Yale School of Medicine, Section of Geriatrics, Department of Internal Medicine, New Haven, CT, USA.
Yale School of Medicine, Palliative Care Program, Department of Internal Medicine, New Haven, CT, USA.
Ann Palliat Med. 2021 Jun;10(6):6297-6306. doi: 10.21037/apm-21-117. Epub 2021 Jun 18.
COVID-19 presents unique challenges to the care of hospitalized older adults, including fractured lines of communication and uncertainty surrounding long term trajectories in cognition and function. Geriatric medicine and palliative care clinicians bring specialized training in facilitating communication in the face of uncertainty. Insurance expansion of virtual visits enabled inpatient virtual consultation, which can preserve personal protective equipment and minimize exposure to clinicians. We examined changes in goals of care and code status following an inpatient virtual consultation with geriatric medicine and palliative care clinicians.
This was an observational case series study performed at a large tertiary Academic Hospital. The study population included 78 patients aged 65 years and older, hospitalized with COVID-19 who had an inpatient consultation completed by geriatric medicine or palliative care clinicians between April 9, 2020 through May 9, 2020. The intervention was targeted, virtual geriatric medicine or palliative care consultation. All patients admitted to a medical floor with COVID-19 were screened four days a week and if a patient was over the age of 65, the medical team was offered a consultation by geriatric medicine (ages 80 and above) or palliative care (ages 65-79). Consultation included medical record review, telephone conversations with clinicians and nurses, telephone or video conversations with patients and/or surrogate decision-makers and collaborative case review on daily virtual huddles with an interprofessional team of geriatric medicine and palliative care clinicians. Descriptive statistics were applied to categorize outcomes after chart abstraction.
Following consultation, 24 patients (31%) patients changed their code status to less invasive interventions. Of patients who were FULL CODE at the time of consultation (n=42), 2 (4.8%) transitioned to DNR only and 16 (38.1%) transitioned to DNR/DNI after consultation. While 8 patients (10.3%) utilized intensive care unit (ICU) level of care prior to consultation, 6 (7.6%) patients utilized ICU after consultation. After consultation, 11 (14.1%) patients were referred to hospice.
Given uncertain trajectories in older adults hospitalized with COVID-19 and variability in patient preferences, virtual goals of care geriatric medicine and palliative care consultations should be considered as a key component of COVID-19 hospital protocols.
COVID-19 给住院老年患者的护理带来了独特的挑战，包括沟通不畅和认知及功能长期轨迹的不确定性。老年医学和姑息治疗临床医生在面对不确定性时具有促进沟通的专业培训。虚拟访问的医疗保险扩大使住院患者能够进行虚拟咨询，从而可以保护个人防护设备并最大程度地减少临床医生的暴露。我们研究了在与老年医学和姑息治疗临床医生进行住院虚拟咨询后，患者的治疗目标和医嘱更改情况。
这是一项在大型三级学术医院进行的观察性病例系列研究。研究人群包括 78 名年龄在 65 岁及以上的 COVID-19 住院患者，他们在 2020 年 4 月 9 日至 5 月 9 日期间接受了老年医学或姑息治疗临床医生的住院咨询。干预措施是有针对性的虚拟老年医学或姑息治疗咨询。每周四天对入住 COVID-19 内科病房的所有患者进行筛查，如果患者年龄超过 65 岁，医疗团队将获得老年医学（80 岁以上）或姑息治疗（65-79 岁）的咨询。咨询包括病历审查、与临床医生和护士的电话交谈、与患者和/或代理人的电话或视频交谈，以及在老年医学和姑息治疗临床医生的跨专业团队的日常虚拟小组会议上进行协作病例审查。通过图表摘录对描述性统计数据进行分类，以得出结果。
咨询后，24 名（31%）患者改变了医嘱，选择了侵入性较小的干预措施。在咨询时为 FULL CODE（n=42）的患者中，有 2 名（4.8%）转为 DNR 仅，16 名（38.1%）转为 DNR/DNI。8 名（10.3%）患者在咨询前使用了重症监护病房（ICU）级别的护理，而在咨询后有 6 名（7.6%）患者使用了 ICU。咨询后，有 11 名（14.1%）患者被转介至临终关怀。
鉴于 COVID-19 住院老年患者的轨迹不确定，且患者的偏好存在差异，虚拟老年医学和姑息治疗治疗目标咨询应被视为 COVID-19 医院方案的关键组成部分。
