Covid-19 Pandemic: Palliative Care in a pickle

The ongoing Covid-19 outbreak has made palliative care services relatively inaccessible for patients with terminal illnesses, said doctors.

Since these patients usually have low immunity, they are more prone to viral or bacterial diseases than a normal person, noted Dr Amirul Morshed Khasru.

The doctor heads the Paediatric Oncology and Haematology Department and Paediatric Palliative Care Unit of Dhaka Medical College Hospital (DMCH).

He said if patients with serious illnesses such as cancer, kidney disease and Alzheimer's contract coronavirus, they suffer more, and often require more time, about 28 to 30 days, to recover.

Thus, it has become difficult to provide palliative care to these patients in hospital wards amid the coronavirus contagion, the physician said.

In fact, DMCH's paediatric palliative unit had to be kept closed for most of April, after a leukemia patient undergoing treatment there was tested Covid-19 positive. 

While the infected child was shifted to Kurmitola hospital for coronavirus treatment, other patients in the unit had to be sent to their homes, private clinics and other hospitals, said Dr Amirul.

Around 13 nurses, who came in contact with the child, tested positive, he added.

"When we reopened the unit, we decided to send the palliative patients to cabins, to limit interaction with others," he said.

However, even the new arrangement couldn't reduce the contagion risk, as two more patients tested positive in the unit since then.

One of them, a six-year-old kidney and cancer patient, Shamim, later succumbed to the disease.

FEWER VISITS

Inpatients and outpatients visits at palliative care units of hospitals and private clinics have also seen a sharp decline.

Many have been skipping necessary appointments and treatment including morphine and painkiller administration and palliative chemotherapies fearing the risk of potential infection.

Salma Chowdhury, founder of Ashic Palliative Care Unit, said earlier 20-25 children with terminal diseases would come to her organisation for treatment every month.

In April, the number of visits by child patients was zero, six in May and nine in June, she said.

According to Salma, most patients, coming in now,  are from Dhaka; those living outside are reluctant to come due to the fear of infection and increased transport cost.

"Earlier, one needed to spend around Tk 500 for transport, which has become around Tk 1,500 in recent times," she said.

The picture is similar at Bangabandhu Sheikh Mujibor Rahman Medical University (BSMMU).

Currently, BSMMU's  21-bed palliative care unit has three patients while its three-bed paediatric palliative care is now empty.

Dr Marufa Khanam, medical officer of BSMMU's palliative care unit, said when patients with terminal illness come in a critical condition, doctors cannot wait for their Covid-19 test result to start the treatment.

"However, when they are tested positive later, it creates a  lot of fear among other patients of the wards and their family members," she said.

The BSMMU also had to stop its home palliative care services in April, as family members of the patients were reluctant to allow medical professionals in their houses, said Dr Marufa.

"Even though it has been restarted from May, the number of patients seeking this service is less compared to before," she added.

The wife of a 60-year-old stomach cancer patient from Gazipur said although her husband's condition has deteriorated, the family is afraid to take him to a hospital in Dhaka for a follow-up, fearing infection.

"The way the doctors and nurses are being infected, my sons don't dare to take him to any hospital. Rather, we are contacting his doctor over the phone for consultation," she said.

Besides, the patient too is reluctant to travel, she added.

Meanwhile, the number of patients in DMCH's eight-bed paediatric palliative care unit, which otherwise remains very busy, also saw a decline in the first few months of the pandemic.

However, from this month, patients have started to come in to palliate their pains, said Dr Amirul.

According to the Quality of Death index 2015 by the Economist Intelligence Unit, Bangladesh stands 79th in a list of 80 countries in terms of quality of life during terminal days.

FEWER MEDICAL CAREGIVERS

Since the coronavirus outbreak a significant number of doctors, nurses and other medical staff from palliative units have been deployed to provide emergency care to Covid-19 patients in many hospitals.

In DMCH, only three out of six consultants are working at the 29-bed paediatric oncology and haematology department and eight-bed paediatric palliative care unit.

Two of the consultants are working at the DMCH's children's Covid-19 unit and one is currently in quarantine.

However, three junior doctors, not yet palliative care specialists, are working alongside the three consultants of the paediatric oncology and haematology department.

When a doctor goes for Covid-19 duty for a week, he is technically unavailable for a month, as s/he needs to be quarantined for 14 days and later, isolated for the next seven days at home, said Dr Amirul.