End-of-life: Planning for compassionate care during COVID‑19

CMPA Podcast

COVID-19: Advance care directives (18 min)

Issues

• Providing end-of-life (EOL) care to patients with COVID-19 and those suffering from other conditions can be challenging because of pandemic-related public health measures and the availability of resources.
• Requests for medical assistance in dying (MAID) pose unique challenges that require special consideration in the COVID -19 environment.

The bottom line

• Advance care planning (ACP) is particularly important for vulnerable patients at risk of serious complications as a result of COVID-19, given the likelihood of rapid deterioration and loss of capacity.
• Directives designed to prevent the spread of COVID-19, and limited access to resources, such as medication, equipment, and palliative care physicians and facilities, can affect your ability to carry out previously established EOL care plans. Communication and adaptability with patients, substitute decision makers (SDMs), and family members is key.
• While some rules around virtual assessments and witnessing of MAID requests are being temporarily relaxed, the legal safeguards and limitations still apply. Stay informed about updated guidance in your jurisdiction and seek advice from the CMPA before proceeding.

Need to know

Advance care planning

• The goal of ACP is to ensure that patients receive the end-of-life care they want. ACP reduces the likelihood of conflicts with family members or between SDMs and the healthcare team by ensuring that patients’ preferences are understood if and when they cannot provide consent.
• Early discussions about healthcare directives are particularly important in vulnerable patients at risk of serious complications resulting from COVID-19, given the likelihood of rapid clinical deterioration and loss of capacity.
• Encourage ACP discussions for patients with multiple chronic diseases, and when patients are diagnosed with a life threatening condition or are likely nearing end of life. Revisit the issue as needed and ensure the patient’s wishes are documented as clearly as possible.
• Difficult decisions about withholding or withdrawing care because of a lack of resources can cause conflict with patients or families. When consensus is not possible, consider available conflict resolution mechanisms, as well as discussions about the impact of COVID-19 ethical frameworks and critical care resource protocols as they relate to end-of-life care. For more information, see Advance care planning: The key to person-centred end-of-life care.

Availability of EOL resources

• Resources for EOL care, such as personal protective equipment (PPE), nursing support, IVs, anesthetics, and paralytics may be unusually limited. When feasible, plan ahead for these issues by working in consultation with public health, hospitals, palliative care facilities, and regional health authorities to develop practices consistent with expected resources and evolving provincial/local emergency directives.
• Directives designed to prevent the spread of COVID-19, and limited access to resources in hospitals and long-term care homes, may require changes to EOL care, including providing care at home instead of a hospice. Family and friends might not be allowed to be present due to physical distancing. Be transparent and supportive with patients, SDMs, and families about limitations and appropriate solutions, including virtual care and support.

MAID

• Given additional challenges related to MAID in the time of COVID-19, you are encouraged to contact the CMPA to obtain context-specific medical-legal advice.
• Where considered a non-urgent medical service, access to MAID may be more restricted in some hospitals. This may result in increased reliance on community MAID providers and, where appropriate, virtual assessments.
• Limited resources and physical distancing may create challenges in complying with legal requirements, including the requirement that an independent witness sign a request for MAID. Virtual witnessing may be an option if arrangements are made to comply with statutory requirements.
• Delivering MAID using oral medications self-administrated by the patient without a physician present and/or without complying with the conditions in the Criminal Code permitting physicians’ intervention in case of complication poses unique challenges and requires careful consideration on a case-by-case basis, taking into account statutory requirements and regulatory standards.
• If the provision of MAID is delayed until the COVID-19 public health emergency subsides, it may be necessary to re-assess the patient’s eligibility at that later time.

Looking ahead

Discussions about EOL can be difficult for patients, families, and healthcare providers, especially in the midst of a public health emergency. In planning ahead for EOL during the COVID-19 pandemic, consider what additional supports are available for your patients and their families.

Be attentive to your own emotional needs when providing EOL care in these challenging times. The CMPA is here to support members experiencing distress. Feelings of being overwhelmed or stressed may be helped by contacting us, speaking with a close colleague, or reaching out to your provincial physician health program.

DISCLAIMER: The information contained in this learning material is for general educational purposes only and is not intended to provide specific professional medical or legal advice, nor to constitute a "standard of care" for Canadian healthcare professionals. The use of CMPA learning resources is subject to the foregoing as well as the CMPA's Terms of Use.