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Palliative Care Article Critique: End-of-Life Care During the COVID-19 Pandemic

Amy Biller

Seton Hill University

Palliative Care, Nursing 474 45

Professor Malissa Williams

July 17, 2021

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The article that I chose for my critique is titled: Health and social care professionals'

experiences of providing end of life care during the COVID-19 pandemic: A qualitative study.

This article was chosen due to my timing of entering the nursing workforce coinciding with the

COVID-19 pandemic. As soon as I graduated, COVID-19 patients seemed to be all I knew and

handled. The selected study focused on the emotional and practical challenges of providing care

to patients, interactions, discussions with loved ones, and family members. 

Background

There were many barriers to being able to provide effective patient care within the

healthcare system when COVID-19 started to spread. There was little known about the cause,

spread, prevention, treatment, and proper ways to protect medical staff members. “The

management of the first infected patients was based on scientific data published since the start of

the outbreak, as well as our experience from previous outbreaks (SARS and MERS-CoV)”

(Peiffer-Smadja et al., 2020).

“About two-thirds of deaths attributed to COVID-19 are taking place in inpatient care

settings, and almost all of these are absent of family members who are typically called upon to

make health care decisions when patients can’t speak for themselves, giving new urgency to

talking about matters of life and death with our loved ones in advance” (Smith, 2020). It is

harder for a family member to make decisions about a loved one they are unable to see. If they

are unfamiliar with medical equipment or do not have a thorough understanding, they rely on the

healthcare workers for all interpretations and explanations. Our severely ill patients were often

intubated, and sedated, leaving them unable to talk.

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Another barrier to providing patient care was gowning in appropriate PPE before entering

a patient’s room, de-gowning when exiting their room, and then re-gowning for the next patient

next door. The process of donning PPE, cleaning P100 masks, and washing hands is time

consuming and adds up over the course of the day. Responding to codes also becomes delayed

when the patients are in isolation because of this process. Prior to going into a patient’s room

required planning and communication between team members. You had to be sure that you had

all of the required materials that would be needed before entering the room. The last thing you

wanted to do was to completely gown up and get into the room and find out that you forgot

something.

Once you were in the patient’s room, communication became the next barrier to

overcome. Inside the patient’s room, there were newly installed COVID-19 ventilation systems.

They were very loud, and hard to hear above. In addition to the loud ventilation, wearing a PAPR

suit added additional noise, making it hard to heard for the wearer. If the healthcare worker wore

a P100, the patient or receiver of information found it hard to understand them due to the muffled

sounds and other background noises. Stethoscopes needed to be disposable which meant quality

of assessments were reduced as well. Everything was diminished or inaudible.

Mobile computers and medical equipment were not permitted to go inside of the COVID

rooms, which presented all new challenges to the staff. IV poles and lines were long lined with

extension tubing to allow these pieces of equipment to stay in the anterooms due to the number

of medications and changes that needed to be made for each patient. Supplies were only to be

taken into the room to cover what the patient needed at that time so there wouldn’t be wasted

supplies. If an excess number of supplies were taken into a room, and the patient was discharged

or died, all of the remaining supplies were tossed in the trash.

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While one of our goals was to keep patients from feeling isolated, the barriers

surrounding the circumstances didn’t make it easy. Again, the rooms were very loud inside so

patients had difficulties hearing on the room phones or their cell phones. When we took the unit

cell phones into patient rooms, they needed to be inside of plastic baggies adding yet another

barrier. When families wanted to facetime, the baggie made it difficult to see. And facetime was

only appropriate in a handful of situations. Either the patients were unable, or their loved ones at

home were unable to figure out how to use facetime.

“During the COVID-19 pandemic, bereaved relatives perceived healthcare teams as

instrumental to: ensuring connectedness between patients and their family at end of life through

proactive measures such as video and telephone calls; providing relatives with ongoing updates

about their dying family member’s declining health; and enabling opportunities for relatives to

‘say goodbye’ when death is imminent” (Hanna et al., 2021).

During all of these complications, nurses were working long hours, picking up extra

shifts to cover other nurses that were out sick or cover areas that were short. Nurses across the

world took the pandemic as a reason to retire early. Nurse and healthcare burnout became

evident on all levels. There seemed to be no end to the patients arriving at the hospitals to be

taken care of but there were staffing shortages worldwide.

Study Summary

The objective of the study was to examine health and social care professionals’

experiences of providing end-of-life care during the pandemic in the UK. The aim of the study

was to learn about the experiences of these individuals providing end-of-life care, learn about the
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needs of the relatives when family members were dying of COVID, and lasty, learn about how

relatives could best be supported at the end-of-life during the pandemic (Hanna et al., 2021).

A descriptive qualitative design using a semi-structured interview process was used as the

method of collection for data. Interviewees consisted of doctors, nurses, allied health

professionals, social workers, and chaplains that worked with patients at the end-of-life during

the initial wave of the COVID-19 pandemic and resided in the UK.

The interviews were conducted between July and December 2020. “Interviews were

completed by two female researchers [RH, TM], who were not known to the participants.

Interviews were conducted via telephone (n = 11) or Zoom (n = 5), audio-recorded and lasted

between 32 and 71 min (mAvg = 55.1 min) (Hanna et al., 2021).

The results of the study were focused on the challenges that were faced along the way

and supporting the needs of the families. “Participants reported emotional and practical

challenges to providing end of life care during the pandemic, including increases in patient

numbers, reduced staffing levels and relying on virtual platforms for sensitive, emotive

conversations with relatives (Hanna et al., 2021).

Amidst the challenges and barriers that were faced during the pandemic, having to be the

sole communicator between family members and dying patients was the heaviest burden. In

conclusion of this study, researchers said this: “Clear guidelines are needed to outline when

relatives can visit a dying family when they are receiving end of life care in an institutional
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setting; this will minimize dilemmas and tensions between health and social care professionals,

relatives and within healthcare teams” (Hanna et al., 2021).

Critique

There were limitations to this study that if changed, may have benefitted the results and

outcome. The three biggest limitations, in my opinion, were the number of individuals

interviewed, the area being limited to the UK, and the time period.

I thought the study involved various levels of care in the healthcare and social working

fields, but I think it would have benefitted by having more interviews and experiences. By

interviewing more than the 16 individuals that they did, they would have gained additional

challenges and barriers to the end-of-life care during the first wave of the pandemic.

Having the time period right at the beginning of the pandemic allowed certain issues to

be included but left out many of the complications that came as the pandemic grew in size and

volume of patients being treated. By the end of the year many of the COVID numbers doubled or

tripled what they were at the beginning of the year. With the increase in patients, the staff was

even more dwindled, and burnout and fatigue had set in. At the beginning of the pandemic this

was not so much of an issue. Also, by the end of the year, many people dealt with personal loss

of a relative or loved one at the hands of the pandemic.

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By having a small group of individuals interviewed, it made sense to keep the polling

area remote to one location. The study may have benefitted from having a wider range of

professionals interviewed from across the globe as reactions to the pandemic and preparedness

greatly varied.

Current Practice

Starting at the beginning of the pandemic and running through the end of 2020, protocols,

policies and procedures could change weekly if not daily. It was of utmost importance to check

in with the CNC or supervisor at the beginning of each shift to check on any updates that may

have occurred. Due to the lack of information we had regarding the virus, routines, treatments,

and visitation policies changed frequently.

The more knowledge that we gained the more flexible policies became. By the middle of

the 2020, we were allowing visitors at the bedside of dying patients. They were only permitted to

come into the hospital and patient rooms for a very brief period of time. We would suit them up

in appropriate PPE and allow them to be in the room for 15 minutes. By the end of 2020, as long

as the visitors were gowned in appropriate PPE, visitations were not time limited of dying

patients.

It became evident that having families at the bedside was a crucial piece of the puzzle

that had been missing along the way. It allowed family members to make better informed

decisions about the patients and their end-of-life care. In addition, it allowed families to have the

closure that they had been missing during the pandemic of being kept away from their loved

ones.
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Even though this study was done in the UK it seems that everyone that worked through

the pandemic experienced very similar things. The longer that the pandemic went on, the more

things changed. Burnout became more relevant and emotions were at an all time high. Healthcare

professionals were dealing with loss at work and most likely loss of loved ones outside of work

too. There was an overwhelming emotional burden that seemed to loom over like a thunderstorm

and it never left.

Being able to learn from our experiences made us better and gave us knowledge to serve

those that came after the first wave. We were better prepared for how to handle things and were

more prepared as to what was going to come. We learned how to protect ourselves from the virus

and how to prevent the spread, and eventually we were able to have the vaccine. It’s impressive

to see how far we’ve come since the beginning and what we can do to better prepare for a

healthy future.
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Works Cited

Hanna, J. R., Rapa, E., Dalton, L. J., Hughes, R., Quarmby, L. M., McGlinchey, T., Donnellan,

W. J., Bennett, K. M., Mayland, C. R., & Mason, S. R. (2021). Health and social care

professionals’ experiences of providing end of life care during the COVID-19 pandemic: A

qualitative study. Palliative Medicine, 35(7), 1249–1257.

https://doi.org/10.1177/02692163211017808

Peiffer-Smadja, N., Lucet, J.-C., Bendjelloul, G., Bouadma, L., Gerard, S., Choquet, C., Jacques,

S., Khalil, A., Maisani, P., Casalino, E., Descamps, D., Timsit, J.-F., Yazdanpanah, Y., &

Lescure, F.-X. (2020). Challenges and issues about organizing a hospital to respond to the

COVID-19 outbreak: experience from a French reference centre. Clinical Microbiology

and Infection, 26(6), 669–672. https://doi.org/10.1016/j.cmi.2020.04.002

Smith, T. M. (2020, June 2). End-of-life care challenges during COVID-19: What doctors must

know. American Medical Association. https://www.ama-assn.org/delivering-

care/ethics/end-life-care-challenges-during-covid-19-what-doctors-must-know.