Palliative Care (PC) aims to provide whole person care to patients with life-limiting illnesses. It includes attention to physical, psychological, emotional and spiritual aspects of symptoms as well as facilitating communication to establish goals of care. Telemedicine has been a growing interest in the field of PC, as a means of using technology to provide community-based specialty palliative care to our vulnerable patients with a serious illness who otherwise live in areas with no existing PC programs.
However, the unexpected advent of COVID-19 has greatly accelerated our specialty’s use of technology, in both the in-patient and outpatient setting. The COVID-19 pandemic resulted in many staff being furloughed or asked to work remotely from home, in an effort to decrease staff exposure and conserve PPE. While previously, PC teams have looked to technology to expand access to palliative care in the community setting, PC teams are now using similar technology to bring palliative care to hospitalized patients (1, 2, 3).
Previous studies of Tele-palliative care have focused on the feasibility of using virtual visits to accomplish symptom management and facilitate goals of care conversations. The use of technology by the Palliative interdisciplinary team (IDT; including palliative social worker, chaplain, nurse) to facilitate sessions focusing on non-pharmacological modalities & interventions for pain and non-pain symptoms has not been widely described.
At our institution, our palliative IDT members were also quick to embrace technology as a way to be able to continue to provide whole person care for our patients admitted to the hospital during the COVID-19 pandemic. At the height of the pandemic over Spring 2020, strict visitor policies were in place and many patients had increased anxiety and distress due to the isolation of being in the hospital without loved ones present. In addition, some of our IDT staff, including our palliative social worker, were asked to work remotely from home. Virtual visits were therefore performed via video platforms and phone encounters.
For our patients with COVID-19 with increased anxiety, emotional distress and dyspnea, our IDT quickly realized that our usual ‘talk therapy’ was not effective as many of these patients were unable to hold long conversations due to their dyspnea. However, we found that other complementary non-pharmacological interventions such as guided imagery, guided meditation and prayer could effectively be facilitated via virtual platforms.
Here we use a case-based approach to reflect on our palliative IDT’s experience using virtual platforms to facilitate guided imagery sessions as a non-pharmacological intervention for anxiety, pain and non-pain symptoms in hospitalized patients in the era of COVID-19.
Guided Imagery Background
Our thoughts, feelings, beliefs, and attitudes can all either positively or negatively affect our biological functioning. Similarly, what we do with our physical body, impacts our mental state, demonstrating the interrelationship that exists between the mind and the body (4). Mind-body practices work to enhance the positive effect this interrelationship has on one’s body and mind. Guided imagery is one example of a mind-body practice that can impact how common symptoms are experienced. Guided imagery is an approach that uses the power of the mind to support healing of the mind, body, and spirit. This therapeutic approach uses gentle phrases and words to evoke sensations to help one heal and can be a powerful way to positively influence emotions and thoughts (5). Imagery refers to perceptions that come through any of the senses (sights, smells, sounds, tastes, and feels) (6, 7).
Guided imagery can be implemented in numerous ways including: practitioners objectively guiding patients to explore their inner resources, audio recordings in the form of CDs, DVDs, mobile phone apps, or internet-based resources. Through each of these approaches, patients are reminded that their most powerful tools, their mind and breath, are always with them. Guided imagery provides a simple, safe and cost-effective strategy to help ease emotional and physical distress. (8).
Case Descriptions: Stories from four patients
Our IDT members have been able to facilitate guided imagery sessions via video platforms with patients with COVID-19 and also with patients admitted during the pandemic for serious illness unrelated to COVID-19. For each consultation, the patient was initially assessed by a Palliative clinician. If it was felt that IDT involvement would be beneficial, the clinician would then discuss the case further with the Palliative IDT. Prior to each session, our team would initially ensure that the patient had an institution supplied roving tablet in the room. We would then co-ordinate with the bedside nurse for a suitable time to call into the room. The bedside nurses were extremely helpful with adjusting volumes and screen heights to ensure that both parties could see and hear each other via the video platforms.
Ms S was admitted for chemotherapy. She spent over a week in the hospital and was unable to have any visitors due to the COVID-19 visitor restriction policies. Our palliative consult team was consulted for symptom management and psychosocial coping support. She had a very close knit relationship with her family and found being away from family emotionally challenging. Guided imagery sessions were conducted using “favorite place” imagery script and also a unique script designed for palliative care patients focused on relaxed breathing, anxiety reduction and journeying to a calm and peaceful time. After the sessions, Ms S shared feelings of relaxation and joy.
Ms R was admitted with severe interstitial lung disease and pulmonary hypertension with symptoms of dyspnea, anxiety and nausea. Her anxiety was heightened by being away from her family and feeling confined to her hospital room. Our first guided imagery session focused on “freedom” and going back to a time in her life when she felt “free”. She shared going back to college days and feeling “liberated”. In the second session, we focused on going to a “favorite place” and feeling a warm embrace from some she loves. She reported visualizing her best friend and enjoyed a “hug” from her.
Mr J was a gentleman who had a prolonged hospital stay in the setting of pancreatitis and associated complications. Our team was consulted to help with symptoms and coping. Being away from his family/friends increased his anxiety and emotional distress. Sessions with him focused on finding a “favorite place” and he was able to verbalize and reminisce on memories that brought him significant joy. We also went through progressive muscle relaxation and diaphragmatic breathing, which helped his nausea. Mr J reported that these sessions helped him feel “calm”, “soothed”, “comforted” and “relaxed”. He also reported that this technique helped him feel more empowered in his overall plan of care, helping him mitigate feelings of anxiety during his extended hospital stay.
Mr H was admitted with respiratory distress due to COVID-19. Our team was consulted for goals of care discussions in the setting of complex medical illness He also had increased anxiety and dyspnea and was not able to hold extended conversations. Helping him focus on a time when his breath felt “expansive”, and when he felt most “alive” brought him back to his mountain-climbing days. This, in addition to utilizing diaphragmatic breathing, helped both his dyspnea and anxiety. As his condition worsened, he began sharing requests for reconciliation with family and himself. We were able to facilitate a session focused on paced breathing, anticipatory grief and forgiveness.
Despite some challenges, our PC IDT found using technology to facilitate non-pharmacological interventions feasible and helpful. Virtual guided imagery sessions focused on finding a “favorite place” seemed helpful for patients with increased anxiety. A more relaxed state was achieved as evidenced by relaxed body posture, slower/deeper breathing and sometimes inducing a state of sleep. In addition, our IDT members were also able use these virtual video sessions to coach patients through progressive muscle relaxation and diaphragmatic breathing, techniques that can also help with pain, nausea and overall wellbeing. (9, 10, 11)
Finally, our team was also able to conduct virtual guided imagery sessions focused on anticipatory grief and forgiveness as healing/life completion opportunities. These are crucial tasks as patients journey closer to the end of life and seek to reconcile with loved ones and find peace when facing their own mortality. These tasks have been made even more challenging with the current pandemic due to the isolation and social distancing.
Telemedicine has allowed us to continue to provide palliative care to our most vulnerable patients, who are experiencing increased anxiety and emotional distress during this time of isolation caused by the COVID-19 pandemic.
We are still learning how best to use this technology and how to tailor our interventions to best meet the needs of our patients. Our experience using virtual platforms to conduct complementary non-pharmacological interventions such as guided imagery has allowed our palliative IDT members to continue to be able to provide whole-person care in these challenging times.
While our institution’s visitor policies have since been relaxed, it is encouraging to know that our IDT will still be able to provide whole person care if we have to enter another lockdown state.
We hope to be able to use this experience to further expand the field of Tele-palliative care both in the in-patient and community settings. This holds great promise in becoming an effective means to provide psychosocial and spiritual care virtually.
Mei-Ean Yeow, BMBCh, FACP, FAAHPM
Abbey Metzger, BSN, RN
Casey Smith, MSW-LICSW
Center for Palliative Medicine
Mayo Clinic, Rochester
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