Palliative Resources for Managing Progressive Life-limiting Conditions (COVID and non-COVID)

1. “Regular” Palliative Care, COVID negative (proven with testing)
   • If home visit needed, use PPE: take precautions to protect yourself, patient and family: surgical mask, gloves and wash hands ++.
   • Reassess if new symptoms that could be COVID related arise, order test* and use PPE while waiting test results.
   • Disease symptoms may mimic COVID symptoms (e.g. dyspnea, delirium, fever) that  cancer-related fever). When in doubt don PPE if home visit.
   • If patient on any aerosol generating procedure-AGMP (e.g. CPAP, BiPAP see Oxygen Supplies below), use PPE with N95 respirator.
2. Requiring Palliation for COVID Disease (COVID positive or suspected)
   • Use PPE if home visit needed. (see criteria link next page) •Get testing* done to confirm if COVID suspected (ir pt cannot leave home
   • Urgent COVID Goals of Care discussions (see resource page).
     • What Matters Most conversation guide
     • What Matters Most patient guide
   • Provide patient and family information (e.g. disease trajectory)
   • Family need PPE and need to be trained on it (home care to help)
3. Requiring Palliative care for cancer or advanced disease but COVID status not known or COVID positive or suspected)
   • Manage as if number 2 above (COVID Positive)
   • Order testing*

*Home testing if patient cannot leave home. Otherwise patient to go to assessment centre)

Ideally, all patients receiving home care and all providers providing home care should be tested (and retested if new symptoms or new contacts)

Please see Hamilton’s Public Health current policies on testing

• Virtual visit is the default, unless nature of care requires in-person visit. See HFAM for tips (how to, billing codes, etc)
  • Assessment, Diagnosis and Management of COVID
  • Billing and Coding
• Consider home visits if:
  • Physical examination needed
  • New moderate to severe dyspnea or agitation
  • Rapid deterioration
  • Symptoms not responding to usual measures
  • Inadequate information to assess functional status and overall status
  • Home care not yet involved or unable to assess.

For home testing (if pt home bound)

Call Public Health to book patients for swab: (905) 974-9848/(905) 645-0105.

– physician or NP has to have screened patient first, determined eligibility with Public Health criteria

Public Health will then send out EMS to do (likely next day)

Testing centre if patient mobile and can leave home

When and how to use PPE (use in all COVID positive or suspected patients, and whenever in doubt or status unknown)

To get PPE:
Hamilton PPE and Office COVID-Related Equipment Suppliers

Hamilton HFT has a supply of surgical masks available to Hamilton primary care practices. To arrange pick-up, please call tel: 905 667 4848.

If practices are really challenged to source PPE they can access a 3 day emergency supply from Ontario West Urgent Pandemic PPE Supply.

Information on PPE use (Hamilton Family Medicine)
Safety and Equipment

How to don and doff PPE at the home when it is needed:

• Home Visit PPE Full Procedure
• HFAM Safety and Equipment

To identify needs related to cancer or end-stage organ disease

• Complete Edmonton Symptom Assessment Scale with patient (in-person or virtually) (Found in Step 2 “Assess” in OPCN Palliative Care Toolkit)
• Assess Functional Status; Palliative Performance Scale (Found in Step 2 “Assess” in OPCN Palliative Care Toolkit)
• Patient self-assessment (provide this link to patients and families it teaches them how to use the ESAS and self assess their symptoms)
• All domains of care (symptoms, social, psychological, spiritual) (see page 5 of Canadian Hospice Palliative Care Association Model to Guide Hospice Palliative Care)
• More detailed information at OPCN Palliative Care Toolkit

To identify needs related to COVID Disease

• Assessment and overall management
• Common symptoms needing palliation: Breathlessness, cough, fever, delirium
• Assess other domains as above.
• Use ESAS to assess symptoms as well

Assess grief-related needs of patients (anticipatory) and family

See attached Symptom Management page

See attached Dyspnea Protocol

• Ensure you are on the OHIP Palliative Care Facilitated Access List (If you are collaborating with a palliative care physician or NP, they can order these. Otherwise, see note below)
• Any pharmacy can provide meds, but only Calea has the regional LHIN contract to also provide supplies.
• For supplies need to contact HNHB LHIN at 1-800-810-000 (May take from 4 to 24 hrs to get to the home once ordered, so be pro-active and order sooner than later)
• Pharmacies include
  • Calea: 1 855 842 3560 or (905) 624-1234 A/H: 1-855-664 6971 (close at 6:30pm)
  • Marchese: P: (905) 528-4214; F: (905) 570-0496
  • Shoppers Drug Mart: P: (905) 387-8656;  F: (905) 387-4901

If Rapid Symptom Response Medications and Supplies Needed (kit) (you will need to fax form to LHIN at 1-866-655-6402). May also call  HNHB LHIN at 1-800-810-000

• Emergency meds to get you over the next 24 – 48 hrs
• For info on criteria, ordering and info for family
  Order Form

If medication or supply changes:

Need to be faxed to

1. the pharmacy, AND
2. the LHIN if supplies like needles needed (see Meds and Supplies box)

OHIP Palliative Care Facilitated Access List

If you are not on  the PCFA prescriber list you  may be able to obtain case-by-case access to the PCFA high-strength long-acting opioid drug products (morphine 200 mg SR Tabs and ER Caps, hydromorphone 24 mg and 30 mg CR Caps, fentanyl 75 mcg/hour and 100 mcg/hour Transdermal Patches) for patients requiring palliative care by contacting the EAP’s Telephone Request Service (TRS). The Telephone Request Service is available between 8:30 am to 5:00 pm Monday to Friday (excluding statutory holidays) and can be reached by calling the Drugs and Devices Division toll-free at 1-866-811-9893. Select the TRS option when prompted. The physician will indicate working with the palliative care services (PCOT, Erin Gallagher, CPOC groups). The approval duration will be granted for up to 12 months for requests meeting the specified criteria.

• Prior restrictions on home oxygen therapy qualifications and funding are being waived during the pandemic
• Several providers
  • VitalAire Order Form
  • ProResp Order Form

For patents with COVID the aim is to keep O2 saturation between 92% but not above 96% for best outcomes for COVID-19.  This can help agitation and confusion. For other symptom management and management of dyspnoea please see the other sections in this palliative symptom management resources pathway.

You can obtain a pulse oximeter for patients who do not have one here.

Evidence for Oxygenation targets

Current NIH guidelines for oxygenation targets in COVID-19 are congruent with local GIM advisers recommendations and state:

“The optimal oxygen saturation (SpO₂) in adults with COVID-19 is uncertain. However, a target SpO2 of 92% to 96% seems logical considering that indirect evidence from experience in patients without COVID-19 suggests that an SpO2 <92% or >96% may be harmful.”

In one trial of ventilated patients with COVID-19 and ARDS, those randomised to a lower target range (88-92%) had poorer outcomes and a higher mortality rate. However this trial has been assessed by the McMaster Evidence Review group as high risk of bias so the evidence remains uncertain.

Regarding the potential harm of maintaining an SpO2 >96%, the NIH guidance refers to a meta-analysis of 25 randomized trials involving patients without COVID-19 found that a higher SpO2 was associated with an increased risk of in-hospital mortality compared to a lower SpO2 comparator (relative risk 1.21; 95% CI, 1.03–1.43).

Is PPE Needed?

Some Oxygen delivery treatments are Aerosol Generating Medical Procedures (AGMP) and require PPE with N95 masks, face shield, etc. E.g. BiPAP, CPCA, high flow oxygen, any nebulized treatment, etc. See the following resource for information on oxygen delivery devices and when PPE is needed: https://www.gghorg.ca/wp-content/uploads/2020/04/Personal-Protective-Equipment-and-AGMP.pdf

Questions to ask patient/family member

• Are you connected with home care? If Yes,
  • Who is your home coordinator? Do you have their 24/7 contacts?
  • What nursing agency is providing home care for you? One or many nurses? Do you have their contact?
  • How often is home care nursing coming in? Is it adequate?
• Any help from family or friends? How quickly can you access that help?
• Are you and your family managing in the home?
• Have you had discussions about what your care goals are? What are your wishes if you were to become seriously ill?
• If COVID +ve: Does the family feel safe? Adequate information re PPE? Access to PPE? Information on how to get PPE if COVID +ve?
• If death is expected, what is the desired place of death? (Discuss  home vs hospice vs palliative care unit  (PCU) vs hospital? Visitation limitations in place. Hospices or PCU  not admitting COVID +ve patients

Please see the Serious Conversations Illness Guide or our Advance Care Planning page.

• Determine if home care nursing in place
  • If YES: get from patient or LHIN the name and 24/7 contact # of LHIN Case Manager for patient, and Nurse Agency providing nursing care (name and 24/7 contact #)
  • If Home Care not in place:
    • Complete and submit LHIN Home Care Referral Form
    • LHIN information sheets
    • OHIP Home Care and LTC Billing Codes

For palliative care in general

Canadian Virtual Hospice

For COVID related palliation

• Coach on when to call you or home care, signs to look for, contacts, when to call EMS
• ACP and GoC material (see Speak Up Otario) for info for yourself and for patient and family (and templates to complete eg POA)

Caregivers supports and information on how to provide care •

• Hospice Palliative Care Ontario
• How to care for a person with COVID-19 at home: Advice for caregivers

If Unable to be cared for at home any further:

Reasons

• Care and/or equipment needs exceed what home care can provide.
• Family exhausted or no family supports
• Inform family about visitation restrictions in hospitals and hospices

If COVID-19 POSITIVE or STRONGLY SUSPECTED

• Contact Hamilton General Hospital to have patient transferred directly to the ED or COVID Unit ……… 
• Or call EMS PPOST Team to transport patient to hospital ED. Call ahead to hospital ED to inform them of situation.

IF COVID-19 NEGATIVE (proven with test- See “Testing”) and patient is end-of-life (last days)

• Contact the LHIN for any referrals to the 2 Hamilton hospices (requires prognosis of days to weeks) and St. Peter’s Hospital Palliative Care Unit (any prognosis).
• For transfer to a hospice, a persons must be tested and be negative. St. Peters PCU will admit if low probability of COVID disease (and will test patient upon admission).
• The two hospices require Allow Natural Death (DNR)(aka DNR) designation.
• St Peters may on a case-by-case basic consider patients who do not have COVID symptoms or suspected disease but have not been tested. St Peters does not on-site ED or ICU and 911 has to be called if a patient desires CPR. AND therefore preferred.
  1. Good Shepherd Emmanuel House Hospice
  2. Dr Bob Kemp Hospice
  3. St Peter’s Hospital Palliative Care Unit (PCU)

TO REFER a patient to a hospice or PCU:

Call the LHIN at  905-523-8600  or 1-800-810-0000

Prepare ahead when a home death is the goal. If possible, don’t wait for when death is imminent (within hours or days).

• Ensure DNR-C form in place.
• Complete “Letter of understanding of expected home death.” This allows nurse to pronounce (need a link here). Document sent to the family physician by the LHIN (if home care is involved) to indicate preference for who is to pronounce death of a patient in the home (nurse or physician). Nurse may pronounce, then funeral home will collect body, and MRP to complete the death certificate and get it to the funeral home within 24 hours.
• Family to identify a funeral home and have their contact information ready.
• Educate family: Not to call 911. Call the nursing agency, LHIN or MRP (family physician). 

Prepare early when a home death is the goal. If possible, don’t wait for when death is imminent (within hours or days).

• See HFAM for information
• Nurse may pronounce if “Letter of Understanding” had been completed.
• Then call funeral home to collect body (unless death unexpected in which case coroner to be contacted before body moved). Notify funeral home if a patient is a confirmed or probable case of COVID-19 or if a family member is a known or probable case.
• All probable or confirmed deaths due to COVID-19 are to be reported by the attending physician or nurse practitioner to their local public health offices. Where the death is due to a probable diagnosis, Public Health Ontario has asked that the body be swabbed and the swab sent to Public Health.
• Death certificate not needed for funeral home to collect body.
• MRP or NP then has 24 hrs to complete death certificate and hand it to funeral home.
• Death Certificate
• See OPCN link on how to completed death certificate for COVID death.
• Reporting COVID deaths to coroner is NOT required unless a death is unexpected or otherwise meets the requirements for reporting that have previously been in place (e.g. surgery or recent fall/injury) .(In LTC all deaths have to be reported to coroner)
• Coroner: 1 (855) 299-4100 ot 1-416-314-4100.