“It is not because we are in a period focused on emergencies that we should forget about humanity.” Palliative care specialists are also at the forefront of the rampant coronavirus epidemic in an effort to prevent any “submersion”.
For these caregivers responsible for relieving people with severe forms of Covid-19, facing anxiety, pain and asphyxia, and who will not be able to benefit from resuscitation, the challenge is to learn from this happened in Alsace, a very affected region.
Do not “get mad”
In Mulhouse, in particular, the teams were not prepared for the massive arrival of patients, says Professor Régis Aubry, former president of the French Society of Palliative Care (SFAP), who works in a unit of a CHU of the Bourgogne Franche Comté region.
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As a result, SFAP, in collaboration with other specialists (geriatricians, resuscitators, pulmonologists, etc.) is mobilizing to help and train healthcare colleagues.
For some patients, resuscitation may be part of the relentless therapeutic S: “Sorting? This is what resuscitators have always done, “said Professor Olivier Guerin, president of the French society of gerontology and geriatrics (SFGG).
Thus, even before the era of Covid-19, for certain chronic diseases, such as “severe respiratory insufficiency (…) we know that resuscitation is not beneficial in the long term, we will make them suffer for nothing”, believes Dr. Thibaud Soumagne, resuscitator at the Besançon University Hospital, who is also a pulmonologist. In this hospital, as elsewhere, a Covid-19 palliative care unit was created.
But if resuscitation needs far outweigh the country’s available supply, people who could have benefited from it risk being deprived of it.
Soothe the sufferings
Whatever happens, the therapeutic approaches offered to all health and medico-social establishments but also at home, in the context of the epidemic, are not aimed at euthanasia, recalls the SFAP, which issued issued proposals and emergency therapeutic advice sheets for the attention of places affected by hospital saturation or which are likely to be saturated soon.
The aim is “to provide relief to the most severely ill patients” in the event of breathing difficulties or distress.
Fear of lack of medication
However, with “the shortage of midazolam (Hypnovel) to fall asleep, the lack of morphine which seems to settle down as well as in electric syringe pumps”, Dr. Bernard Devalois, doctor in palliative care at the Protestant house of Bagatelle in Bordeaux warns against “the temptation to euthanasia” that caregivers in the nursing home could feel when faced with residents plunged into horrible suffering such as asphyxiation.
Bernard Devalois deplores in this regard “the absence of a strategic midazolam stock” which he claims to have “proposed to constitute, fifteen years ago, in the event of a pandemic”.
Morphine to relieve pain and breathing difficulties (dyspnea), midazolam (Hypnovel) for sedation (to fall asleep) and a medication for bronchial congestion, combined, serve to soften the end of life, according to SFAP. In the absence of Hypnovel, other injectable products such as Valium or Rivotril, are possible but “it is a degraded procedure”, judges Dr. Devalois.
Need for “dignified” care
The respiratory symptoms are very anxiety-provoking. Anxiolytics improve patient comfort. Some by mouth are useful, but can no longer be used in the late stages of respiratory distress. At the asphyxiation stage, the urgency is then to implement deep sedation very quickly, recommends Dr. Devalois.
The regional health agencies (ARS) should ask hospital pharmacies to deliver sufficient stocks of the necessary medicines to nursing homes and small hospitals, he suggests.
Professor Claude Jeandel, president of the National Professional Geriatrics Council, asked the Minister of Health for access to the drugs recommended by the SFAP “for treatment worthy of the asphyxious respiratory distress of the very large number of residents who do not have hospitalization which will die in Ehpad “.
The current model is not adapted to the structured care of aging and chronically ill people in the city, notes for his part Professor Guérin, fault according to him, in some Ehpad, of coordinating doctor, empowered to prescribe in situations of emergency, and night nurse.