End-of-life care during Covid-19: Tips for GPs
Advice from Professor Mayur Lakhani, past RCGP president and former chair of the National Council for Palliative Care
End-of-life and palliative care implications of Covid-19
Tips for GPs on how to prepare for Covid-19 deaths, by Professor Mayur Lakhani
As of 29 March 2020, the UK has seen 19,522 cases of coronavirus, with 1,228 deaths. A surge of cases is expected in the next two weeks, which, sadly, will claim more lives. More people will get pneumonia and may not recover even with the best treatment. Although it is gruesome to talk about this scenario, we must do by planning the future care of patients on the GP list if they are frail and in chronic poor health.
I appreciate that practices are working extremely hard at these tough times. I am proud of the leadership that GPs, practice managers, and primary care networks clinical directors have shown. For this they deserve thanks. This end-of-life care ask might thus be seen as yet another demand adding to workload; however, I would urge everyone to engage with this plan and see this as part of the national effort.
Aims of a Covid-19 palliative care plan
The aims of a Covid-19 palliative care plan in primary care is fivefold:
- To continue to support non-COVID-19 patients at the end of life in the community
- To anticipate the discharge of, and provide care to dying patients with COVID-19 in their preferred place of care
- To support families and communities who may need enhanced support including bereavement
- To play a part in supporting local health economies and specialist colleagues and to ensure a safe approach for staff by minimising the risk of infection during home visits when absolutely essential.
The key message is: Think ahead – be proactive: create, update, and share more advance care pans for vulnerable patients
1. Ensure every patient on the end of life register (GSF) has an up-to-date advance care plan including resuscitation status and ceilings of care. In some areas this is through the use of ReSPECT plans. This is particularly necessary for those with an amber (few weeks life expectancy) or red (last two weeks of life) prognosis
2. Ensure that all patients with severe frailty have had an up to date review (desktop +/- remote) with an updated frailty* status (or score) added to their advance care plan.
3. Ensure that every vulnerable patient has a consent status for eSCR (enhanced summary care records* - automatic searches are available to do this.
4. Ensure every care home resident has an up to date desktop/remote review and an advance care plan in place.
5. Any admission from a care home or a severely frail patient will need to be discussed individually with a geriatrician prior to conveyancing (except for fracture, or other similar emergencies). More information is available here for care home management: https://www.bgs.org.uk/resources/covid-19-managing-the-covid-19-pandemic-in-care-homes
6. Ensure the practice register is as complete as possible by identification of vulnerable groups using the SPICT guidance www.spict.org.uk/. Particular groups to examine are those with severe heart failure, severe COPD, dementia.
7. Have key discussions about preferences including: DNACPR, merits/demerits of hospital admission, treatment ceilings e.g. ventilation. Update plans and issue anticipatory medication (prioritise amber and red patients). Add contact information of professionals who can be called by urgent care services for advice and support.
8. Be prepared to support discussions about advance directives. You may get more requests to discuss Advanced Decision to Refuse Treatment (ADRT); sometimes called a living will.
Patients can also write their own ‘living wills’ (https://mydecisions.org.uk/).
9. Collaborate with local services to ensure pathways are clear for:
a. Non COVID 19 and EOLC – maintain a good standard of care – usual care but with more remote working
b. Discharge of COVID -19 patients to die in PPD – COVID-19 specific protocols
c. Procedures for EOLC patients with COVID 19 in the community
d. Protocols for home visiting where this is strictly necessary e.g. to set up syringe drivers. First line assessment should be video consultation and or telephone calls.
e. COVID-19 triage of all requests for help from households where there is an EOLC patient including inquiry of other residents for pertinent symptoms
10. Be aware of and be prepared to support families whose loved ones are very ill in hospital and where clinicians have to make very difficult decisions for admissions to critical care (ITU). Please be aware of the NICE guidance that will be followed here in deciding admissions to ITU:
11. Develop skills and try out technology to consult remotely with patients and/or to speak to community staff. If you have a method that works, this is fine. If not, an approved standalone method is suitable for use by any clinicians and is approved by the NHS (NHS.net email needed)
Ideally use video where possible, by health care professionals known to the patient and handle sensitively. Prior notification is helpful. Tailor each discussion and plan to individual patients. Age alone is NOT a criterion – functional status is a key determination as indicated by the frailty status or the clinical frailty score (CFS which is used in hospital) or the Karnofsky Performance Status: https://www.mdcalc.com/karnofsky-performance-status-scale.
12. Shielding advice
Note this important caveat from HM Government advice on shielding and Group One patients
‘We also suggest that anybody with a terminal diagnosis who is thought to be in their last 6 months of life should be excluded from (shielding) this group (unless they wish to be included), to allow them to maintain contact with their loved ones during the last phase of their illness’.
13. Support for upskilling in difficult conversations and management of clinical issues specific to COVID 19:
- COVID 19 specific training:
- General Training:
- LOROS Webpage for GPs:
14. Death certification
The government has issued and passed legislation to stream line the requirements for death certification and cremation. It is essential that GPs are aware of the latest guidance:
- mean a coroner is only to be notified where a doctor believes there is no medical practitioner who may sign the death certificate, or that they are not available within a reasonable time of the death
- enable electronic transmission of documents that currently have to be physically presented in order to certify the registration of a death
- remove the need for a second confirmatory medical certificate in order for a cremation to take place
15. Implantable Cardioverter defibrillators (ICDs/CRT-D): These should be recorded on ReSPECT. If somebody is in last weeks of life consider discussing deactivation of shock function of ICD to avoid painful and distressing shocks which are not going to improve clinical picture. There are many GPs who already do this well. It’s not specific to COVID-19. The BHF has good patient leaflet deactivating shock function of ICD