• Aaron K Wong, Jennifer Philip, Olivia Wawryk, Michael G Sabe, Jaclyn Yoong, Rachel Everitt, Ruwani Mendis, Joyce Chua, Maria Pisasale, and Brian Le.
• Parkville Integrated Palliative Care Service (A.K.W., J.P., R.E., J.C., B.L.) Peter MacCallum Cancer Centre & The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine (A.K.W., J.P., O.W.), University of Melbourne, Fitzroy, Victoria, Australia. Electronic address: aaron.wong@petermac.org.
• J Pain Symptom Manage. 2022 Sep 1; 64 (3): e139-e147.

ContextGuidelines exist to direct end-of-life symptom management in COVID-19 patients. However, the real-world symptom patterns, and degree of concordance with guidelines on medication use, and palliative care involvement has received limited attention.ObjectivesTo describe the evolution of COVID-19 symptoms, medication used to alleviate these, and degree of palliative care involvement in the final week of life.MethodsThis retrospective study reviewed all COVID-19 inpatient deaths across five metropolitan hospitals in Australia from January 1 to December 31, 2020. Outcome measures were collected at day of death, and days one, two, five and seven before death. These were COVID-19 symptom severity (measured by the Palliative Care Outcome Scale), and use of supportive pharmacological and non-pharmacological therapies. Palliative care referral timepoint was also collected.ResultsWithin the sample of 230 patients, commonest symptoms were breathlessness, agitation, pain, and respiratory secretions. On day of death, 79% (n = 181) experienced at least one symptom, and 30% (n = 68) experienced severe/extreme symptoms. The use of midazolam, glycopyrrolate, and infusions for symptom management occurred late, less frequently, and at lower doses than suggested in guidelines and other studies. Palliative care referrals were made late, at median three days before death (IQR 1-6 days), and for only half of people dying from COVID-19 (51%; n = 118).ConclusionSymptoms peaked in final three days of life. Earlier use of in fusional and breakthrough medications should be considered in anticipation of symptoms given high likelihood of dying in discomfort. Earlier palliative care referral for high-risk patients should be considered at hospital admission.Crown Copyright © 2022. Published by Elsevier Inc. All rights reserved.

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