For all patients

• • Document the discussion around goals of care with the patient and/or substitute decision makers and update the patient's category status in the medical record.

• • Consider involving Spiritual Care, Social Work, and/or Palliative Care if appropriate. Ensure you have communicated the patient's COVID-19 testing status, whether confirmed or pending, so that all providers are aware of the need for appropriate personal protective equipment.

• • Place the patient in a private room if possible, with clear instructions to follow contact and droplet precautions.

• • Visitation

  • ○ Due to COVID-19, visitation in most centers is being restricted. Please refer to the most up-to-date local protocols.

  • ○ When visiting, family members must follow droplet and contact precautions, including wearing a procedure mask with face shield, isolation gown, and gloves, and perform hand hygiene before and after their visit.³

  • ○ Encourage visits with relatives by means of telephone or video conferencing, if possible, to minimize physical visitors.

Nonpharmacological symptom management

• • Recognize that nursing assessments of patients dying of highly transmissible acute respiratory infections are intensive, time consuming, and require a high degree of cognitive load. This will likely require a lower patient to nurse ratio and/or frequent relief of nursing duties.

  • ○ Assessments will involve:

    • ■ Frequent symptom assessments using validated tools for signs of distress (pain, agitation, dyspnea) and provision of medication as appropriate for symptoms.^{Reference Sessler, Gosnell and Grap4–Reference Campbell, Templin and Walch6}

    • ■ Frequent patient repositioning.

    • ■ Eye and mouth care (avoiding deep suctioning).

    • ■ Emotional support to patient and family.

• • Review all medications and discontinue those not contributing to patient comfort.

• • Discontinue devices not necessary for comfort or medication administration (i.e., monitors, nasogastric tubes, additional intravenous lines).

• • Discontinue or minimize intravenous fluids and enteral feeding as this does not contribute to patient comfort nearing end of life.^{Reference Baillie, Anagnostou, Sivell, Van Godwin, Byrne and Nelson7,Reference Gillespie and Raftery8} If the decision is made to continue enteral feeding of intravenous fluids, monitor closely for complications, including aspiration and pulmonary or peripheral edema.

• • Consider insertion of a subcutaneous lock for medication delivery.

• • Avoid the use of the following as they may generate aerosolized SARS-CoV2 virus particles and infect health care workers and family members.^{Reference Cheung, Ho, Cheng, Cham and Lam9–12}

  • ○ Fan

  • ○ Oxygen flow greater than 6 L/minute

  • ○ High-flow nasal cannula oxygen

  • ○ Continuous positive airway pressure (CPAP) or bilevel positive airway pressure (BiPAP)

  • ○ All nebulized treatments (bronchodilators, epinephrine, saline solutions, etc)

Pharmacologic symptom management

While the information in online Appendix 1 provides recommended dosing of medications to manage common symptoms patients experience at end of life, dosing and frequency of medication administration should be individualized based on the patient's response. Consultation with Palliative Care is recommended if there is difficulty in managing symptoms.

Withdrawal of life-sustaining therapy

There will be instances where decisions will be made to withdraw life-sustaining therapy, such as mechanical ventilation. Figure 1 provides a simplified overview of initial steps in weaning mechanical ventilatory support while ensuring patient comfort, but please also refer to local institutional resources where available for best practices to wean ventilatory support.

Figure 1. Approach to withdrawal of mechanical ventilation in the patient with suspected or confirmed COVID-19 in the ED.

Given that extubation is considered an aerosol generating procedure and thus can be high risk to health care workers and family members present in the room, our recommendation is to not extubate the patient in the ED, but to decrease ventilatory support and ensure comfort throughout (see Appendix). If extubation is being considered, the patient should be in a negative pressure room, and all providers should be prepared with airborne personal protective equipment. Before this, we recommend speaking with experts in Critical Care and following best practices for withdrawal of mechanical ventilation.

Support to staff who are providing end-of-life care

Being responsible for decisions around resource rationing and use, on top of witnessing an increased frequency of suffering and death means ED health care workers are at heightened risk of burnout, compassion fatigue, and moral injury during pandemics.^{Reference Doherty, Hauser, Waldman and Glass13} It will be imperative for workplace colleagues to support each other and to perform frequent debriefs. Resources to support ED staff will vary by region, and they should be made easily accessible to all. Additionally, resources can be accessed through various licensing authorities and should be strongly encouraged.