Feature Article Field Notes From the Frontline of a COVID-19 Outbreak Dyspnea Management for Hospitalized Patients at End-of-Life 12/05/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= by https://journals.lww.com/jhpn from Downloaded Dawn Pavlu, MSN, APN, AGACNP-BC, ACHPN, CCRN ¦ Katherine DeMarco, DNP, MSHS, APN, FNP-BC, ACHPN ¦ Downloaded Yusimi Sobrino-Bonilla, MSN, APN, ANP-BC, ACHPN, CCRN from https://journals.lww.com/jhpn Northern New Jersey was inside one of the worst initial dyspnea are described. These accounts include Lessons coronavirus disease 2019 pandemic epicenters in the Learned in order to assist others who may need to quickly United States. At the peak of the pandemic surge in mid- implement changes in the future due to pandemic April 2020, New Jersey saw 8045 hospitalized patients resurgence or second-wave events. with severe coronavirus disease 2019 symptoms, of which by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of KEY WORDS critically ill patients, the national opioid shortage, and air hunger, COVID-19, dyspnea, end of life, opioids, transmission prevention measures for standard palliative palliative, pandemic, refractory dyspnea, care treatment protocols in place for refractory and/or shortness of breath end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the n the early months of 2020, as the coronavirus disease following Notes From the Field is to provide concise, 2019 (COVID-19) pandemic reached the shores of the pragmatic, and experiential reflection by 3 palliative care United States, New Jersey became one of the worst advanced practice nurses from 3 different hospital I epicenters in the nation. This pandemic surge threatened systems within the pandemic epicenter. The novel to overwhelm the existing health care systems. Initially, methods and opioid strategies implemented by their the northern counties of New Jersey were hit the hardest respective palliative care teams to ensure continued both in numbers of cases and deaths. The first laboratory- effective and appropriate treatment for end-of-life confirmed case was diagnosed on March 3, 2020. At the peak incidence of hospitalizations (April 4, 2020), the state- wide hospital census was 8045, including 2002 patients in the intensive care unit (ICU) (representing 86.3% of state- Dawn Pavlu, MSN, APN, AGACNP-BC, ACHPN, CCRN, is a palliative care nurse practitioner, VA New Jersey Health Care System, East Orange, wide available capacity), with 1705 patients requiring me- New Jersey. chanical ventilation (54.7% of statewide ventilator capacity). Katherine DeMarco, DNP, MSHS, APN, FNP-BC, ACHPN, is a palliative In the first 100 days of the pandemic, New Jersey saw a total on medicine APN, Clinical Supervisor, Pain & Palliative Medicine Institute, 12/05/2020 of 165 816 confirmed positive COVID-19 cases: the most Hackensack Meridian University Medical Center, Hackensack, New Jersey. occurring in Bergen County (18 667), followed closely by Yusimi Sobrino-Bonilla, MSN, APN, ANP-BC, ACHPN, CCRN, is a pallia- tive care nurse practitioner, PalliativeCareClinicalSupervisor,TheValley Essex County (18 206). The statewide rate of laboratory Health System, Ridgewood, New Jersey. confirmed COVID-19 mortality was 7.5% (12 443 deaths): Address correspondence to Dawn Pavlu, MSN, APN, AGACNP-BC, ACHPN, the most occurring in Essex County (1723), followed closely CCRN, 385 Tremont Ave, East Orange, NJ 07018 ([email protected]). by Bergen County (1635).1,2 The unprecedented need for The authors have no conflicts of interest to disclose. critical care services saw rapid expansion and conversion Disclaimer of Endorsement: Reference herein to any specific commercial of existing regular medical floors into ICUs. Field hospitals products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, were constructed by the Army Corp of Engineers at the recommendation, or favoring by the United States Government. The views Meadowlands Sports Arena (northern New Jersey), NJ Con- and opinions of authors expressed herein do not necessarily state or vention and Expo Center (central New Jersey), and at the reflect those of the United States Government, and shall not be used for advertising or product endorsement purposes. Atlantic City Convention Center (southeast New Jersey). “ ” Copyright © 2020 by The Hospice and Palliative Nurses Association. All Draconian measures to flatten the curve , such as social rights reserved. isolation and closure of nonessential businesses, were DOI: 10.1097/NJH.0000000000000728 undertaken. Journal of Hospice & Palliative Nursing www.jhpn.com 1 Feature Article The goals of palliative care are to promote quality of life services, as well as a broad range of specialty programs and relieve suffering due to the symptoms and stress re- for the greater New Jersey area veteran population. lated to serious or life-threatening illness. It is a widely accepted standard of care even on the global level.3,4 High-quality palliative care includes expertise in symptom INTRODUCTION management and therefore remains an essential facet in the multidisciplinary care for patients who require hos- The causative agent of COVID-19 disease is SARS-CoV-2 pitalization due to severe COVID-19 infection. In this brief (severe acute respiratory syndrome coronavirus 2), a novel “Notes From the Field”, novel approaches for end-of-life betacoronavirus, likely of zoonotic origin that rapidly spreads dyspnea symptom management are described. The aim is through person-to-person contact. As the name implies, it is to provide concise, pragmatic, and experiential reflection characterized by acute and severe lung dysfunction that onmethodsusedby3palliativecareteamsatdiffering may progress to respiratory failure due to adult respiratory hospital systems within the New Jersey COVID-19 pan- distress syndrome necessitating high-flow oxygen with demic epicenter to conserve scarce opioid resources during 100% FIO2 andmechanicalventilation,especiallyinthe the surge while ensuring quality care. 5% to 14% of patients with severe hypoxia requiring hospi- The 3 hospital systems include Hackensack University talization.5-7 Medical Center, the flagship hospital of the Hackensack Dyspnea is a subjective experience often described as Meridian Health System, a 770-bed nonprofit research air hunger, increased effort of breathing, or a feeling of suf- and teaching hospital providing tertiary and health care focation.8 In addition to reversing underlying causes, the needs to northern New Jersey and the New York metropol- criterion standard for treatment of severe, refractory, or itan area; The Valley Hospital, part of Valley Health Sys- end-of-life dyspnea is the administration of opioids.8-10 tem, a 451-bed fully accredited acute care not-for-profit For patients who cannot self-report, the Respiratory Dis- community hospital serving the 32 towns of Bergen County tress Observation Scale (RDOS) is the only known valid and adjoining communities; and East Orange VA Medical and reliable tool for assessing dyspnea.11 The RDOS tool, Center, part of the Veterans Administration New Jersey an 8-item ordinal scale, was utilized to guide effective treat- Health Care System, a 100+ acute care bed teaching hospi- ment for COVID-19 patients experiencing end-of-life dys- tal providing general medical, surgical, and psychiatric pnea. Scores of 0 to 3 indicate no distress; 4 to 7 indicate FIGURE. Respiratory Distress Observation Scale. © Margaret Campbell, PhD. 2 www.jhpn.com Volume 00 • Number 00 • Month 2020 Feature Article moderate distress; and greater than 7 indicate severe dis- lastly, palliative care teams being overstressed and members tress (Figure, RDOS tool). being reassigned to other critically needed roles. All 3 of the institutions listed in this report had well es- Given the potential for rapid decompensation and high tablished palliative care teams in place utilizing evidence- mortality even in those with no pre-existing conditions, based end-of-life care protocols derived from resources early palliative care services are essential for hospitalized including the Center to Advance Palliative Care (CAPC), COVID-19 patients.20 The palliative care teams in this Notes National Comprehensive Cancer Network, Palliative Care From the Field report faced the same challenges with re- Network of Wisconsin (PCNOW), and the National Coalition spect to the treatment of severe end-of-life dyspnea that for Hospice and Palliative Care.12-15 Associated order sets was refractory to standard dyspnea management protocols for dyspnea management included pharmacologic guid- in the setting of a national opioid shortage. The Lessons ance addressing the use of opioids and benzodiazepines, Learned section describes how flexibility and adaptability as well as nonpharmacologic interventions including the functioned to overcome various obstacles encountered use of fans; complementary therapies such as therapeutic due to the pandemic surge. touch and aroma therapy; and environmental controls such as music therapy, reduction of extrinsic noise, and compassionate presence with loved ones. NOVEL