Outpatient palliative care during the COVID-19 pandemic: a retrospective single centre analysis in Germany

COVID-19 has the highest mortality among elderly patients and those with pre-existing conditions [17]. Considering the rapidly ageing western societies, especially in Germany, there is a strong demand for palliative care structures. The number of patients under the care of our OPC service increased by 89 patients between 2019 and 2020. Therefore we calculated the average treatment days for both collectives without finding a statistically significant difference. We conclude the growing number of patients is likely not an indirect effect of the COVID-19 pandemic due to patient decisions to evade hospital admissions, but rather reflects the rising demand for palliative care in general (Table 1).

Historically, palliative care mainly focused on inpatient care such as hospice or specialised clinical palliative care wards. However, due to demographic change and medical progress a rising number of multi-morbid patients live in non-hospital institutions such as nursing homes. At the beginning of the pandemic, this patient collective in particular was in danger of contracting and dying of COVID-19 [18]. In many cases, critically ill nursing home residents with COVID-19were admitted to our university hospital for further care. Many of these patients were not treated on our intensive care unit and died subsequently in one of the designated general care COVID-19 wards (Fig. 1B).

The outpatient COVID-19 patient collective we treated included 28 patients (Table 2). Only 10 COVID-19 patients in the district of Giessen died at their homes. However, all of them were treated by our OPC service. The fact that only 2.1% of COVID-19 patients died at their homes stands in stark contrast to regularly reported patient wishes mentioned in the literature, in which approximately 60.0% of all patients hope to die at home [19, 20]. This might suggest the difficulty of making adequate end-of-life-decisions for rapidly deteriorating COVID-19 patients who were previously in a relatively good or at least stable health condition. Earlier studies have shown that COVID-19 patients often are clinically stable and then deteriorate rapidly [21]. This is highlighted by our finding, that there are significantly more patients categorised as ECOG-status 4 in the OPC COVID-19 patient collective, than in the OPC non-COVID-19 patient collective. Furthermore, 46.4% of COVID-19 patients were treated at nursing homes and 21.4% had the highest degree of care possibly assigned by their health insurance. Even though the distribution of the degree of care did not statistically differ between both groups, all these parameters indicate that most of the COVID-19 collective consisted of multi-morbid patients. However, a limitation of this study was the considerably low number of COVID-19 positive patients in our OPC service and the lack of standardised testing in patients without symptoms (debatable number of undetected COVID-19 cases among the non-confirmed COVID-19 collective). Furthermore, the number of hospitalised and deceased COVID-19 patients started to decline rapidly after the implementation of the German vaccination program in December 2020 (weekly status report of Robert Koch Institute). This was especially true for elderly and multi-morbid patients as their vaccinations were prioritized. This also explains the difference in observation time for the confirmed COVID-19 and the non-confirmed patient collective, as the vaccinations started to prevent severe COVID-19 infections.

In addition, no hospital admissions were observed in the confirmed COVID-19 OPC collective. Nevertheless, it is unclear whether well prepared ACP planning and sufficient symptom control or reduced status of health are responsible for this finding. Multimorbidity accompanied by low mobility in this collective also could offer a possible explanation for the lack of hospital admissions.

Previous studies have shown that silent hypoxia precedes respiratory failure and ultimately cardiac arrest in COVID-19 patients [21]. Therefore, OPC service providers should be well trained in palliative respiratory symptom control. In our OPC patient collective the number of emergency home visits and emergency phone calls were not significantly different among the non-COVID-19 and the COVID-19 collective (Table 2). Whether this was caused by rapid deterioration of COVID-19 patients or simply reflects equivalent symptom control in both collectives has to be further explored in order to understand the needs of palliative COVID-19 patients. Interestingly, a higher portion of the COVID-19 OPC collective could be stabilised (39.3% vs. 16.9%), which differs significantly from the regular OPC collective.

However, based on these results we can not conclude whether OPC services are able to provide equivalent care to patients with or without COVID-19. Further studies regarding effectiveness of APC programs and OPC treatment in this special collective should be considered.

Our study further shows that the majority of nursing homes did not offer structural palliative care services during the COVID-19 pandemic in 2020 although they were one of the most frequent places of death. At the same time, only a minority (40.0%) of the surveyed nursing homes had structured ACP systems in place. This demonstrates that palliative care services were not generally available in nursing homes at the beginning of COVID-19 pandemic, even though the German public health insurance system financially supported their implementation [22]. Future studies must investigate whether the COVID-19 pandemic has changed these circumstances.

Therefore, our data underscores a strong need for the expansion of palliative care structures in German nursing homes. A well-structured and trained palliative care service for nursing home residents is needed to reduce unwanted and unnecessary hospital admissions. This could be achieved by creating more awareness for the patients ACP at the nursing home and by critically evaluating whether a multi-morbid resident would benefit from an emergency hospitalisation. This prehospital evaluation also could be helpful to avoid overburdening of healthcare systems during a pandemic. Technologies such as telemedicine also could be helpful, specifically in cases of infectious diseases and entry restrictions in nursing homes [23,24,25]. Interestingly, the majority of referrals of COVID-19 patients to our OPC team came from general practitioners (75.0%). These physicians usually are in very close contact with their patients and often able to assess their wishes, including those of patients without a written advance healthcare directive. Nevertheless, our data shows that those patients treated by our OPC service had an advance healthcare directive in 75.0% of all cases. This demonstrates that the outpatient COVID-19 collective was more likely to make conscious decisions about end-of-life medical care in comparison to the control collective (61.0%). This finding was not statistically significant, but it hints at the decisive role of general practitioners in advising patients and their relatives towards OPC. Even in a pandemic, the main motive for a hospitalisation or the decision towards OPC treatment should be according to the patient-will. Additionally, OPC services are capable of not only treating patients in their familiar surroundings but also advising and training their caregivers or families. This gives them a key role not only in conducting palliative care, but also in having a consulting role concerning the decision for or against hospitalisation.

An important difference when comparing the COVID-19-confirmed and non-COVID-19 OPC collectives was the number of patients with a cancer comorbidity. The number was significantly lower in the COVID-19-confirmed collective than in the non-confirmed collective (39.3% vs. 66.6%). This circumstance also possibly indicates the growing importance and knowledge about OPC not only for cancer patients but throughout the German health care system.

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