 (70-87) [36-102], y
       Sex
       Male212 (56)
       Female164 (44)
      Race
      Race and language data were collected by self-report in prespecified fixed categories.
       White178 (47.3)
       Asian40 (10.6)
       African American49 (13)
       Other/multiracial4 (1.1)
       Unknown105 (27.9)
      Ethnicity
      Race and language data were collected by self-report in prespecified fixed categories.
       Hispanic or Latino67 (17.8)
       Non-Hispanic or Latino301 (80.1)
       Unknown8 (2.1)
      Language
      Race and language data were collected by self-report in prespecified fixed categories.
       English292 (77.7)
       Spanish38 (10.1)
       Other46 (12.2)
      Underserved population
      Medically underserved areas/populations are areas or populations designated by Health Resource and Service Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.20
      77 (20.5)
      Underserved population race
      Race and language data were collected by self-report in prespecified fixed categories.
      ,
      Medically underserved areas/populations are areas or populations designated by Health Resource and Service Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.20
       White16 (20.8)
       Asian5 (6.5)
       African American24 (31.2)
       Unknown32 (41.5)
      Underserved population ethnicity
      Race and language data were collected by self-report in prespecified fixed categories.
      ,
      Medically underserved areas/populations are areas or populations designated by Health Resource and Service Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.20
       Hispanic or Latino24 (31.2)
       Non-Hispanic or Latino50 (64.9)
       Unknown3 (3.9)
      LACE, median (IQR)
      LACE index evaluates length of stay (L), acuity of the admission (A), comorbidity of the patient (C) and emergency department use in the duration of 6 months before admission. It predicts short-term and long-term frequent admissions and short-term and medium-term mortality with a score ≥10 increasing the risk of death within 6 months of discharge by 6.8-fold among all ages.21
      11 (9–13)
      CRP mg/dl, median (IQR)12.9 (6.2–22.6)
      D-dimer ng/ml, median (IQR)1832 (656.3–3419.3)
      Any pressors191 (50.8)
      Mechanical ventilation
      Defined as any patient with any other for intubation or mechanical ventilation.
      196 (52.1)
      Discharge disposition
      Discharge disposition up to May 11th. Follow-up discharge disposition for patients still admitted to the hospital after May 11th are presented on Table 2.
       Home24 (6.4)
       Rehabilitation center20 (5.3)
       Nursing home0 (0.0)
       Expired243 (64.6)
       Home with hospice
      For this study, hospice, refers to an insurance benefit provided in the U.S. for patients believed to have a terminal illness process (with a possible life expectancy of less than 6 months) and where disease-modifying treatments are not possible or looked for by the patient. This benefit provides support services that are delivered by a multidisciplinary team and that focus on improving quality of life. Hospice care is provided wherever a patient resides.
      8 (2.1)
       Inpatient hospice
      Inpatient hospice care refers to services provided by this insurance program, in a specialized facility, for patients having intractable symptoms that otherwise cannot be provided wherever they reside.
      19 (5.1)
       Other4 (1.1)
       Admitted58 (15.4)
      Abbreviations: COVID-19 = coronavirus disease 2019; GAP = geriatrics and palliative medicine; IQR = interquartile range; CRP = C-reactive protein.
      a Race and language data were collected by self-report in prespecified fixed categories.
      b Medically underserved areas/populations are areas or populations designated by Health Resource and Service Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.
      c LACE index evaluates length of stay (L), acuity of the admission (A), comorbidity of the patient (C) and emergency department use in the duration of 6 months before admission. It predicts short-term and long-term frequent admissions and short-term and medium-term mortality with a score ≥10 increasing the risk of death within 6 months of discharge by 6.8-fold among all ages.
      • Heppleston E.
      • Fry C.H.
      • Kelly K.
      • et al.
      LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge.
      d Defined as any patient with any other for intubation or mechanical ventilation.
      e Discharge disposition up to May 11th. Follow-up discharge disposition for patients still admitted to the hospital after May 11th are presented on Table 2.
      f For this study, hospice, refers to an insurance benefit provided in the U.S. for patients believed to have a terminal illness process (with a possible life expectancy of less than 6 months) and where disease-modifying treatments are not possible or looked for by the patient. This benefit provides support services that are delivered by a multidisciplinary team and that focus on improving quality of life. Hospice care is provided wherever a patient resides.
      g Inpatient hospice care refers to services provided by this insurance program, in a specialized facility, for patients having intractable symptoms that otherwise cannot be provided wherever they reside.
      Overall total and ICU mortality for the COVID-19 population were 448 (21%) and 226 (52%), respectively. The GAP team consulted on 265 (59.2%) of the total number of patients that died from COVID-19; this resulted in the 70.5% mortality rate of all COVID patients seen in palliative consultation. Over half of these cases expired in the ICU. The GAP team consulted on 147 (65%) of the 226 ICU mortalities. Most of these deaths, 86.4%, occurred in patients aged ≥65 years (IQR, 69-86; range, 37-102); 68% were male. One hundred twenty-two (46%) of these patients were identified as white, 51 (19.2%) as Hispanic or Latino, and 32 (12.1%) as African Americans. Finally, there were 59 (22.2%) patients that died and were both part of minorities and underserved areas (Table 4).
      Table 4Mortality of Patients Hospitalized With COVID-19 Seen by the GAP Consult Team up to Last Date of Follow-up (August 8th, 2020)
      Number Survivors and NonsurvivorNo. (%)
      Total376
      All mortality265 (70.5)
      Age mortality, median (IQR) [range]77 (69-86) [37-102]
      ICU mortality147 (55.3)
      Race
      Race, ethnicity, and language data were collected by self-report in prespecified fixed categories.
      mortality
       White122 (46)
       Asian28 (10.6)
       African American32 (12.1)
       Other/multiracial2 (0.8)
       Unknown/secline81 (30.6)
      Ethnicity
      Race, ethnicity, and language data were collected by self-report in prespecified fixed categories.
      mortality
       Hispanic or Latino51 (19.2)
       Non-Hispanic or Latino208 (78.5)
       Unknown6 (2.3)
      Language
      Race, ethnicity, and language data were collected by self-report in prespecified fixed categories.
      mortality
       English202 (76.2)
       Spanish29 (11)
       Other34 (12.9)
      Underserved
      Medically underserved areas/populations are areas or populations designated by Health Resource and Service Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.20
      population mortality
       White12 (4.5)
       African American14 (5.3)
       Hispanic/Latino20 (7.5)
       Other/unknown25 (9.4)
      Abbreviations: COVID-19 = coronavirus disease 2019; GAP = geriatrics and palliative medicine; IQR = interquartile range; ICU = intensive care unit.
      a Race, ethnicity, and language data were collected by self-report in prespecified fixed categories.
      b Medically underserved areas/populations are areas or populations designated by Health Resource and Service Administration (HRSA) as having too few primary care providers, high infant mortality, high poverty, or a high elderly population.

      Reasons for Palliative Care Consultation

      Seventy-five percent of consults seen by the GAP team were for GOC or ACP, 9.6% for symptoms, and 15.2% for both. Only 27 (7.1%) of these patients had a previously documented advanced directive. During the index admission, 69.7% became do not resuscitate.

      Palliative Care Services Rendered

      Of the referred patients, 14% were seen by the palliative care social worker, and 7.7% by the GAP team dedicated chaplain. Specialized palliative care social work services were active in assessing social needs, rapport building, providing active listening and emotional support, referring for resources (e.g., bereavement, home health aide hiring), and facilitating audiovisual communication between patients and families (which was limited because of COVID-19 inpatient visitation guidelines). Chaplaincy referrals were predominantly virtual, using audiovisual platforms to provide emotional, existential, and spiritual support for patients and families.

      Pre-COVID vs. COVID-19 Operational Metrics

      During the pre-COVID pandemic period, the GAP team saw a median of 205 (IQR, 197-215) new consults and completed a median of 2 (IQR, 0-4) follow-up visits per patient. Median time to consult and consult-to-discharge were 4 and 7 days, respectively. Median LOS was 12 days, and overall consultation mortality was 38.3%. The median number of consults in the ICU was 19.5 (9.5%). The typical patient seen by the GAP team was aged >65 years (77.2% of all consults), and about 40.9% were of racial/ethnic minorities.
      Operational metrics compared between the two time periods (six months before COVID-19 and during COVID-19 [i.e., April 2020]) show a significant increase in volume of new consults (204.2 vs. 371, P < 0.001), any ICU stay (9.5% vs. 36.9%, P < 0.001), overall mortality (38.3% vs. 70.4%, P < 0.001), and ICU mortality (55.2% vs. 78.1%, P < 0.001). Compared with the pre-COVID-19 time period, the April 2020 patients had lower LACE scores (13.8 vs. 11, P < 0.001), experienced longer interval from admission to consultation (6.7 vs. 8.1, P = .04), and a shorter interval from consultation to discharge (10.8 vs. 7.2, P < 0.001); number of follow-up visits was significantly lower during the pandemic (3 vs. 1.4, P < 0.001).
      Table 5 highlights the differences between the pre–COVID-19 period and the height of the pandemic. Of note, during this entire time, the number of FTEs and ancillary providers that comprised the GAP team remained the same.
      Table 5Comparison of Operational Metrics for Pre-COVID-19 and COVID-19
      Up to May 11th, for 58 patients, from which 40 were still in the ICU, outcomes such as consult to discharge, disposition, and LOS were not available because they had not completed their hospital course. However, their outcomes were followed up to August 5th, 2020, and they are presented on Table 2.
      Time Period
      Operational Metric/OutcomesPre–COVID-19COVID-19 (April)
      Peak of COVID-19 in NYC.19
      P value
      Median (IQR)MeanSDMedian (IQR)MeanSD
      Number of new consults
      P value for new consult computed using single-sample t-test with COVID-19 consults inputted as the hypothetical population mean.
      205 (197–215)204.214.9371<0.001
      LACE
      LACE index evaluates length of stay (L), acuity of the admission (A), comorbidity of the patient (C) and emergency department use in the duration of 6 months before admission. It predicts short-term and long-term frequent admissions and short-term and medium-term mortality with a score ≥10 increasing the risk of death within 6 months of discharge by 6.8-fold among all ages.21
      14 (12–16)13.8311 (9–13)112.9<0.001
      Time from admission to consult (days)4 (1–8)6.711.95 (2–13)8.19.70.04
      Consult to discharge7 (3–13)10.813.34 (2–10)7.27.9<0.001
      Median number of follow-ups per patient2 (0–4)34.41 (0–2)1.41.8<0.001
      Total LOS
      LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      12 (7–22)17.620.512 (6–20)15.313.60.08
      ICU LOS8 (3–22)15.217.213 (5–20)14.611.50.21
      No.%No.%
      Any ICU stay<0.001
       No110990.523463.1
       Yes19.5 (17.5–21.5)1169.513736.9
      In-hospital mortality<0.001
       Expired46938.326170.4
       Survived75661.711029.6
      ICU mortality<0.001
       Expired6455.210778.1
       Survived5244.83021.9
      Abbreviations: COVID-19 = coronavirus disease 2019; IQR = interquartile range; SD = standard deviation; LOS = length of stay; ICU = intensive care unit.
      P values calculated using independent samples t-test or Mann-Whitney U for continuous data and χ2 or z-ratio for proportions for categorical data.
      a P value for new consult computed using single-sample t-test with COVID-19 consults inputted as the hypothetical population mean.
      b Up to May 11th, for 58 patients, from which 40 were still in the ICU, outcomes such as consult to discharge, disposition, and LOS were not available because they had not completed their hospital course. However, their outcomes were followed up to August 5th, 2020, and they are presented on Table 2.
      c LACE index evaluates length of stay (L), acuity of the admission (A), comorbidity of the patient (C) and emergency department use in the duration of 6 months before admission. It predicts short-term and long-term frequent admissions and short-term and medium-term mortality with a score ≥10 increasing the risk of death within 6 months of discharge by 6.8-fold among all ages.
      • Heppleston E.
      • Fry C.H.
      • Kelly K.
      • et al.
      LACE index predicts age-specific unplanned readmissions and mortality after hospital discharge.
      d LOS begins with admission time and ends with discharge time, time at death, or midnight on the last day of data collection for the study. It does not include time in the emergency department.
      e Peak of COVID-19 in NYC.
      COVID-19: Data
      COVID-19: data main - NYC health.

      Discussion

      In this study, we report one of the largest series of COVID-19 patients seen by an inpatient palliative care consultation team. Overall, patients were older than 70 years, had severe disease (indicated by high LACE scores, CRP and D-dimer, ICU admission, and orders for mechanical ventilation or pressors), and high mortality. Our experience is similar to smaller studies, with the GAP team caring mainly for those vulnerable and critically ill patients affected by COVID-19. Two small case series have provided a rudimentary description of COVID-19 patients seen by palliative specialists, the interventions provided, and the therapeutic benefits resulting from specialized palliative care.
      • Lovell N.
      • Maddocks M.
      • Etkind S.N.
      • et al.
      Characteristics, symptom management, and outcomes of 101 patients with COVID-19 referred for hospital palliative care.
      ,
      • Lee J.
      • Abrukin L.
      • Flores S.
      • et al.
      Early intervention of palliative care in the emergency department during the COVID-19 pandemic.
      Our large case series allows for a more granular analysis of this population and provides a picture of the additional resource demands these patients may create on palliative care consulting teams. At time of writing, few (if any) other studies have emerged describing these elements.
      According to the United States Census Bureau, as of July 2019, 69.6%, 19.3%, 17.6%, and 9% of the population in New York State were white, Hispanic or Latino, African American, and Asian, respectively.
      U.S. Census Bureau
      QuickFacts: New York.
      These data were comparable with the population seen in our study (Table 3). Minority patients had similar demands for inpatient palliative care services as their Caucasian counterparts during the pandemic (178 [47.3] vs. 198 [52.7], P < 0.30). However, this represented a significant increase when compared with the pre-COVID time frame (40.9 vs. 52.7%, P < 0.001). Patients coming from underserved areas represented 20.5% of the COVID-19 patients seen by the GAP team, and 68.9% were minorities (Table 3). These underserved minority patients accounted for a disproportionate burden of all mortality when compared with other groups (22.2% vs. 4.5%, P < 0.001). This surge in demand for palliative care services warrants further study to determine what needs are/are not being met for these minority/underserved groups and identifying the best resources to improve care for these patients.,
      • Kirby T.
      Evidence mounts on the disproportionate effect of COVID-19 on ethnic minorities.
      Among interdisciplinary team members, palliative care social workers play an important role in addressing psychosocial aspects of critical illness.
      A National framework and Preferred Practices for palliative and Hospice care quality . NQF: a National framework and Preferred Practices for palliative and Hospice care quality.
      However, data from 2012 to 2016 show that many palliative care teams lack social workers, with availability of this fundamental aspect of care varying from 58% to 69%, respectively.
      • Spetz J.
      • DE M.
      • AH K.
      • et al.
      Few hospital palliative care programs meet National staffing Recommendations.
      , In this study, the dedicated GAP social worker was involved on 14% of palliative consultations for hospitalized COVID-19 patients. Utilization of these services may have been impacted by staffing, demand for services by non–COVID-19 patients, and personal time off to prevent burnout. The main interventions provided by the GAP team social worker were described in our methods, but further research is needed to fully appreciate the duration, frequency, and therapeutic benefit of these interventions. In the setting of a pandemic, palliative care social workers should be available to support palliative care teams and the patients they see.
      In our academic medical center, there was a greater demand for specialized palliative care for COVID-19 patients requiring ICU level of care. During the time frame of this study, 42.3% of the total hospital COVID-19 ICU patients were seen in consultation by the GAP team. At the same time, the GAP team provided consultation on 65% (147) of all COVID-19 ICU-related mortalities. These data suggest the need for creating educational strategies and partnerships between ICU and palliative care teams. As most consultations in the ICU were for GOC or ACP, strategies to improve ICU provider's skills in these discussions should be developed and tested. Having the “The Family Meeting as Therapeutic Intervention” is probably the key for developing strategies to support collaborative efforts among these teams.
      • Carney M.T.
      • Liberman T.
      The family meeting as therapeutic intervention.
      Our experience reveals a significant increase in demand for specialized palliative care services during a time of public health crisis compared with usual consult volumes (Table 5). In the month of April, the GAP team faced an 81% increase in the number of new consults, up to 83.8% increase in overall mortality, and 41.5% ICU mortality among their caseload seen in consultation. There was a 50% decrease in number of follow-up visits, which may have been the result of increased consultation demand, limited manpower, and the high mortality of the population seen. The increase in consult requests was mainly driven by a need for GOC and ACP discussions. These conversations are not an easy task and are often time-consuming and emotionally draining.,
      • Sean Morrison R.
      Advance directives/care planning: Clear, Simple, and Wrong.
      Inpatient palliative care teams faced challenging times while helping with decision-making and providing support for critically ill patients diagnosed with COVID-19 and their families. These challenges were magnified by restrictions on family visitation and the need to communicate remotely. Further studies may provide insight regarding the content, timing, and quality of such discussion. Furthermore, more research is needed to understand the burnout and/or compassion fatigue these high demands of GOC and ACP discussions may create on palliative care consult teams.
      Our existing palliative care team was able to handle the bulk of the increased demand for a limited period. However, in the long run, such a small number of skilled providers is unlikely to be able to meet continuing demands at this level. Creating sustainable staffing models is fundamental to providing effective care in these situations. Hiring per-diem providers and identifying and educating champions among other disciplines and learners are among the strategies that may improve sustainability for palliative care inpatient teams while responding to a pandemic crisis. Increasing technological resources (e.g., telehealth) and expanding billing models to finance non-face-to-face GOC and ACP encounters may also enhance the viability of inpatient palliative care teams.
      Finally, as GOC and ACP were the main reasons for consultation, palliative care teams might in the future be better supported by promoting ACP in the outpatient and community settings. Our study showed that only 27 (7.1%) of these patients had a previously documented advanced directive. In the outpatient or home settings, for patients at risk for poor outcomes - those older than 70 years, and/or with comorbid conditions (mainly cardiovascular disease, diabetes, chronic respiratory illness, hypertension, and cancer) - a more proactive approach towards GOC and ACP should be taken. As an alternative, pre-emptively encouraging these patient to have discussions with their loved ones about having a definitive “cut-off … below which percentage of chance of survival should doctors stop using machines and infinite resources to keep you alive?”, instead of when they are already facing challenging – potentially fatal – COVID-19 related complications, may better direct both inpatient providers and hospital resources. Furthermore, for this at-risk population, completing specific forms such as a Health Care Proxy, Medical Orders for Life Sustaining Treatments, or a living will should be considered. Again, education and expanded billing models are needed to achieve better ACP before hospital admission. This will also facilitate inpatient GOC discussions, decision-making for health-care proxies or surrogates, and optimize the viability of inpatient palliative care teams.

      Limitations

      This study has several limitations. First, the study population only included patients within the New York metropolitan area and, although representative of the diverse communities of the New York City's 5 boroughs and Long Island, may not be generalizable. Second, subgroup descriptive statistics were unadjusted for potential confounders. Finally, our study is a retrospective study; therefore, it is difficult to determine causal effects for the outcomes described.

      Conclusion

      The peak of COVID-19 in New York State is a perfect example of how a rapid increase in the number of patients with acute, critical illness impacts not only the need for hospital beds, ICU services, and devices but also for palliative care services. Our study describes the surge and unsustainable demand for specialized palliative care resources created by hospitalized patients with COVID-19, the social disparities among this population, and the need for better allocation of resources and support services for the multidisciplinary team of palliative care providers at the front line of this and future pandemics.

      Disclosures and Acknowledgment

      For this article, from the initial conception and planning to the present, the authors did not receive any financial support from any third parties to support the work.
      The authors are supported by the Department of Medicine, Division of Geriatrics and Palliative Medicine at Zucker School of Medicine at Hofstra Northwell; the Center for Health Innovations and Outcomes Research; and NIA, United States grant R21 NR018500, NIA, United States R21 AG061307 and NIA, United States UH3 AG060626. These funding organizations and sources played no role in the design and conduct of the study; no role in the collection, management, analysis, and interpretation of the data; and no role in preparation, review, or approval of the article and decision to submit the manuscript for publication.
      The authors would like to thank Sebastian Lopez, M.Sc., and Marta Carnelli, M.Sc., for their help with graphics; Christopher J. Magalee, AS for editing; and Zachary Klein, M.A., and Thomas A. Fasano, M.S. for providing pre–COVID-19 data.

      Data Accessibility

      All data collected for this research are available through the COVID-19 research consortium data base as well as through the palliative care dashboard created by the Krasnoff Quality Management Institute (KQMI).

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