Pandemic Palliative Care Consultations Spanning State and Institutional Borders

Abstract

To the Editor: Many critically ill patients with 2019 coronavirus disease (COVID-19) need specialty-level palliative care to manage symptoms, conduct goals of care conversations, and facilitate medical decision making in ethically and emotionally charged situations. During the apex of the COVID-19 crisis in New York, the Adult Palliative Care Service at Columbia University Irving Medical Center (CUIMC)/NewYork-Presbyterian (NYP) received a sevenfold increase in consultation requests. This unprecedented increase in demand outpaced the palliative care team’s ability to respond. We describe the rapid development and implementation of a scalable virtual consultation model staffed by out-of-state palliative care specialist volunteers. Under Governor Andrew Cuomo’s executive order,1 administrative leadership at NYP facilitated a fast-track licensing and credentialing process for out-of-state palliative care specialists within a few days. Volunteer physicians were recruited from the University of California San Francisco (UCSF), Stanford University, and Dartmouth-Hitchcock. To ensure a high level of expertise requiring minimal quality control, volunteers were required to be experienced palliative care clinicians holding active board certification status in hospice and palliative medicine. Once credentialed, the volunteer physicians completed a rapid orientation process including use of the hospital’s electronic medical record, the palliative consultative workflow procedures, and were briefed about the organizational culture. Cases were selected for staffing by off-site consultants based on a number of criteria. First, patients were primarily intubated/sedated or otherwise unable to participate in conversation with clinicians. This allowed for the remote consultant to conduct all conversations with family members who themselves were not able to visit the hospital due to restrictions related to COVID-19. Second, cases were selected where the reason for consultation was clarification of goals of care, as opposed to symptom management or transition planning that require in-person assessment and management by clinicians with knowledge of local resources. Third, cases selected for remote consultants were generally high-complexity cases; lower complexity cases were reserved for home institution trainees. Unlike the 24-7 PAlliaTIve Care Help line (PATCH-24) intervention, which was primarily focused on providing onetime palliative care consultations in the emergency department,2 our intervention was focused on critically ill patients, some of whom were intubated for weeks. Indeed, given the evidence that onetime palliative care led consultations for critically ill patients are ineffective,3 we felt this population required a longitudinal approach. Key quality control processes included ongoing case monitoring by CUIMC palliative care physicians, periodic weekly or biweekly joint service check-ins to troubleshoot workflows and debrief experiences, and frequent relaying of feedback from primary inpatient care teams, as well as from patients and family members. The COVID-19 pandemic has created significant challenges for healthcare systems, especially in hard-hit areas. One of these challenges is to meet the dramatic increase in demand for specialty-level palliative care services created by the sudden surge of critically ill patients. These circumstances have led to new opportunities for palliative care colleagues in different institutions to collaborate in unprecedented ways. The cross-pollination experienced in the course of the model described here provided a humbling reminder of the mutual benefit that accompanies extramural collaboration. Our experience with providing high-quality specialist-level palliative care spanning institutional, state, and perhaps even national borders can serve as a model for other sites during this pandemic. Underserved racial and ethnic minorities and immigrant or displaced communities have been especially hard hit in crisis times, and the current pandemic is no exception.5 Unfortunately, palliative care is one of the subspecialty areas to which these populations routinely experience diminished access.6 Collaborative efforts such as the one described here may prove critical in meeting demand for palliative care with greater equity and justice across our systems and societies. Looking forward, this collaborative model may also serve as a guide for meeting palliative care needs during non-pandemic times in resource-limited settings, where access to specialist-level palliative care may be limited. Consideration should be given to the extension of policies to facilitate nationwide licensure and universal credentialing created in states of emergency, so the feasibility and ease of providing these palliative care consultative services across institutional and state borders can continue into the future beyond the current crisis.7 The authors have declared no conflicts of interest for this article. All authors contributed to conceptualizing, drafting, and revising this work. No specific funding was received for this work.

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