The COVID-19 pandemic presented unprecedented challenges for healthcare services. The provision of the Palliative Care Consultancy Service at Western Health, a major metropolitan health service in Melbourne, Australia, was no exception.
During 1 April – 30 September 2020, a retrospective audit revealed a total of 65 deaths from COVID-19, with 50 patients referred to the Palliative Care Consultancy Service. The majority of these patients (41) were seen by Clinical Nurse Consultants (CNCs).
There are many rewards of palliative care nursing; not least of which is the human connection to patient, carer/family and relationships built with care providers. COVID-19 necessitated significant changes in this practice as CNCs navigated new ways of working as separate teams and communicating with families via virtual interactions.
To reduce risk of COVID-19 transmission to other wards and limit the impact of team exposure; CNCs divided into two working groups at two separate sites and only worked on the COVID-19 wards for two weeks at a time. Cross campus travel was forbidden.
Staff on the COVID-19 wards faced significant pressures and challenges. The CNC’s role became focussed on imparting decades of skills in minutes. CNCs endeavoured to prepare junior doctors for discussions regarding end of life care and handling emotive conversations. Palliative Care provision for COVID-19 patients focused on ensuring teams knew how to access prescribing guidelines available online, providing symptom management and end of life care, whilst supporting ward staff.
A major challenge for the CNCs was donning personal protective equipment (PPE) and switching to time limited interactions with patients dying from COVID-19. Repeated visits were often performed indirectly with the nurse caring for the patient and through observation.
Patients dying from COVID–19 were frequently referred late in their illness. The median time from referral to death being three days, leaving little time to build up any rapport with families. Most families were negatively impacted by hospital visitor restrictions with a majority of patients dying alone.
PPE became a visible barrier between patients, families and hospital staff. Families who visited were not familiar with donning PPE and were often afraid and anxious of becoming infected.
CNCs are experts in preparing families for dying and face-to-face bereavement support. This practice was impacted during COVID-19 as visiting bans and restrictions led to more virtual interactions. Treating teams and social workers took on the role of providing updates to families. Further contacts with families from the CNC team were met with varied responses and were often filled with anger at visitor restrictions.
CNCs found it confronting to be repeatedly exposed to the level of loneliness and distress many patients on COVID and non-COVID wards expressed. Many had no visitors throughout their admission, and CNCs noted that wearing PPE was restrictive as patients were unable to see facial expressions or a comforting smile.
During the pandemic, palliative care consultancy referrals grew by 33%, not as a direct result of COVID-19, but a sicker patient demographic and decrease in length of hospital stay. The focus turned to rapid referrals and discharges to community services for symptom management and end of life care at home.
Daily debriefings became the norm across the organisation and weekly cross campus team meetings were conducted via Zoom.
CNCs at each campus noted increased bonding within their site team during the uncertainty. Virtual meetings led to a loss of camaraderie and heightened isolation, with each team relying on each other rather than the overall team for support.
One CNC had to self-isolate at home, which required a role change to data entry, referral writing and virtual multidisciplinary team meetings, and led to feelings of guilt and disconnection from the team.
CNCs noted numerous stressors during the pandemic from working with heightened levels of patient, family and staff emotional distress, constantly changing guidelines and working environment. Repetitive actions of removing clothes and shoes and showering on arrival home for fear of becoming infected and bringing COVID-19 home, social isolation, and home schooling, had a cumulative effect on CNC stress levels.
Repetitive COVID screening whenever patients on non COVID wards exhibited COVID-19 like symptoms or failed to divulge potential exposure, also heightened anxiety.
Learnings from the pandemic were the need to build greater connections across separated teams and staff working at home and to focus more on self-care.
Positively, existing relationships with the Aged Care Team and COVID-19 wards strengthened during the pandemic through shared clinical responsibilities, collaborative education sessions and mutual support.
We wish to acknowledge our clinical colleagues at WH who continue to provide dedicated care to patients during the pandemic and beyond. Caring for patients dying from COVID-19 remains a privilege.
Anita Haines, RGN,GradCertEd, GradCertMgt. is a Team Leader, Palliative Care Consultancy Service, Western Health, Victoria
Kirsten Mitchener, RN, MP is a Clinical Nurse Consultant. Palliative Care Consultancy Service, Western Health, Victoria
Loretta Williams, BHlthSc, GrDcert is a Palliative Care Clinical Nurse Consultant, Palliative Care Consultancy Service, Western Health, Victoria.
Marianne Phillips, BHlthSc, PgDAdvClinCancer, is a Clinical Nurse Consultant, Palliative Care Consultancy Service, Western Health, Victoria.
Fiona Grimaldi, BHealthScN is a Clinical Nurse Consultant, Palliative Care Consultancy Service, Western Health, Victoria
Margaret Shaw, RN is a Clinical Nurse Consultant, Palliative Care Consultancy Service, Western Health, Victoria