End‐of‐life care during the <scp>COVID</scp>‐19 pandemic—What makes the difference?

Abstract

The novel coronavirus SARS-CoV-2 (COVID-19) has rapidly led to a global pandemic, with a second and third wave following the first, presenting a hitherto unprecedented challenge for critical care staff. Intensive care units (ICUs) and corresponding health care professionals have been overwhelmed in almost all countries across the globe.1 Current estimates indicate that ~10% of patients with COVID-19 will develop a severe disease, such as Acute Respiratory Distress Syndrome (ARDS), and require intensive care.2 Although older adults represent a high-risk group with increased mortality—like other patients with comorbidities such as diabetes and cardiac disease3—young people without pre-existing illnesses are also severely affected.1 During this pandemic, rapid and constantly evolving end-of-life decisions are needed. These decisions are influenced by factors such as judicious allocation of ICU beds due to scarce resources, acute life-threatening illnesses, unknown COVID-19 disease progression, and unexpressed end-of-life wishes. Due to severely restricted visitation policies, it is more difficult to involve relatives directly. This has a major impact on the relatives' end-of-life involvement and their consequent grieving process, resulting in mental health problems, such as depression, anxiety, complicated grief, and symptoms of post-traumatic stress disorder.4 These symptoms have been described by the term “post-intensive care syndrome - family” (PICS-F).4 Moreover, the exponential progression of the pandemic, with a sudden and substantial increase in ICU health care professionals' workload, requires a focus on patient care. This may lead to relatives feeling neglected or as if they are only involved at a late and final stage of a patient's ICU life. In the face of these unprecedented challenges, there is no single correct approach to end-of-life care. Nevertheless, an in-depth examination of this subject is important for clinical practice. Therefore, the aim of this commentary is to (a) describe end-of-life care and decision-making structures and processes on ICUs, (b) explore their relevance in COVID-19, and (c) identify recommendations for practice during a pandemic. During the COVID-19 pandemic, non-COVID patients are still admitted to ICUs. It is important not to forget these patients and their relatives. Depending on the severity of their illness and condition, an end-of-life discussion is also needed for these patients and relatives. These relatives, who are already under considerable strain, now have the additional worry of their weakened family member contracting a COVID-19 infection while in the hospital. Furthermore, relatives of dying and deceased patients may experience a severe grief reaction with intense yearning or separation distress.14 Therefore, it is also important to consider providing help for these relatives in their grief, by facilitating follow-up visits to the ICU or through psychological or spiritual support. However, it is important to meet the individual needs of the relatives.15 Providing end-of-life care for ICU patients during a pandemic is challenging. Individualizing end-of-life care is crucial even in a pandemic. Existing feasible concepts must be combined with pandemic-adapted concepts to allow patients to die gracefully in the ICU.