Cancer being a time sensitive disease and patients appear to be at increased risk of COVID-19 infection. The prime concern and challenge is related to patient safety. The dilemma revolves around, whether cancer patients should visit hospital to continue their treatment as coming out of homes can expose them to COVID infection. Also, cancer treatment can compromise their immunity putting them at increasing risk of infection.
The overall impact of this pandemic on cancer patients is significant as it is going to affect the management, quality of life and survival . Priority based cancer treatment plans are being decided on the basis of risk/benefit ratio. In conditions where the risk of Severe Acute Respiratory Symptom Corona Virus (SARS CoV 2) infection outweighs the expected cancer related outcome, shared decision making while discussing the potential risks and benefits of planned treatment, will empower patients and caregivers to prioritize their preferences.
The major domains identified from evidence available globally in guiding health care workers can be summarized as TRI-SPEED approach for cancer patients. It helps in providing holistic care combating current pandemic situation.
1. TRI- Triage
2. S- Symptom Control
3. P- Psychosocial Support
4. E- Ethical based care discussion
5. ED- End of life Care
Priority based cancer therapies in the context of COVID pandemic is the need of hour. It can be done by
Triaging patients based on symptom burden which helps in prioritizing care and leads to proper utilization of resources. Taking care of limited resources, the decision to either continue or stop cancer therapy should be made before going for aggressive treatments. Irrespective of condition of cancer patients the palliative care services should continue till end in the form of telecommunication, follow up, home based care and bereavement if possible. Triage towards most urgent palliative care cases with severe uncontrolled symptoms like pain, oncological emergencies such as spinal cord compression should be done and treated.
Patients with advanced cancers present with both physical and psychosocial symptoms. Acknowledgement and adherence to key palliative care principles is needed for adequate symptom management and care. There is a need of careful attention to minimize suffering including end of life care. The common symptoms like pain, nausea and vomiting can be managed at home. Extra morphine tablets can be given to patients in order to prevent frequent visits to hospital. The home based palliative care worker plays a vital role in it. For patients with severe dyspnea, sepsis and pneumonia, it must be differentiated with COVID-19. Therefore, suspected patients should be screened for COVID 19 and managed as per the existing guidelines. Use of telecommunication helps in managing symptoms at home and allows a hospital free follow up.
This Pandemic has also brought a surge of fear, uncertainty, anxiety and depression. The magnitude is even more in cancer patients, survivors and their family members. The patients who are not able to continue their cancer therapy due to restricted movements in lockdown are filled with guilt and depressive thoughts. There is a strong need of psychosocial support to such patients. Empathetic communication, honesty, trust, compassion with patient and support to family throughout the process are important components in such cases. The emerged psychological crisis needs evidence based management, training of ground level health care workers in communication skills, use of telecommunication and home based palliative care
Ethical Based Care Discussion
In view of limited resource and shifting of focus more towards COVID patients, the decision making process in cancer patients for and against an intervention creates a major ethical challenge. Effective communication and detailed discussion with patient, family, primary physician and palliative care team can simplify the process. Documentation of decision is an important part of ethical based discussion. The patients who are denied of further medical intervention shouldn’t feel neglected. This is possible with sensitive and compassionate discussion with patient and family members.
End of life Care
In addition to care and symptom management, communication and compassion matters in patients with advanced cancer. Use of technology like telecommunication, recorded messages, music and prayers can be advocated. Patients at terminal stages with refractory symptoms can be managed with palliative sedation. The impact of the COVID-19 pandemic on end-of-life care must be addressed as it may not be possible at the family’s preferred place. There may be limitations on the presence of family members at funeral process due to government policies. Realistic hope and true communication regarding the prognosis is the key. This leads to a confidence and trust among the caregivers and doctors who are engaged to provide better bereavement process
(This article has been co-authored by Dr Abhishekh along with other doctors)