Telemedicine is hardly a new concept, but it has taken a global health crisis to gain a strong – and possibly permanent – foothold. Undoubtedly, telemedicine helps to fill important gaps in care during ‘shelter in place’ orders. It can also address key challenges facing palliative care teams, struggling to keep pace with the clinical, psychological and emotional needs of dying patients.
Several critical barriers to widespread telemedicine implementation, including HIPAA restrictions and reimbursement issues, have been lifted as a result of the pandemic. Now, a number of recently published reviews and research letters highlight invaluable telemedicine experiences of clinicians at various institutions, including the University of California-San Francisco, University of Michigan and Dalian and Yangzhou Universities in China.
While general approaches to telemedicine might vary, these research efforts were based on one shared premise: ‘No visitors’ policies, aimed at reducing COVID-19 transmission and acquisition rates and preserving scarce resources, directly conflict with the need for in-person discussions about care goals, management approaches and decisions about death and dying.
The three C’s: connectivity, counseling and contingency
With relaxed HIPAA restrictions, HCPs are now able to leverage non-public facing platforms (i.e. those that employ end-to-end encryption technology to preserve privacy) to deliver palliative services. Acceptable video platforms include Apple FaceTime, Facebook Messenger, Google Hangouts, WhatsApp, Zoom and Skype along with associated texting applications. Consider the following factors to ensure an optimal telemedicine experience:
Patient and Family Support:
- Ensure that both patients and families have access to a smart device or computer with a camera and audio, as well as to accessible internet connection.
- If possible, designate one or two staff ‘liaisons’ to help with family platform setup, conduct test runs and address technical questions before and during sessions. Ideally, divide tasks so that one person is responsible for technology and the other for scheduling visits.
- Counsel patients and family members on basic etiquette, such as keeping background noise to a minimum, looking at the camera, speaking slowly and making sure everyone can hear and understand what is being discussed.
- Carefully consider the patient and family members’ mental states before the chats. Set family and patient expectations accordingly, especially if patients are experiencing symptoms of delirium or confusion.
Care Team Support:
- Develop and set communication and documentation protocols. Be sure to include telemedicine environments (e.g. quiet, private, neutral spaces) and device guidelines (e.g. laptop or desktop vs. handheld devices to avoid distractions).
- Train all care team members on etiquette, such as the need to look at the camera vs. the screen or at medical notes. It is also important to give patients and family members a heads up at least five to 10 minutes before the session ends so they have the opportunity to ask questions or share thoughts.
- Consider staffing needs to minimize workflow disruptions.
- Develop a contingency plan that includes factors like triaging provider consultations based on urgency, technology glitches and sudden patient deterioration during the session.
Additional resources and tips are freely accessible on the Center for Palliative Care’s website.
- The Evolution of Telehealth: Where Have We Been and Where Are We Going? National Academies Press.
- OCR Issues Guidance on Telehealth Remote Communications Following Its Notification of Enforcement Discretion. U.S. Health and Human Services.
- General Provider Telehealth and Telemedicine Tool Kit. Centers for Medicare & Medicaid Services.
- Telemedicine in the time of Coronavirus. Journal of Pain and Symptom Management.
- Telemedicine and the COVID-19 pandemic, Lessons for the future. Telemedicine and e-Health.