The coronavirus (COVID-19) pandemic has caused a majority of countries to take measures in controlling the spread of this contagious virus. These measures have ranged from limiting gatherings and enforcing social distancing to complete lockdowns with government surveillance. This has, in turn, changed the way many people operate daily. In an effort to limit transmission of COVID-19, many governments and employers have decided to instate work-from-home policies. Because many patients with certain disease processes and conditions are in an immunocompromised state, they are advised to limit their exposure in high-risk settings so that they do not contract COVID-19. With this, healthcare facilities and providers have offered certain services through virtual platforms, such as telehealth. Recently, scientists showed that urgent care telemedicine visits at a large healthcare system in New York, the epicenter of the pandemic, reported a 683% increase in telemedicine visits just from March to April 2020 (Abbott et al., Reference Abbott, Johnson and Wynia2020). With this perspicuous rise in telehealth visits comes an increasingly urgent question: how does this affect end-of-life (EOL) conversations between patient and provider?
At baseline, EOL conversations are already difficult discussions. They often include serious dialogue about prognosis, support systems, future intentions and interventions, healthcare goals, and treatment plans. Due to the magnitude of COVID-19, we must ensure that the nature and integrity of these conversations should not be compromised via telemedicine. Providers should also have these online EOL conversations by learning how to discuss goals of care in EOL discussions (Hewitt et al., Reference Hewitt, Gafaranga and McKinstry2010). With the second wave of the pandemic on the horizon, and the potential for this state to become our “new normal,” EOL conversations may not include a vital component of its character.
For many patients, the dying process is a journey with their loved ones, friends, and healthcare team. They have conversations with various physicians and nurses in different specialties, oftentimes together in the form of a family meeting. Patients experiencing this are able to talk to behavioral medicine, psychiatrists, palliative and hospice care, and pastoral care or hospital chaplains. The presence of one unified team in a central location is undeniably important when it comes to conversations such as family meetings, which are further compromised due to pandemic visitor restrictions. Continual emphasis on these meetings is crucial, as they show commitment to the patient's care, importance on the patient's outcomes, and stresses the gravity of the situation and decisions to be made. The collaborative dialogue, collective silence, and raw body language are essential when conveying human emotion. While silence and space can be devoted to the patient using telehealth as well, it is difficult to imagine that the same effect is elicited when your Outlook calendar sends you notifications about your next patient and the meetings you missed because you forgot to press the “dismiss” button.
The vital component from the EOL meetings conducted over telemedicine is the physical and emotional presence of your providers and loved ones in the room with you. Intimacy is inherently woven into the fabric of palliative care. Through telemedicine visits, this essence is distinctly erased. Researchers have found that, although there are no communicative differences between telemedicine and in-person visits, physicians employing telemedicine are 23% less likely to ask further questions regarding primary concerns brought up by patients (Mann et al., Reference Mann, Chen and Chunara2020). Therefore, while these conversations will still happen, they may not be conducted with the same depth and breadth as they would in person. Raw emotions may muddle your thoughts, and you may lose the salient takeaways necessary for your mental and physical well-being. Without the analysis of physical body language, telemedicine conversations may not have the same effect for both the patient and provider if they feel less submerged in the conversation. Additionally, the implementation of telemedicine also leaves behind the therapy of our oldest and most personal healing tool: the human touch. In one study, therapeutic treatments involving the use of gentle touch had a 67% decrease in severe stress levels for cancer patients, and a 31.5% decrease in those experiencing severe pain (Tieman et al., Reference Tieman, Swetenham and Morgan2016). We are aware of the importance of safety and public health measures due to a virus that has taken the lives of over 250,000 Americans and over 1 million human beings around the world. By no means do we suggest any measure that can increase the risk of spread, and, therefore, the risk of human suffering. Despite this, we must consider the impact that this pandemic has on EOL conversations, as individuals who crave direct human contact in a sacred, allotted space may not be able to do so.
In the midst of a pandemic affecting millions globally, perhaps telemedicine visits can be cherished as an act of love. These visits may be one of the only ways to restore intimacy in the form of a warm, inviting smile or raw tears. Maybe wearing a mask and goggles in-person may cover an appreciable amount of our face, leading to fragmented empathy. While intimacy via telemedicine may not be ideal, it is an undeniable signal to the person on the receiving end that their concerns and fears are being emphatically met, and seen, by someone with compassion. Telehealth may also promote equity in management of palliative care resources for patients, as clinical time per patient or community can be adjusted based on need (Weze et al., Reference Weze, Leathard and Grange2004).
As medical students and future healthcare professionals, we urge for an adaptation to our curriculum so that we are able to learn how to use telemedicine resources to fulfill even the most complex tasks, such as the discussion of EOL care. We must find a way to make the impersonal personal. People often state that nothing can replace the feeling and connectedness of the human touch. Whether this decision to move to telemedicine is based on the ubiquitous presence of technology in our society or dire necessity in the setting of a pandemic, only time will tell if a person's touch is best suited on the patient's shoulder or the “end call” button on their cell phone.
Open access
