As we now know, COVID-19 is a devastating respiratory infectious disease with over 500 000 deaths globally and rising (World Health Organization, 2020). The death rate for COVID-19 is 0.66% rising to 7.8% in patients over 80 (Mahase, 2020), as such the need for adequate end-of-life care (EoLC) is paramount. When COVID-19 cases rapidly rose, the NHS quickly implemented a strategy to combat the virus. This strategy was to erect temporary hospitals across the country, now known as the NHS Nightingale Hospitals. The most successful of these was the NHS Nightingale Hospital North West (NNHNW), a 650-bed ‘pop-up hospital’ based in Manchester. It was erected in the space of 2 weeks in the Manchester Central convention centre complex, a massive convention centre able to hold up to 10 000 people, which began its life in 1880 as a railway station.
This temporary hospital, now on standby, was used to provide general medical care and rehabilitation to COVID-19-positive patients being stepped down from hospitals across the North West region. The hospital was staffed by health professionals from a range of backgrounds, from people working in the airline industry to retired nurses with over 40 years experience in the NHS. The nursing structure comprised clinical support workers (healthcare assistants), registered nurses, senior nurses acting as clinical nurse advisors, ward managers and matrons.
Although not quite the field hospital seen in other parts of the world, there were many challenges faced working in a temporary hospital here in the UK. It was very difficult to transition from a well-established NHS hospital to one built in 2 weeks inside a convention center. By far the biggest challenge, was communication due to having to wear personal protective equipment (PPE), although this was paramount to our own safety. Other challenges included delivering holistic care without visits and simply the environmental factors of providing care in a building built and designed to be a railway station. EoLC was an important part of setting up the NNHNW, as it presented a multitude of challenges.
Challenges of end-of-life care
Being such a rapidly evolving field, there have been few publications looking into EoLC during the COVID-19 pandemic and there are no publications about patients receiving EoLC in a temporary hospital setting. In any pandemic, potentially huge numbers of patients may perish, and being able to provide patients with a dignified death, whether in the community, in temporary hospitals, or in well-established hospitals is important not only for patients and their families, but also for the staff caring for them.
During COVID-19 and in the short time the NNHNW was open, we provided EoLC to 6 patients. Marie Curie (2018) defines EoLC as ‘the care and support of patients in their last year of life.' To have a ‘good’ or ‘successful’ death is very subjective, what constitutes a good death is a vast topic in itself. However, some of the factors that can constitute a good death are: preferred place of death, being pain free, the environment during the last days of life, family support and emotional wellbeing (Meier et al, 2016). Some patients received EoLC at NNHNW were often COVID-19 positive and as such were unable to return to their previous place of residence. A patient receiving good EoLC should have a dignified, respectful, pain-and suffering-free death.
The environment
The NNHNW environment is a large open space with large ceilings (Figure 1). Sagha et al (2018) reported that the environment in which a person receives care either supports or detracts from their needs. Rasmussen and Edvardsson (2007) found that environmental factors can significantly affect quality of life, while also affecting patients' ability to tolerate disease symptoms, and emotional control.
NNHNW had Nightingale-style wards with all patients in view of each other, and the nurses' station—no isolation rooms were available. Patients could also not bring in personal belongings from home, such as family photos or comfort items, due to infection control standards. This absolutely inhibited the aim of trying to create a home-like environment, which has been identified as an optimal environment for EoLC (Rasmussen and Edvardsson, 2007; Sagha Zadeh et al, 2018; Hoare et al, 2019). Although the environment was not ideal, the limitations of practice were no different to any other hospital ward where no side rooms are available.
Support and wellbeing
A family liaison team (FLT) was introduced in the hospital to keep patients in touch with families and friends through the use of tablets and video calls. The aim of this was to allow patients to keep in touch with their relatives, some of whom they had not seen for months—no visitors were allowed inside the hospital. This team was made up mainly of dentists and student dentists, due to the fact that most dentistry procedures and clinics were put on hold because of COVID-19. Although useful for patients able to communicate, it was felt that video calls were not appropriate or adequate for patients at the end of their lives. After much scrutiny it was decided that limited number of visitors would be allowed in such scenarios, with family members donning PPE and accepting the risk of entering a COVID unit. Unfortunately, some family members were unable to visit – sometimes because they or those in their household were shielding or vulnerable. This has the potential to impact on decisions taken by the family, and it also hindered use of touch between the patient and loved ones (Sagha Zadeh et al, 2018).
PPE and communication
COVID-19 brought about strict guidelines surrounding PPE; ensuring safety for both patients and staff. However, this equipment does not come without disadvantages. PPE at NNHNW comprised scrubs, an apron, gloves, face mask and full face visor. A number of difficulties arose as a result, many of which adversely affected patients at the end of their lives. The surgical masks and visors muffled voices, making it virtually impossible to communicate effectively with patients. Gloves hinder the very important use of touch. The National Institute for Health and Care Excellence (2015) guidelines convey that good communication at the end of life can improve care and bereavement alike. This can also ensure the patient's expressed wishes are considered, ultimately providing EOLC and minimising distress, hopefully aiming to facilitate a good death. Staff at NNHNW felt that care could become very impersonal due to their PPE, as they were unable to display simple facial expressions such as smiling. There has been a movement of ‘smiling with eyes’ that some patients have been able to identify through the creases then displayed on the upper half of faces. However, this is often lost on seriously ill patients.
There were also barriers for patients who have hearing impairments and communicate through lip reading, which isn't an option through a face mask as it entirely covers the lower half of the face. We found we could overcome this through the use of a communication board or just pen and paper to communicate in writing.
Furthermore, patients who were already confused, in an altered mental state or had dementia found that staff welcoming them had facial coverings and a visor on, could be distressing for them. The solution was not obvious and came down to individualised care—finding what works individually for that patient and using it to aid care and communication.
Impact on staff
Cedar and Walker (2020) recently highlighted that there is an extra burden on healthcare workers during COVID-19 when providing EoLC. Although no studies have been done to highlight this at NNHNW, the survey given to staff gives them the opportunity to feed back their thoughts. The free text box allows staff to comment on their time. The majority of this survey focused on EoLC in particular, with themes including: more training required for junior members of staff or those who do not have a background of providing EoLC, environmental factors to incorporate a home-like environment and the possible use of a palliative care team. The majority of staff felt that they were supported to provide EoLC; but felt that more could have been done to support staff personally. One of the widely researched resolutions is a team de-brief. Death has not always been experienced by a health professional and therefore can be a traumatic experience. Unresolved emotional problems can result in poor performance and loss of staff (Irish Hospice Foundation, 2013).
Going forward
NNHNW is now on standby ready to open its doors once again if needed. Going forward, it is important to take note of past experiences at this base and use them to further improve care. Although PPE was a communication barrier, there is little that can be done to change this. Staff training sessions could be given to aid communication facilitating PPE as a main barrier and how this could be worked around. Patients may be able to bring in personal belongings if kept in a plastic bag to isolate them prior to use, for infection control. Furthermore, there is the suggestion of a trial de-briefing staff following EoLC to ensure staff feel supported and highlight areas for training.
Working at NNHNW was not without its challenges, but the care provided there was tailored to meet needs. During their time there staff could be seen singing with patients, playing bingo and providing second-to-none care.