A guideline for Physicians to help family
Author: Dr Stanley C. Macaden , Ex. Director and Honorary Palliative Care Consultant, Bangalore Baptist Hospital (BBH) & Honorary Consutant, The Christian Medical Association of India (CMAI)
The second severe multi-variant Covid-19 wave and recent surge has caused unprecedented challenges for the health care system all over the country and many parts of the world. A common denominator now is the crucial lack of hospital and ICU beds to treat those with serious and critical COVID-19 infections and especially the care of the actively dying. The only remaining and possible course of action is to provide them the best possible care at home, that is managed by the immediate family and supported by community health care providers and volunteers.
A guideline for the family and those caring for the affected is outlined below. Some of the specific instructions are as applicable in Bangalore. However, the same can be modified as appropriate for any local situation.
Shared decision making (by patient, family, and heath care providers) through good communication is key in this whole process.
Please do not panic. These guidelines and support of a Palliative Care Team will help you take care of your loved one at home.
- If proven to have COVID-19 (by RT-PCR) and having symptoms possibly necessitating hospital admission, get yourself on to the Hospital Admission Waiting List, in case this becomes necessary.
- Family to contact their treating Physician/Hospital, for an e-Consult and follow their instructions for treatment of Covid infection.
- Family to keep the following documents available on WhatsApp to share them as needed.
- Family to register the person with a Hospital using its on-line form and take a printout.
- Family to sign an online ‘Informed Consent Form.’ (specific for Covid -19) available with the same hospital.
- Family to have a referral letter from their treating Doctor/ Hospital on letter head and/or seal with the Doctors name and Registration number.
- Family to produce a copy of their RT-PCR Positive report.
- Family to keep a list of patient’s current medication/ Doctor’s Prescription.
- Copy of any recent Discharge Summary.
A Video Consult is helpful to see the person and family.
- Family to take all precautions as per Covid appropriate behaviour and by using Personal Protection Equipment (PPE) or improvised protective wear, as much as possible. (Masks – N95 Respirator, Face Shield, Gloves,)
- For regular monitoring keep a standard Pulse Oximeter and small Digital Thermometer.
- Please help the person to practice prone position breathing if they have difficulty in breathing and SpO2 falls below 94. Please see a video on this under information.
- Family to approach a Palliative Care Unit/Team and collect an ‘Emergency Kit’ with necessary medications, syringes, and butterfly needle and canula for starting the Subcutaneous (SC) route. Contact details for Bangalore Baptist Hospital (BBH) given below.
- May continue oral route for medication if person able to swallow without choking. However, in any case, keep the SC route available.
- See the attached video for starting the SC route and loading the syringes. Video shows using a 5ml syringe for individual single medication. For giving a combination of meds use a 10ml syringe.
- For a person who is actively dying SC medications need to be given. This palliative sedation is only to reduce the distress of dying by sedating, and reducing symptoms of pain, breathlessness, vomiting, and restlessness. It is not intended to end life, but death may occur as an inevitable progression of the severe illness.
- For a person actively dying with breathlessness, severe anxiety, anguish, and restlessness, make a call to the Palliative Care Doctor regarding palliative sedation (e.g., Dr Stanley C. Macaden 9663323810 / firstname.lastname@example.org) and follow up with a video call if instructed. If unable to contact, start with medication as given below and contact the doctor again later.
- Then load a 10ml syringe as follows –
- Injn Morphine 15mg/ml x 1 ampules – 15 mgs (1 ml)
- Injn Midazolam 5mg/ml x 3 ampules – 15mgs (3ml)
- Injn Haloperidol 5mg/ml x 2 ampules – 10mgs (2ml)
- Injn Ondansetron 4mg/2ml x 2 amps – 8mgs (4ml)
The doses of these drugs may be adjusted by the Palliative Care Doctor/Nurse as appropriate.
Give 1ml of the above combination every 15 mts till person just sedated and then continue 1ml 4 hourly regularly by the clock at 6:00 am – 10:00 am – 2:00 pm – 6:00 pm – 10:00 pm and 2:00 am (Start at the next closest time) may omit 2:00 am dose if person is comfortable).
Also give 1ml of the same combination anytime in between for any distressing symptom. You must still continue with the next regular dose due. (eg. person is restless around 9:00 am, give 1ml of extra dose and still continue with regular dose at 10:00 am). May omit a dose if person adequately sedated, but always after consultation with the palliative care doctor.
In honour of the many families in the past (non-Covid times), who were fully involved in caring for their loved one by using the sub-cutaneous route (SC), we call it the ‘Family Driver’ as opposed to the ‘Syringe Driver’ used in other parts of the world which is not practical for home care in India.
- For noisy breathing – keep person on their side to allow accumulated mouth secretions to trickle out. Also give bolus Injn Buscopan 20mgs SC every 4 hours if needed to prevent further secretions.
- Dexamethasone 4 – 6 mgs SC once daily – 5 days.
- Budesonide (Budecort) 400 mcg Rotacap powder inhaler 8:00 am & 1:00 pm daily or 400 mcg Metered Dose Inhaler (puff inhaler) 8:00 & 1:00pm using spacer.
- Continue with Covid specific treatment as much as possible.
- While in BBH to collect the ‘Emergency Kit’ also visit ‘Mercy Drops’ to collect any equipment needed and as available. (Including Hosp beds, wheelchairs, walkers, commodes etc.)
- If the person is seriously ill and deteriorating, fix a time with the Palliative Care Doctor/Nurse for daily video call follow-up and management.
- For Spiritual support, play favourite Sacred music, Bhajans, poems etc. May read Sacred Scripture verses and pray to submit completely to the Almighty’s Will for healing and wholeness.
Bibliography & Information:
- BBH Video on starting a Sub-cutaneous (SC) route. : https://drive.google.com/file/d/1tqULHTuKGiBsRWgznFIYzylP6zjHpi9d/view?usp=drive_web For giving a combination of medicines use a 10ml syringe.
- 5 IAPC position on providing home-based palliative care and nursing support for serious COVID-19 patients dying at home and those with cancer and chronic or end-stage organ impairment dying at home whose treatment got limited due to COVID-19 situation. Dr Stanley C. Macaden and Sr Alice Stella https://www.palliativecare.in/palliative-care-in-covid-19-pandemic/
- NICE – COVID-19 rapid guideline: managing COVID-19 COVID-19 rapid guideline: managing COVID-19 (nice.org.uk)
4) Scottish Palliative Care Guidelines – Alternatives to Regular Medication Normally Given via a Syringe Pump When this is Not Available
- International Collaborative for Best Care for the Dying Person https://www.bestcareforthedying.org/
6) Bangalore Baptist Hospital (BBH)
For Emergency Kit: BBH Palliative Care Department: 080 22024395 during office hours Mon – Fri 8 – 4.30,
Sat 8 – 12.30, email: email@example.com For Mercy Drops: 080-22024411/553 or 9480827846
- Prone position for Covid-19 patients / Proning breathing exercises for Covid-19 patients – Bing video
- For Oxygen cylinders/concentrators contact https://mediniq.in/product/portable-oxygen-machine-inogen-sale/
Bangalore Local Information
- For PPE Kit – PPE kit in Bengaluru, Karnataka | PPE kit, Personal Protective Equipment Price in Bengaluru (indiamart.com)
Karnataka Govt BBMP Portal for Bed Availability
- BBMP-Covid Bed Status – Live (bbmpgov.in)
- Bed Availability update – Google Drive
- Govt of Karnataka, Drugs Control Dept,
Covid-19 War Room for REMDESIVIR and OXYGEN HELP LINE: 8951755722