As we enter the new year we\u2019re offered a prompt to take stock and reflect on the 12 months that have just gone past. 2020 has given us lots to talk about, most notably COVID-19 and the wholesale changes to our personal and professional lives that it has forced. Earlier this year we went out to colleagues caring for patients dying from COVID-19 across the country to gather perspectives on how the pandemic had affected them, their practice and their local areas in an attempt to capture that moment in time (Perspectives 1<\/a> & 2<\/a>). Now as we look forward into 2021, which will doubtless bring new challenges, we have again conducted structured interviews with colleagues around the country to see what\u2019s changed since Spring.<\/p>\n Question 1: How does it feel where you\u2019re working at the moment?<\/strong><\/p>\n \u201cTense\u201d says Rebecca \u2013 a palliative medicine consultant in Bolton. \u201cWe get a trust update three times a week with the total number of patients with COVID-19 in the hospital. You open it with trepidation and then your heart sinks as the numbers continue to rise\u201d. This feeling seems to be shared across the acute sector with a junior doctor in a London hospital telling us, \u201cAs you walk into work you alternate between feeling really anxious about what might happen today and feeling completely hardened to it, trying not to remind yourself about how bad things have become\u201d. Certainly in the hospital setting, Rebecca reminds us that, \u201cTeams have never been surrounded by this amount of death before. I bumped into one of the Acute Medics coming off MAU, his face was sombre, so I enquired into how he was feeling. He said \u2018it\u2019s all just death in there\u2019\u201d<\/p>\n Sharmila, a gastroenterology consultant in Portsmouth, tells us of the changes to practice she\u2019s had to make, \u201cI haven\u2019t lived through any wars, but I can\u2019t think of anything else in my lifetime that has changed almost all aspects of the way we live and work\u201d. These changes come at a cost and \u201cit sometimes feels like I\u2019ve stopped doing good old fashioned medicine and am just \u2018processing\u2019 patients along the safest \u2018virtual\u2019 route\u201d. This is something Thomas, an oncology registrar in London, has also felt, \u201cIt\u2019s interesting having the flexibility now to offer face-to-face appointments\u2026 the number of patients who have said to me, I’m so glad you brought me in to see you, I just wanted to see somebody who’s looking after me\u2026 I think only practicing remotely takes away that personal approach that we have as clinicians looking after people\u2026 and they feel like no one is really overseeing things\u201d.<\/p>\n Sharmila tells us about a \u201csense of weariness\u201d, something mentioned by a lot of our contributors. Haz, an anaesthetic CT2 in Bedfordshire tells us \u201coverall people feel tired and kind of fed up of how all the rule changes are affecting work and the efficiency of work\u201d. Nicola, the lead clinical nurse specialist for a palliative care team in London also comments on this while saying the \u201ccontinued sense of valuing staff and putting practical measures in place to support this\u201d is really helping. Feeling supported isn\u2019t ubiquitous however, with our junior doctor in London telling us \u201cIt feels as though the goodwill has gone, no more clapping, no more following the rules, no more donations to the frontline staff. We\u2019re still here, still struggling but neither the management or the public have been able to maintain the level of support we saw in the Spring\u201d.<\/p>\n Question 2: What challenges are you facing?<\/strong><\/p>\n \u201cDealing with constant change can be exhausting\u201d says Nicola in London, a sentiment echoed with our junior doctor who tells us, \u201cAdmitting that you\u2019re exhausted, tired, burnt out doesn\u2019t go with the wartime mentality we\u2019ve been encouraged to adopt. A lot of staff need support but don\u2019t know where to turn\u201d. Now that many staff are needing to shield, isolate following contact and isolate with the illness, teams are stretched and it\u2019s difficult to provide the care they would want to. Rose, a microbiology registrar in York, tells us that often staff working in stretched services default to diagnosing COVID-19, causing \u201cdelays to other diagnoses. People aren\u2019t able to think about the other conditions that could cause similar presentations\u201d. Having completed her core medical training through the pandemic, she remembers being on wards earlier in the year where \u201cit\u2019s hard to recognise when a patient is dying with the virus as opposed to deteriorating from something reversible\u201d which poses the challenge of what to say to loved ones, especially where communication is more difficult.<\/p>\n Rebecca in Bolton tells us that her hospital serves quite a large Muslim faith community and that in normal times they are used to supporting patients in meeting their spiritual and cultural needs. \u201cSome Muslims believe in having as many people as possible around someone\u2019s death bed to pray and the fact we are only allowing two visitors at the end of life is very distressing for them. Having been present for a huge virtual Muslim death bed, it was a very moving moment. I\u2019m not ashamed to say I cried, as it was such a distressing, but beautiful moment and I felt privileged to be present\u201d.<\/p>\n Haz tells us about the challenges communicating between colleagues \u201chuman factors play such an important part in our work and now we\u2019re all wearing the respirator style mask that are really difficult to hear anyone talk through\u201d. PPE is discussed by most of our contributors as a challenging thing to adapt to, while also holding the worry that one might not be wearing the right equipment for the task at hand, putting staff and patients at risk.<\/p>\n Sharmila tells us of the impact on endoscopy which \u201chas been one of the hardest hit areas in the \u2018non-COVID\u2019 hospital stream given the risk around aerosol generation\u2026 my heart sinks when I encounter a patient with a cancer that could have been picked up earlier had the pandemic not stymied endoscopy services and had the fear of coming to hospital not been so strong in many patients. These instances are now, sadly not uncommon\u201d. Thomas also speaks of the fear of COVID-19 in his patient group \u201cI think the thing that I have to remember is that a lot of my patients\u2026have a reasonably short prognosis. So for me to advise them not to see loved ones will make a big difference to their quality of life. Especially when some of them may not actually have a prognosis longer than months. So I think being pragmatic in the advice about this is the approach that I’ve adopted. And I have said to people that it’s important to protect themselves from the risks of catching coronavirus, but it’s also important not to underestimate the impact of keeping themselves away from their loved ones would have on that mental health and their overall wellbeing.\u201d<\/p>\n Question 3: What\u2019s helping?<\/strong><\/p>\n Rebecca in Bolton tells us of the ongoing changes to working in her integrated hospital\/community palliative care team \u201cWe\u2019ve found being flexible and getting rid of organisational boundaries is key\u201d.<\/p>\n Rose in York tells us how helpful both national and local guidance on \u201cwhat investigations to do\u2026how to help with symptoms\u2026how to have difficult conversations with families over the telephone\u201d (such as this from the Chelsea and Westminster team<\/a>) has been. Nicola explained that, \u201cIn the first wave there was a sense of underlying fear as we were unsure of what was to come. We are now better armed with the experience, knowledge and resources. The use of Microsoft Teams, zoom etc has been a real plus in many ways. It has encouraged more creative ways of teaching and communicating with one another\u201d.<\/p>\n Support for staff has been varied through the year but our junior doctor in London tells us how useful regular debriefs have been for offloading and activities like raffles and the big departmental medical Christmas quiz. They go on to tell us that he feels the most helpful thing remains \u201cthe sense of camaraderie between staff\u201d and Thomas tells us that he feels this with patients as well, \u201cthat we are all in this together\u201d.<\/p>\n Thomas tells us that \u201cthe fact that all the staff where I work are being tested regularly, so that fear that we could unwittingly give it to our vulnerable patients is slightly less\u201d. A lot of our contributors felt the rapid development of large scale testing and the promise of the vaccination programme was helping morale. Sharmila put it very clearly, \u201cNews of the vaccine filled me with hope and promise, although I know that we need to have realistic expectations of it. It also reminded me of how resilient the human race is and how science will ultimately triumph!\u201d.<\/p>\n Question 4: <\/strong>Have you noticed any emerging themes in caring for people dying with COVID-19?<\/strong><\/p>\n \u00a0<\/strong>The resounding answer from those of our contributors caring for people dying with COVID -19 is around uncertainty. Rebecca \u2013 \u201cIn those sick enough to die, it is very difficult to predict who will die or not\u201d, Rose remembers similarly \u201cit\u2019s difficult to assess their trajectory, they deteriorate quickly and often quite symptomatically\u201d. Now that visitors are allowed into some hospitals when patients have been recognised as dying, this poses a particular challenge \u201cwe are trying to bring visitors in earlier so contact is meaningful\u201d but as Nicola reminds us of the challenges with, \u201cConfusion about the visiting policy across the hospital\u2026and inconsistency in practice\u201d.<\/p>\n Symptoms wise, Rebecca tells us of the \u201csilent breathlessness\u201d where patients \u201cappear very tachypnoeic, but when questioned says they don\u2019t feel breathless\u201d leading to uncertainty around the role for medication like opioids. She describes a delirium that is less responsive to midazolam and so one of the challenges she has faced is \u201cgetting wards comfortable using levomepromazine\u201d especially at higher doses when this is outside their normal practice. In contrast, Haz tells us of the deaths she\u2019s witnessed in the controlled environment of the intensive care unit being quick and relatively uncomplicated when patients have progressed to multi-organ failure states.<\/p>\n Our contributors talked of the distress faced by the other patients on wards, in bays or nearby when someone is dying symptomatically and how this then impacts upon their care. \u201cOne patient who witnessed another\u2019s agitation whilst on CPAP, consequently refused to have CPAP on himself when he needed it. We reflected that in normal times patients would witness another\u2019s death, but they might be able to detach themselves from it, as they will likely have had a different condition or illness. On the COVID wards though, they are all there for the same reason and the risk of their own death is there for them all to see\u201d.<\/p>\n Question 5: <\/strong>Any advice for people across the country?<\/strong><\/p>\n Rebecca \u2013 \u201cI think I will say something that a lot of my patients say to help them cope, which is often true; \u2018don\u2019t worry, there is always someone out there worse off than you\u2019. Focussing on the positives is a real asset to me at the moment\u2026 Be kind to those that fight against the restrictions or who don\u2019t believe in COVID-19. They are likely the ones worse off than ourselves, trying to protect themselves the only way they see how\u201d<\/p>\n Rose \u2013 \u201cOne of the more positive elements of working in the pandemic was how I felt that we worked really well as a team and communicated and shared ideas and tried to figure out solutions to problems. And there’s been lots of support from both doctors and other healthcare professionals and nursing staff to help support and care for patients\u201d<\/p>\n Haz \u2013 \u201cI guess the most important thing is to keep families involved in the conversations as much as possible. I think we have to remember that patients and relatives are terrified of COVID from the coverage on the news and in the media, especially when they don\u2019t understand a lot of what you\u2019re talking about in ITU etc… I think when people feel they have a grasp of the situation, it makes it easier for them to manage and it makes it easier to feel involved with what’s happening\u201d<\/p>\n Thomas \u2013 \u201cI think it’s really important to take a pragmatic approach for our patients, especially those who have incurable illness. We can’t replace face-to-face contact when it’s required. So breaking bad news, giving information, allowing the patients time to meet the team looking after them is vitally important\u2026 and it’s something that really cannot change\u201d<\/p>\n Nicola \u2013 \u201cThe importance of robust team working is necessary on so many levels. Self-care is integral to healthy and productive functioning. This will take different shapes and forms for each individual but it is taking the time and energy to consciously think and plan what works for you\u201d<\/p>\n Junior doctor in London \u2013 \u201cTake care of yourselves. Wash your hands, cover your face and maintain your space and please stay home if you can\u201d<\/p>\n Summary<\/strong><\/p>\n Looking to the year ahead we will doubtless face challenges both currently foreseeable and not. Our understanding of COVID-19 has advanced rapidly over the last year with production of research and guidance to help with patient care but significant uncertainty remains. Staff continue to work outside their comfort zones and face stark reminders each day of the severity of the pandemic, trying to support patients as best they can. As we go into the new year the importance of supporting each other, checking in on people who aren\u2019t speaking out as well as those who are, and remembering where we can access support (NHSe<\/a>, BMA<\/a>, Samaritans<\/a>) is so important. 2020 has been a year for trying to focus in on what matters most<\/a> to each of us and we\u2019ve seen examples of the wonderful and kind efforts of society to support those most vulnerable. We\u2019d like to thank you all, and wish you a happy new year.<\/p>\n Thanks to our contributors who agreed for this to be published:<\/strong><\/p>\n Nicola Henawi \u2013 Lead CNS for palliative care team at the Royal Free Hospital in London Part three in this exploration of themes from frontline care staff during the pandemic Authors: Dr Simon Tavabie \u2013 Royal London Hospital, Dr Katie Ball \u2013 Marie Curie Hospice Hampstead, Dr Rory Carrigan \u2013 University College London Hospital, Dr Stephanie Lister-Flynn \u2013 St Catherine\u2019s Hospice Crawley As we enter the new year we\u2019re offered a […]<\/p>\n![\"\"](\"https:\/\/blogs.bmj.com\/spcare\/files\/2020\/12\/sp-care-blog-dec.png\")
<\/a><\/p>\n
\nJunior doctor in London contributing anonymously
\nDr Sharmila Subramaniam \u2013 Consultant in gastroenterology in Portsmouth
\nDr Rebecca Lennon \u2013 Consultant in palliative medicine in Bolton
\nDr Thomas Carter \u2013 Specialist registrar in oncology in London
\nDr Rose Harrison \u2013 Specialist registrar in microbiology in York
\nDr Harriet Kent \u2013 CT2 anaesthetics in Bedfordshire<\/p>\n","protected":false},"excerpt":{"rendered":"