Urgent Need to Address the Immense Suffering Due to the COVID-19 Pandemic Surge: Subcutaneous Route to the Rescue!

‘The worst thing we can do is abandon someone who is hurting. Attitudes which promote death rather than affirm life are the ultimate abandonment.’ – Dame Cicely Saunders.

The second wave surge of the COVID-19 pandemic in India has presented a challenge to urgently mitigate the immense suffering. The rapid spread due to the variant, airborne transmission, and flaunting of prevention guidelines has resulted in fear and panic. The rapid deterioration in severe COVID infection results in total suffering, which is physical, emotional, social, financial, and spiritual for both the person and family. Compounding this is the overwhelmed health-care system resulting in a lack of vaccinations, oxygen, hospital and ICU beds. All these lead to despair, anguish, and hopelessness. How can we mitigate this immense suffering? There is a need for a more effective integration of palliative care with COVID care at all levels. A recent BMJ article outlines palliative care for patients with serious COVID-19.^[1] This integration must result in a better quality of life and recovery as the immediate goal and also better quality of death if it is inevitable. This is wartime and the need of the hour is for all palliative care teams to prioritise this need and be involved in effective palliative care integration with COVID care, in addition to their primary area of responsibility.

In the context of severe COVID infection, the acute shortages of hospital and ICU beds can only be addressed by making the bed at home functional. Desperate families need to be supported and empowered to take care of their loved ones at home by both COVID care and palliative care joining hands and adhering strictly to all personal protection measures. This can be done by effective use of the subcutaneous route (SC) for symptom control coupled with simultaneous ongoing specialist COVID care support including oxygen provision as possible.

There is a good experience by Bangalore Baptist Hospital (BBH) palliative care over the past more than two decades of using the SC route by family, in non-COVID persons and keeping them comfortable at home and also when inevitable to allow a peaceful death at home. This ‘Family Driver’ method, so called, is in honour of the families past and present, who were willing to be involved in caring for their loved one at home. This involves drawing up a combination of necessary medications in a 10 ml syringe as instructed by the palliative care specialist, and giving 1 ml, regularly every four hours and in between as needed by the family. This is possible when syringe drivers are not available or not practical in the Indian situation. The use of the SC route for COVID persons, especially the elderly in their homes by the CanSupport home care teams in Delhi, has been a great encouragement and example for all of us. The two recent articles in the Indian edition of ehospice newsletter give more details on the above methods.^[2,3] (Please note a clarification that giving ‘emergency palliative kit’ is not BBH protocol for COVID-19. Emergency kits with morphine are not given to any patient with COVID-19 who did not get a bed. At present, BBH palliative care is not making home visits to COVID patients due to increased COVID care workload within the hospital.).

A detailed guideline for palliative home care is outlined in the Indian Association of Palliative Care (IAPC) Position Statement on COVID Care in the Indian Journal of Palliative Care^[4] and linking it with more details in the IAPC newsletter.^[5]

It is interesting to note in a recent BMJ editorial, the authors are raising the possibility of dying people in the United Kingdom being cared at home by family.^[6] Furthermore, the Scottish NHS guidelines of managing COVID patients at home or in the community using the SC route, when syringe drivers are not available, are on the lines of our Indian experience.^[7]

The IAPC is an organisation member of the International Collaborative for Best Care for the Dying Person. ‘Project India’ of the collaborative has in its documentation included the intermittent regular 4 hourly and as needed SC injections for end-of-life care.^[8,9]

With ongoing specialist COVID care and good support through specialist palliative care, it is possible that some of the serious cases may recover. However, if they continue to deteriorate and death becomes inevitable, it would be a peaceful death at home with family present. Families and carers, must be made to understand by sensitive explanation, that allowing people to die peacefully by controlling their distressing symptoms is totally different from killing them which is euthanasia and never part of palliative care.

At present, many people are dying in ambulances, hospital compounds, and corridors while waiting for a hospital bed. They could be cared at home by family while someone is exploring the availability of a hospital bed. On the other hand, an elderly who decides with their family to stay at home can be managed and kept comfortable by family. The 10 ml syringe with a combination of necessary medication as advised by the palliative care specialist can even be used by carers to keep their family member comfortable while waiting in an ambulance or hospital compound or corridors. In all these circumstances, the role of the palliative care specialist is pivotal.

Another area of upcoming need is bereavement support as many families are experiencing distressful last moments of their loved ones and unable to say their goodbyes or perform their last rites properly. Dame Cicely Saunders rightly cautioned ‘How people die remains in the memory of those who live on.’

Let us all in palliative care advocate for the integration of palliative care with COVID care and be available to use our expertise to mitigate this tremendous serious health related suffering. We need to exploit the SC route and leverage it with our two strengths of family and faith. Yes, we can make a difference by working closely with our specialist COVID care colleagues.