Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

Peter Lawlor; Leila Cohen; Samantha Rose Adeli; Ella Besserer; Valérie Gratton; Rebekah Murphy; Grace Warmels; Adrianna Bruni; Monisha Kabir; Chelsea Noel; Brandon Heidinger; Koby Anderson; Kyle Arsenault-Mehta; Krista Wooller; Julie Lapenskie; Colleen Webber; Daniel Bedard; Paula Enright; Isabelle Desjardins; Khadija Bhimji; Claire Dyason; Akshai Iyengar; Shirley H Bush; Sarina Isenberg; Peter Tanuseputro; Brandi Vanderspank-Wright; James Downar; Henrique Parsons

doi:10.1136/bmjopen-2023-075518

Comorbidities, symptoms and end-of-life medication use in hospitalised decedents before and during the COVID-19 pandemic: a retrospective regional cohort study in Ottawa, Canada

BMJ Open. 2023 Sep 5;13(9):e075518. doi: 10.1136/bmjopen-2023-075518.

Authors

Peter Lawlor^{1

2

3}, Leila Cohen^{4

5}, Samantha Rose Adeli⁶, Ella Besserer⁷, Valérie Gratton^{4

8

9}, Rebekah Murphy^{4

5}, Grace Warmels^{4

2

5}, Adrianna Bruni^{4

5}, Monisha Kabir³, Chelsea Noel³, Brandon Heidinger³, Koby Anderson³, Kyle Arsenault-Mehta¹⁰, Krista Wooller^{11

12}, Julie Lapenskie^{2

3}, Colleen Webber², Daniel Bedard⁸, Paula Enright^{4

11}, Isabelle Desjardins^{11

12}, Khadija Bhimji^{4

5}, Claire Dyason^{4

11}, Akshai Iyengar^{13

14}, Shirley H Bush^{4

2

3}, Sarina Isenberg^{4

3

7}, Peter Tanuseputro^{4

2

3}, Brandi Vanderspank-Wright^{2

15}, James Downar^{4

2

3

13

16}, Henrique Parsons^{4

11}

Affiliations

¹ Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada plawlor@bruyere.org.
² Ottawa Hospital Research Institute, Ottawa, Ontario, Canada.
³ Department of Palliative Care, Bruyere Research Institute, Ottawa, Ontario, Canada.
⁴ Department of Medicine, Division of Palliative Care, University of Ottawa, Ottawa, Ontario, Canada.
⁵ Department of Medicine, Queensway Carleton Hospital, Ottawa, Ontario, Canada.
⁶ Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada.
⁷ Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
⁸ Institut du Savoir Montfort, Ottawa, Ontario, Canada.
⁹ Department of Medicine, Hopital Monfort, Ottawa, Ontario, Canada.
¹⁰ Department of Psychiatry, University of Ottawa, Ottawa, Ontario, Canada.
¹¹ Department of Medicine, Ottawa Hospital, Ottawa, Ontario, Canada.
¹² Department of Medicine, Division of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada.
¹³ Department of Medicine, Division of Critical Care, University of Ottawa, Ottawa, Ontario, Canada.
¹⁴ Department of Critical Care, Queensway Carleton Hospital, Ottawa, Ontario, Canada.
¹⁵ School of Nursing, University of Ottawa Faculty of Health Sciences, Ottawa, Ontario, Canada.
¹⁶ Department of Critical Care, The Ottawa Hospital, Ottawa, Ontario, Canada.

Abstract

Objective: To compare comorbidities, symptoms and end-of-life (EoL) palliative medication (antisecretories, opioids, antipsychotics and sedatives) use among decedents before and during the COVID-19 pandemic.

Design: In a retrospective cohort study, decedent records in three acute care hospitals were abstracted, generating a prepandemic (November 2019-February 2020) group (pre-COVID) and two intrapandemic (March-August 2020, wave 1) groups, one without (COVID-ve) and one with COVID-19 infection (COVID+ve). Control group decedents were matched 2:1 on age, sex and care service (medicine/intensive care unit (ICU)) with COVID+ve decedents.

Setting: Three regional acute care teaching hospitals in Ottawa, Canada PARTICIPANTS: Decedents (N=425): COVID+ve (n=85), COVID-ve (n=170) and pre-COVID (n=170).

Main outcome measures: Data were abstracted regarding demographics, admission comorbidities and symptoms, and EoL medication use; opioid doses were standardised to parenteral morphine equivalent daily dose (MEDD), and the predictors of upper quartile MEDD in the last 24 hours of life were examined in multivariable logistic regression with adjusted ORs (aORs) and 95% CIs.

Results: The prevalence of dementia (41% vs 28% and 26%, p=0.03), breathlessness (63.5% vs 42% and 47%, p<0.01), cough (40% vs 27% and 19%, p<0.01) and fever (54% vs 9% and 13.5%) was higher in COVID+ve versus pre-COVID and COVID-ve groups, respectively. The median (IQR) of MEDD over the last 72 hours of life was 16.7 (9-36.5) vs 13.5 (5.7-21.8) and 10.5 (5.3-23.8) for COVID+ve versus pre-COVID and COVID-ve groups, respectively, (p=0.007). Male sex, COVID+ve grouping, ICU death and high-flow nasal cannula use predicted upper quartile MEDD dose, aORs (95% CIs): 1.84 (1.05 to 3.22), 2.62 (1.29 to 5.3), 5.14 (2.47 to 10.7) and 1.93 (1.05 to 3.52), respectively. COVID+ve group decedents used highest lorazepam and propofol doses.

Conclusions: COVID-19 decedents, particularly those in ICU, required higher EoL opioid and sedating medication doses than matched prepandemic or intrapandemic controls. These findings should inform and guide clinical practice.

Keywords: COVID-19; adult intensive & critical care; adult palliative care; pain management.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Analgesics, Opioid
COVID-19*
Canada
Cohort Studies
Death
Humans
Male
Morphine
Pandemics
Retrospective Studies

Substances

Analgesics, Opioid
Morphine