End of life in the time of COVID-19 pandemic: take care of death.

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To the Editor,

COVID-19 outbreak is a public health emergency of international concern. Its manifestations range from asymptomatic forms to a severe respiratory distress needing intensive care unit (ICU) admission.[1] One of the most important characteristic of SARS-CoV-2 is the high transmissibility of the infection so hospitals suddenly ran out of ICU beds. The distribution of resources has rapidly become a priority and the most fragile people as elderly and multimorbidity patients often risk to be excluded from advanced care; in fact, life expectancy in these groups of patients is low and many national guidelines suggest to wisely evaluate the real possibility to survive before deciding on ICU admission.[2] Moreover, many people are conscious of their heath conditions and they often express the wish to die in their familiar environment.

Many efforts are dedicated to save lives in this emergency, but poor attention is focused on the quality of last hours and days of people which could not access hospital care.

People developing a severe infection by SARS-CoV-2 suffer from many symptoms, not only dyspnoea, but also delirium, pain, and existential suffering. Palliative care guidelines consequently represent the cornerstone to assist this kind of patients.

One of the most difficult challenge is to guarantee patient’s assistance, but at the same time the safety of care providers; consequently, medical examinations have to be reduced as much as possible and a therapeutic planning has to be drawn up and accessible all the time.[3] This planning has to take into account the possible evolution of clinical conditions (e.g. prescribing subcutaneous formulation in view of incoming difficulty swallowing) and a way to communicate with a palliative care provider should be established.

Sometimes symptoms are resistant to treatment; palliative sedation might be the answer to this dramatic condition. Palliative sedation is defined as a pharmacological reduction of consciousness to relieve intractable symptoms.[4] It needs to be carefully explained to the patients and his relatives because it is a point of no return and an informed consent has to be recorded. It is not a form of euthanasia: data so far collected shows that palliative sedation does not hasten death, so it can reconcile the right to die without suffering and religious issues.[5]

In conclusion we would like to highlight the fundamental importance of palliative care for the most fragile people because, even though they cannot have access to life sustaining treatments, they absolutely deserve a dignified death.