Crisis Symptom Management and Patient Communication Protocols Are Important Tools for All Clinicians Responding to COVID-19
Epidemiological data from China suggest that the two factors most closely associated with coronavirus disease 2019 (COVID-19) severe illness and mortality are age, and underlying health conditions—precisely the characteristics of the palliative care population of seriously ill older adults. This pandemic is already causing widespread suffering among patients and their families because of symptom burden (most commonly from dyspnea and fatigue) and fear and anxiety (present in any serious illness but exacerbated by the lack of information and understanding about a novel disease). If the health system's capacity is surpassed, this suffering may also be compounded by the existential distress caused by lack of availability of medical services and life-saving equipment. Although palliative care specialists are trained to address these sources of physical and psychological suffering—and are thus well equipped as individual clinicians to meet the demands of the COVID-19 crisis—the national palliative care workforce was insufficiently sized to meet the needs of patients with serious illness even before this crisis emerged. As specialists whose clinical skills are particularly appropriate for responding to COVID-19, palliative care teams must strategically deploy scarce resources where they can provide the most benefit in the form of relief of suffering for patients and families. The role of palliative care teams is thus twofold: to provide direct consultation to colleagues when they need help caring for those patients whose needs are most acute, and to enable all clinicians to provide palliative care services, by connecting nonpalliative care colleagues to crisis-appropriate resources for symptom management and patient and family communication. Because of widespread training gaps in symptom management and patient communication, , , practical protocols and algorithms are needed to support frontline clinicians responding to COVID-19 in emergency departments, intensive care units, general medicine units, and outpatient and other care settings. Although crisis conditions are unlikely to be conducive to comprehensive continuing education, palliative care teams working in hard-hit regions of the country can fill a critical role by disseminating practical symptom management protocols to clinicians. In regions that are preparing for but not yet in crisis mode, palliative care teams have an important role to play by facilitating systematic approaches to symptom management and patient/family communication with training specific to COVID-19 within their organizations. The authors of this article—along with other educators across the country—have developed publicly available rapid response education and tools specific to clinical scenarios facing health care professionals responding to COVID-19. 

Symptom management is key to providing relief for patients suffering from a serious illness, whether to improve patient experience during illness and recovery or to ease the dying experience. In areas where hospitals are at or more than capacity, it will be important for health systems to have the capacity to safely manage patients' symptoms at home and other community residential settings—whether those symptoms are caused by COVID-19 or by an unrelated serious illness. This means that clinicians working in the hospital, making visits to patient homes, or providing care and monitoring patients telephonically will all benefit from symptom management training. Palliative care teams are encouraged to work with their organization's leadership to ensure that all clinicians receive symptom education, prioritizing dyspnea, pain (and opioid-induced constipation), and delirium. The Center to Advance Palliative Care (CAPC) has developed a series of symptom protocols in response to the COVID-19 pandemic that provide stepwise symptom guidance for all clinicians. The protocols account for care provided in all settings, including oral, sublingual, intravenous, and subcutaneous medication administration. Importantly, these tools are specific to COVID-19. They will be continuously updated as the global medical community learns more about the pathophysiology of the virus (e.g., recent evidence suggesting that nonsteroidal anti-inflammatory drugs are contraindicated for patients with COVID-19) as well as to account for potential drug shortages and common formulary restrictions. These clinical tools are publicly available at https://www.capc.org/toolkits/covid-19-response-resources . 

Clinicians across the globe are suddenly faced with explaining unprecedented situations to patients and families with no road map. Although anecdotal, VitalTalk and Mount Sinai Health System faculty report that frontline clinicians in their organizations experience distress in patient and family conversations about whether COVID-19 testing is appropriate and/or available, limitations on care delivery resources, difficult decision making, families separated from sick or dying loved ones to prevent the spread of infection, and fear of a virus whose characteristics and long-term consequences are not yet known. VitalTalk—a clinical communication education provider—has developed an open source communication guide to help clinicians navigate these unprecedented conversations. The guide identifies common questions being asked by patients and families across the U.S. and provides specific phrases and techniques (conversation maps) designed to support patients during crisis. The guide is publicly available through VitalTalk's Web site ( www.vitaltalk.org ) and via COVID-19 response toolkit of CAPC. Like the symptom protocols of CAPC, the VitalTalk communication guide will be continuously updated to ensure that it addresses the real-world experiences of patients and health care professionals living through the COVID-19 pandemic. 

All leaders of health care organizations, crisis committees, and clinical leaders are urged to provide tools and training to help their clinical teams respond to COVID-19. Palliative care leaders have a critical role to play in raising awareness among their leadership and colleagues about the availability and implementation of existing resources and in developing or adapting materials specific to their organizations. Symptom and communication tools may be added to COVID-specific internal toolkits (e.g., on an intranet site or via electronic mail dissemination), and quick-reference materials may be printed and made available as pocket cards. These workforce training and technical assistance materials should be accompanied by guidance or criteria for allocation of the scarce resource that is the specialty-level palliative care team. Palliative care allocation should include clinical scenarios when it is appropriate to request a face-to-face or telemedicine consult from the specialty palliative care team (including phone numbers and other relevant contact information). During the COVID-19 crisis, health care organizations can deploy a strategy to reduce human suffering by supporting all frontline clinicians to communicate compassionately with patients and families and to address burdensome symptoms. 

