Palliative Renal Care and the Covid-19 Pandemic

Introducao: O cuidado paliativo e uma abordagem voltada para alivio do sofrimento, controle de sintomas e melhora da qualidade de vida. Deve ser oferecido em conjunto com o tratamento padrao de qualquer doenca que ameace a continuidade da vida, como, por exemplo, a infeccao pela Covid-19. Discussao: Os principios bioeticos e as estrategias utilizadas pela medicina paliativa podem auxiliar os nefrologistas no cuidado dos pacientes com disfuncao renal, que, alem de serem do grupo de risco para evolucao mais grave da infeccao por coronavirus, enfrentam as dificuldades do isolamento no seguimento do tratamento dialitico e ambulatorial. Essas ferramentas sao: I) tomada de decisao compartilhada, que proporciona a participacao do paciente e dos familiares como facilitadores na sistematizacao do raciocinio da equipe, alem de respeitar o principio da autonomia; II) manejo de sintomas, que deve ser prioridade para a garantia do alivio do sofrimento mesmo em momento de isolamento social; III) habilidades em comunicacao, sendo possivel amenizar dificuldades em anunciar mas noticias ou decisoes complexas atraves de tecnicas de comunicacao; IV) assistencia ao luto, em que, em situacoes agudas como a pandemia, de perdas inesperadas, a importancia do acolhimento dos profissionais de saude torna-se ainda maior. Conclusao: Os principios dos cuidados paliativos sao essenciais para enfrentar os desafios de uma crise humanitaria, que causa sofrimento ao ser humano em todas as dimensoes e exige a construcao de estrategias que possam manter os pacientes assistidos, confortaveis e com medidas proporcionais a sua condicao clinica e as suas preferencias.
Introducao: O cuidado paliativo e uma abordagem voltada para alivio do sofrimento, controle de sintomas e melhora da qualidade de vida. Deve ser oferecido em conjunto com o tratamento padrao de qualquer doenca que ameace a continuidade da vida, como, por exemplo, a infeccao pela Covid-19. Discussao: Os principios bioeticos e as estrategias utilizadas pela medicina paliativa podem auxiliar os nefrologistas no cuidado dos pacientes com disfuncao renal, que, alem de serem do grupo de risco para evolucao mais grave da infeccao por coronavirus, enfrentam as dificuldades do isolamento no seguimento do tratamento dialitico e ambulatorial. Essas ferramentas sao: I) tomada de decisao compartilhada, que proporciona a participacao do paciente e dos familiares como facilitadores na sistematizacao do raciocinio da equipe, alem de respeitar o principio da autonomia; II) manejo de sintomas, que deve ser prioridade para a garantia do alivio do sofrimento mesmo em momento de isolamento social; III) habilidades em comunicacao, sendo possivel amenizar dificuldades em anunciar mas noticias ou decisoes complexas atraves de tecnicas de comunicacao; IV) assistencia ao luto, em que, em situacoes agudas como a pandemia, de perdas inesperadas, a importancia do acolhimento dos profissionais de saude torna-se ainda maior. Conclusao: Os principios dos cuidados paliativos sao essenciais para enfrentar os desafios de uma crise humanitaria, que causa sofrimento ao ser humano em todas as dimensoes e exige a construcao de estrategias que possam manter os pacientes assistidos, confortaveis e com medidas proporcionais a sua condicao clinica e as suas preferencias.

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# Abstract
Introduction: Palliative care is an approach aimed at relieving suffering, controlling symptoms and seeking to improve quality of life. It must be offered in conjunction with standard treatment for any disease that threatens the continuation of life, such as a Covid-19 infection. Discussion: The bioethical principles and strategies used by palliative medicine can assist nephrologists in the care of patients with renal dysfunction, who face the difficulties of isolation at the beginning and follow-up of dialysis in outpatient treatment, and those who are at risk for a more serious disease progress. Some of them: -a Shared decision making, which enables the patient and family to participate as facilitators in the systematization of the team's reasoning, in addition to respecting the principle of autonomy; -Symptom Management: which should be a priority to ensure relief of suffering even in times of social isolation; -Communication skills: making it possible to alleviate suffering in announcing bad news or complex decisions through communication techniques;; -Bereavement assistance: which in acute situations such as the pandemic, causing unexpected losses, the importance of sympathy from healthcare professionals becomes even greater. Conclusion: The principles of palliative care are essential to face the challenges of a planet-wide crisis, which raises human suffering in all dimensions, and which requires the construction of strategies that can keep patients assisted, comfortable and with measures proportional to their clinical condition and preferences. According to the World Health Organization (WHO), the role of palliative care is fundamental in facing large human crises like this. These crises are defined by large-scale events that affect populations or societies, causing a variety of difficult and distressing consequences, which can include massive loss of life, disruption of livelihoods, society collapse, forced displacement and other political and economic factors, psychological and spiritual effects, such as, for example: pandemics, natural disasters and civil wars 1 .

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How to we explain the link between palliative care and a pandemic, a situation of acute and unexpected nature?
Palliative care is an approach aimed at relieving suffering, controlling symptoms and improving quality of life. It should be offered in conjunction with standard treatment for any disease that threatens the continuity of life. In a time of Covid-19 pandemic, although the main goal of care is to save lives, it is not the only one. Not all lives can be saved, and even the saved ones will go through a process of great suffering, either in the physical sphere, with the appearance of symptoms that need to be controlled, or in the social sphere (family support, isolation, access to proper hygiene); and emotional, expressed by fear, anxiety and sadness, from patients, their family members and the care team 2 .
In this context of public calamity, with different rules, the collapse of the healthcare system is a real risk; with healthcare professionals often physically and emotionally exhausted, and in which the very important presence of family members is not recommended, knowledge of palliative care can greatly contribute to assistance in the Covid-19 pandemic. Professionals on the front lines may face unprecedented situations, which will require skills and technical knowledge, common to palliative care professionals who routinely deal with human suffering. Some palliative care tools are also very relevant for nephrologists at this time of crisis:
- Shared decision-making: Although decision-making is a technical issue and, therefore, related to the care team, it can be improved and even facilitated when we know the values, previous health information, social support and patient's wishes in a shared decision (team, patient and family). This is an example of good medical practice in complex situations, and one of the pillars of palliative care. The limitations of advanced life support, including the failure to perform renal replacement therapy, requires systematization of clinical reasoning, and must take into account a number of factors. In an attempt to follow the bioethical principle of not causing harm, nephrologists must careful assess the real benefits of offering dialysis to patients with other chronic diseases in progress that are not responding to the standard treatment already in place; to very old patients (but not as an isolated factor); fragile and totally dependent patients; to people with previous cognitive impairment and without social support. Thus, it is important to be aware of the fact that many patients infected by the coronavirus may already have such conditions, and therefore, regardless of an acute situation such as Covid-19, they would not benefit from intensive treatment involving more invasive measures, if their clinical condition requires it. Transfer to the intensive care unit, orotracheal intubation, dialysis, cardiopulmonary resuscitation, among others, can become procedures out of proportion to the health condition of some patients. - Symptom management: Patients who are already receiving renal palliative care should be reassessed periodically; especially those who have chosen not to undergo dialysis therapy and those who are rapidly progressing from an underlying disease. Uremic symptoms are expected to worsen over time, and with the progression of kidney disease, making the management of symptoms a priority to ensure suffering relief. Since they are a high-risk group, it is recommended to avoid travel and exposure in face-to-face consultations and opt for teleconsultation. The relief of human suffering involves the mastery of techniques and specific knowledge to control symptoms at any stage of the disease, especially in the case of patients who inevitably progress to the end of life. - Communication skills: Many conflicts related to death, clinical worsening or the feasibility of certain treatments, such as dialysis, could be mitigated by means of communication techniques that ensure clarity of information, listening, acceptance, respect for emotions and the cognitive ability of each one. It is necessary to be careful when communicating bad news and that is why we must prepare, with an appropriate environment, take time and plan the approach, always respecting the emotions of each one, including the desire to be informed or not of certain aspects of the disease. - Bereavement assistance: In acute situations such as a pandemic, the risk of unexpected loss is higher. A family member who takes his loved one to the hospital on one day, and never sees this person again, and on another day receives the news of the death, without having followed the illness process and without even being able to attend a funeral or a farewell event, has greater difficulty in accepting the loss. In these situations, the risk of complicated mourning is high, so the sympathy of health professionals becomes essential and must be maintained in the follow-up and care of the family members.To enable the best care during social isolation, the nephrologist can use telemedicine, which has been properly authorized by the Federal Board of Medicine, and not suspend family meetings to deal with the most diverse subjects, such as shared decision making, provide information about the progress of the patient, and assist in grieving. At this moment, a hug and the expression of a touch should be replaced by a phone call or a videoconference, and not by the silence of the lack of information, which can be misinterpreted by abandoning care.
In nephrology, we also live an unprecedented scenario in the care of nephropathic patients. Despite the universal recommendation of social isolation, for dialysis patients (specifically, those on hemodialysis -93%) this is not a reality. They cannot stay at home, as they depend on treatment to stay alive, and the fear and risk of exposure increases, both for the team and the patient. Hemodialysis clinics need to adapt for this new reality, requiring greater allocation of financial resources, which are insufficient to date. All these new difficulties can generate physical and emotional stress on the healthcare team and on the dialysis patients, who need to be valued and cared for, in order to avoid the collapse of dialysis clinics.
The principles of palliative care are essential to face the challenges of a huge crisis, which causes suffering to human beings in all dimensions. The humanitarian commitment focuses not only on the needs of the individual as an individual, but on the context in which he/she lives, gathering resources that ensure basic human rights, such as dignity. In a time of pandemic, we must understand that it is our role to fight to save lives, but not less important, it is also our role to alleviate the suffering of patients, family members and the healthcare team.