The covid-19 pandemic has presented multiple challenges to healthcare systems around the world. We want to highlight the difficulties in Kerala, India, of providing palliative care for patients with pre-existing advanced disease who are infected with coronavirus.

There are difficult ethical issues related to triage and care rationing when resources are limited and demand is high, alongside the logistical challenge of making such decisions. The pandemic has now laid bare issues about futile and inappropriate medical interventions in certain contexts. 

As best practice in intensive care units (ICUs), palliative care has been recommended to be initiated as early as possible to allow focused interventions that anticipated or minimised unnecessary suffering. 

In the current pandemic, this is relevant when people with severe, advanced diseases are admitted to critical care facilities because they have tested positive for covid-19. People with comorbidities have higher mortality if they are infected with covid-19. However, in at least some patients with pre-existing advanced diseases aggressive treatment may be inappropriate and cause needless suffering. 

In the Indian context, where covid-19 cases are increasing exponentially, this is a pressing concern because of the existing low take up of end-of-life care principles and practice, as well as the huge socioeconomic impact of ineffective medical care (Razvi 2020). 

At the time of writing there are 68,000 covid-19 patients in Kerala. Under 0.2% are currently admitted to critical care units and current bed use is less than half of the designated critical care beds. There is a tendency to admit people with severe advanced comorbidities to critical care. More than a quarter of documented deaths in covid-19 ICUs in Kerala are patients who died in hospital of severe comorbidities (Government of Kerala 2020).

There are multiple reasons for this. 

• • Globally, the majority of patients who need palliative care do not have access to such services (WHO 2020). In Kerala, which has extensive community-based palliative care systems, access to palliative care for patients in critical care may still be limited.
  • Healthcare teams face practical challenges:
    — The difficulty of predicting the course of a disease even in patients with advanced systemic diseases.— If beds are available, it is often easier for the physician to admit a patient to the standard covid-19 treatment track rather than arriving at a consensus with the patient and their family about palliative care. Such discussions pose a communication challenge normally, and are now exacerbated by new communication barriers, such as isolated patients, family members who may be in quarantine with no access to the patient, and professionals wearing Personal Protective Equipment.
    — Socio-political pressure on healthcare teams, as deaths from covid-19 are often seen as a failure of healthcare.

Integrating consultative models of palliative care into ICU care have been proposed to improve patients’ quality of care (Mercadante et al 2018), but this is far from happening. Critical care and palliative care groups in India have also tried to find ways to reduce inappropriate admissions to ICU through collaborative work (Myatra et al 2014). 

In the covid-19 context, there have been further recommendations about ways to reduce inappropriate hospitalisations (Sprung et al 2020). These include exclusion from critical care if patients have severe cerebral injury or metastatic cancer with poor prognosis. 

Integrating palliative care with disease-modifying care is an aspiration that remains unrealised. What is needed is an interdisciplinary approach where palliative care and critical care teams blur their boundaries and overlap their expertise to meet the challenging dynamic of patient needs.  

The current pandemic may be an opportune moment to bring together these two strands of clinical care to ensure the best quality of care for all patients. Adding palliative care to the capacities of already overburdened critical care professionals at short notice will be difficult. What is feasible is closer working of palliative care professionals with the general/ICU healthcare teams. Ernakulam, one of the districts in Kerala has taken steps in this direction.

In Kerala, given the existing widespread community-based capacity for palliative care, embedding palliative care workers in hospital settings may prove effective during patients’ hospital care and follow-up community care. This could enhance delivery of palliative treatment in covid-19 care, build the capacity of general/ ICU healthcare teams through joint working with palliative care workers, and lay a strong foundation for the future development of comprehensive care for all patients. 

Suresh Kumar is Director at the WHO Collaborating Centre for Community Participation in Palliative Care and Long-Term Care, Institute of Palliative Medicine, Kerala, India.

Jairam Kamala Ramakrishnan is a psychiatrist and honorary consultant at the WHO Collaborating Centre for Community Participation in Palliative Care and Long-Term Care, Institute of Palliative Medicine.

Competing interests: None declared.