Raffaella Bert\u00e8 and colleagues recount the experience of managing the covid-19 outbreak in a small town in Italy<\/p>\n
One of the biggest emergencies of our times, the covid-19\u00a0<\/span>pandemic, is spreading around the world as we write this, and it is striking Italy particularly hard.\u00a0<\/span>In the Emilian town of Piacenza, Italy, it all started on 21 February 2020. The first case was identified in nearby\u00a0<\/span>Codogno. There was the immediate search for the identity of patient zero. There was the minute-by-minute news, a good\u00a0<\/span>dose of panic, and many questions\u2014for citizens and the authorities alike.\u00a0<\/span><\/p>\n It was perhaps at the local hospital that the gravity of the situation was perceived more clearly, and the\u00a0<\/span>actions that were needed to reorganise happened quickly. Among the various interventions that were\u00a0<\/span>rapidly approved, was the conversion of almost all wards into \u201cCovid Emergency Departments\u201d and the\u00a0<\/span>creation of a dedicated ward aptly named the \u201cEnd-of-life Department.\u201d <\/span><\/p>\n The health department\u00a0<\/span>in Piacenza took the difficult and perhaps controversial decision that one of its emergency\u00a0<\/span>departments be exclusively dedicated to the palliative care of the many patients who were rapidly\u00a0<\/span>succumbing from the infection. The hospital\u2019s palliative care team was asked to assist with the\u00a0<\/span>organization of the newly created structure and charged with providing guidelines for the support and\u00a0<\/span>assistance of patients destined for that department and their family.\u00a0<\/span><\/p>\n End-of-life treatments are meant to improve the quality of life of dying patients and their families\u00a0<\/span>through the prevention and treatment of pain, but also address psychological, social, and spiritual issues\u00a0<\/span>related to the end of life. The hospitalization of elderly patients presenting with bilateral pneumonia and\u00a0<\/span>highly suspected or confirmed covid-19 infection, deemed to be at the end of life, had the purpose of\u00a0<\/span>addressing primarily their severe dyspnoea. For this highly morbid symptom, appropriate palliative\u00a0<\/span>therapeutic interventions involve the use of drugs such as morphine and benzodiazepines, providing\u00a0<\/span>symptomatic relief and alleviating suffering.\u00a0<\/span><\/p>\n Organising the new department<\/strong><\/p>\n The end-of-life department <\/span> is equipped with 12 beds distributed over five rooms.\u00a0<\/span>All patients are\u00a0<\/span>treated as if they were covid-19 positive, even though many of them have presumed covid-19 and no\u00a0<\/span>confirmed infection. The medical team includes primarily surgeons, guided during the day by members\u00a0<\/span>of the palliative care team, while the night shift is covered by an \u201cinterdivisional\u201d attending physician.\u00a0<\/span><\/p>\n The non-physician team is comprised of six nurses and six nurse aids, aided by three palliative care\u00a0<\/span>team members (a nurse, a case manager, and a psychologist).\u00a0<\/span>The request for transfer to the end-of-life department typically starts already in the emergency department. The emergency department\u00a0<\/span>physician, after determining that a patient is terminally ill,\u00a0refers the patient\u00a0to the end-of-life department. This is based on clinical parameters, such as imaging, the\u00a0<\/span>presence of multiple comorbidities, or a decision that the patient would not benefit from aggressive measures.\u00a0<\/span>Some patients, however, are transferred from the regular floors or the\u00a0<\/span>intensive care unit when irreversible deterioration of their status occurs. <\/span><\/p>\n The movement of patients across\u00a0<\/span>departments is avoided, though, if it is deemed that their death is imminent. The palliative care team\u00a0<\/span>case manager is in charge of admissions, deaths certificates, liaison with the bed manager, pharmacy\u00a0<\/span>orders and shifts, and a palliative care team nurse gives daytime support to the shift workers. Attempts\u00a0<\/span>are made to work in pairs, so that one person can function as the \u201cclean worker\u201d. The general rule is\u00a0<\/span>that there are always two staff members present who collaborate, and that nothing can leave the room\u00a0<\/span>without it being decontaminated.\u00a0<\/span><\/p>\n Visitors are not allowed to enter the hospital. This necessary rule is particularly devastating for the\u00a0<\/span>families of terminally ill patients. These patients, unfortunately, mostly die without the comfort of their\u00a0<\/span>family members. Hence, the issue of communicating with families is of the highest importance. Daily\u00a0<\/span>updates are provided to them on the status of their relatives. At the time of death, the physician\u00a0<\/span>personally communicates with the family. In the early days, brief operational instructions were issued to\u00a0<\/span>staff to guarantee a homogenous message in response to the ongoing tragedy.\u00a0<\/span><\/p>\n The role of palliative care<\/strong><\/p>\n The role of palliative care had to brutally be adapted to manage a situation of an “ultra-emergency”; in this\u00a0<\/span>situation the fundamental basis of palliative care is lacking: there is no relationship with the patient\u00a0<\/span>and his family, there is no typical palliation timing that allows sharing and planning the treatment path,\u00a0<\/span>all hospitalized patients die and these deaths are linked to a traumatic and startling psychological\u00a0<\/span>experience for the family and the members of the treating team.\u00a0<\/span><\/p>\n Palliative care is, by definition, a combination of “chemistry” and “relationship”. In an emergency\u00a0<\/span>situation like the one we found ourselves experiencing and managing, the palliative care team had to\u00a0<\/span>make a choice: putting chemistry before relationship, without forgetting its mandate. Still, the palliative\u00a0<\/span>care team provided daily contact with the family and the continuity of care was guaranteed by the\u00a0<\/span>palliative psychologist through telephone updates on the clinical status of the patients and monitoring\u00a0<\/span>of the emotional experiences and basic psychological needs of the family. We feel that the\u00a0<\/span>implementation of a dedicated end-of-life departments in the midst of the covid-19 crisis has allowed,\u00a0<\/span>on the one hand, the compassionate management of terminally ill patients, on the other hand it has\u00a0<\/span>made it possible for the hospital management to distribute resources appropriately, proportionately, and\u00a0<\/span>ethically in exceptional conditions of imbalance between needs and available resources.\u00a0<\/span><\/p>\n