A NEW ONLINE GUIDE provides tips to help oncology and other clinicians navigate the difficult and distressing communications with patients that have arisen during the COVID-19 pandemic.
Anthony Back, MD
Anthony Back, MD, a medical oncologist and palliative medicine specialist at the University of Washington and Co-Director of the Cambia Palliative Care Center of Excellence, Seattle, offered an overview of the guide—COVID-Ready Communication Skills: A Playbook of VitalTalk Tips—in a virtual plenary session of 2020 Annual Conference of the American Psychosocial Oncology Society (APOS).1
PROJECTIONS from the UW Institute for Health Metrics and Evaluation suggest that nationally, the COVID-19 pandemic will result in shortages of thousands of acute care and intensive care unit beds and possibly more than 100,000 deaths. “As we ramp up into the peak days of this pandemic, we are going into a situation that, honestly, I don’t think any of us have ever seen before. Certainly, not in my lifetime or over 30 years practicing as a physician, have I seen anything that approaches this kind of disaster planning and challenge,” Dr. Back commented. “It brings with it some special issues related to how we practice, how we communicate, and how we take care of ourselves as clinicians.”
Dr. Back continued: “We are seeing a group of patients who are diagnosed with COVID-19 and go rapidly downhill: admitted one day, on high-flow oxygen the next day, intubated the day after, cardiovascular collapse the next day.” This pattern contrasts sharply with the typical trajectory of even advanced cancer.
Compounding matters is the need for and shortage of personal protective equipment as well as the associated stress of balancing professional responsibilities with personal risk of infection, reminiscent of the early years of the HIV epidemic. “Besides the issue of not having the right equipment for yourself, the other issue that it creates is a kind of distance between us and our patients. As we communicate with people, that’s something we are going to need to intentionally counterbalance,” Dr. Back advised.
Conversations About Difficult Topics
IN DEVELOPING THE GUIDE, Dr. Back and colleagues with VitalTalk, a nonprofit foundation that disseminates clinician skills training for serious illness, focused specifically on what to say, as the majority of clinicians involved in care for serious illnesses often prefer a more practical, less reflective approach to such content. “We are trying to model ways to talk about difficult things,” he said. “As experienced communicators, you all know this is just the first level of accomplishment in communication, but now we are in a situation that needs rapid adaptation.”
The guide covers 11 topics spanning the care continuum and includes 4 demonstration videos. Certain topics are especially relevant to the oncology population. For example, the “Preferencing” topic addresses the situation in which medically compromised patients may now wish to opt out of hospitalization, because they likely would not survive a severe COVID-19 episode.
Clinicians should undertake a limited review of existing advance directives specific to the pandemic, according to Dr. Back. “I would focus on proactive planning for COVID-19 without revisiting the entire advance directive,” he recommended. Top priorities are ensuring that surrogate decision-makers have been identified and that wishes for end-of-life care are clear.
The current situation presents a “moment of opportunity,” even for patients who have not wanted to talk about these documents, added Dr. Back. “The pandemic is prompting many people—those who are healthy and those living with a serious illness—to think about what might happen in a worst-case medical scenario in a way they never have before.”
The guide’s “Resourcing” topic addresses the potential situation in which shortages force clinicians and patients to allocate and even ration beds, equipment, interventions, and drugs.
Concerns among patients with advanced cancer that they may be denied limited resources are likely valid, according to Dr. Back. “Many crisis standards and local groups who are making these plans are not going to prioritize people with advanced cancer,” he explained. Clinicians can address patients’ anxiety about this possibility by ensuring they are taking safety precautions, have put their affairs in order, and have considered how and where they wish to spend their last days (in the comfort of their own home or in an unusually chaotic hospital).
“Health-care professionals experience not only anxiety and stress during the pandemic, but also the later psychological fallout of being first responders.”— Anthony Back, MD
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Certain guide components are flagged for use solely under crisis (surge) conditions, Dr. Back pointed out. That was done because communication issues will differ as the pandemic unfolds, with institutions progressing from usual care to contingency care (in which they prepare for an influx of patients with the stretching of resources that are still adequate) to crisis or surge care (in which resource demand outstrips supply and resource allocation is explicit and common).
Saying Goodbye, Remotely
MEDICAL CENTERS vary in their current pandemic-driven policies regarding allowing family members and others to be at the bedside of dying loved ones. At some centers, goodbyes are now taking place remotely, by telephone or video conference, to limit the spread of the virus.
“In normal circumstances, we would never prevent a family member from coming into a patient’s room, but we are in an extraordinary time,” Dr. Back commented. “The idea of dying away from their families is one of the hardest things to get our heads around. That will undoubtedly add to our personal and professional trauma. This situation is a setup for moral distress: the sense that you knew the right thing to do but could not do it.”
However, much of the psychological process of saying goodbye—preparing, delivering the message, and having it received and witnessed by another person—can still take place without being in the same room. “Psychosocial clinicians are the ones who will understand that principle and not miss the opportunity for some of those things to happen in the moment. Things are going to be so rushed and chaotic that there will be a tendency to say, ‘Oh, it’s not important, let’s just skip it.’ As all of you know, it’s super important. You can’t skip it—if you skip it now, you do so at your own peril for the aftermath and consequences later.”
Psychological Fallout for Clinicians
“FOR ALL OF YOU in psychosocial care, this pandemic is going to be a huge shift. All the nuances of a personality, of a family system, of a relationship with that patient will fall away under crisis standards of care, and decisions about who gets a ventilator, for example, will be made on purely medical grounds,” Dr. Back said. “The reality is that many of these triage decisions are going to be very tough.”
In developing the guide, he interviewed professionals involved in the responses to 9/11, Hurricane Katrina, and the Haitian earthquake. “What they all tell me is that this is practicing on a different planet, and for some clinicians, it is very, very hard to adjust to,” he commented. Past disasters suggest that health-care professionals experience not only anxiety and stress during the pandemic, but also the later psychological fallout of being first responders. In fact, some have sequelae lasting for years, with symptoms similar to those of posttraumatic stress disorder: hyperarousal, rumination, persistent regret, and flashbacks.
Psychosocial professionals will therefore also be key in supporting their colleagues, Dr. Back commented. “One of the proactive things we can do is to create communities within our settings now, where doctors, nurses, and other clinicians can start to learn and relearn how to provide support to each other,” he advised.
“Psychological and psychosocial care is—and of course has always been—regarded as one of the first things to go because people think it’s a luxury. One of the things this pandemic is going to prove to us all is that psychological care is not a luxury; it is a mainstay of how we all live our daily lives,” concluded Dr. Back. “It will be up to all of us to figure out how we advocate for that in our institutions. Leadership’s ears may be a little bit more open after this.”
DISCLOSURE: Dr. Back is cofounder of VitalTalk (vitaltalk.org).