Dr Will Cairns, is a palliative care specialist and member of the Australian COVID-19 Palliative Care Working Group (ACPCWG). He is editor of the ACPCWG newsletter, content of which from 30 September 2021 is now published within PCA’s e newsletter, and in long form on the PCA website.

Dr Cairns writes, “Palliative care services need to prepare for the inevitable surge in cases of COVID that are expected to emerge as states open up. Whereas in many other countries opening up was not worse than their prior experience, for Australians who have seen very little of COVID, the numbers will be a big shock from our low baseline."

It has been over six months since my last comment.

Over that time, we have watched the ebb and flow of COVID, and more recently the surge of Delta, with their wide variety of impacts across Australia. Many of our colleagues working in palliative care services will have experienced few consequences, while others have experienced great disruption and remain under severe stress.

More recently there has been a growing awareness of the complexity of the issues of the endgame (although it will not be the end of COVID).

As I ruminated on the question in the dark of one night, I imagined our dilemma as a three-cornered dance of equipoise between the benefits and harms lockdown for prevention (to minimise death and healthcare disruption), vaccination (to minimise morbidity and mortality), and social necessity (the psychosocial and economic wellbeing of community). The parameters of each have changed continuously and we are now approaching the point where sufficient numbers of us have been vaccinated that the returns from lockdowns will diminish and the social harms will predominate.

As our proportion vaccinated increases, it will become increasingly difficult to achieve incremental gains as we run into the wall of intransigence. The moment is approaching when it will become necessary to warn that opening is coming so that those who have chosen not to be vaccinated will have the chance to do so.

It seems inevitable that the incidence of COVID will increase when restrictions are eased and our health services are being prepared for the COVID care of those who are most vulnerable in spite of vaccination. At the same time, we must consider the possibility that triage may be necessary if healthcare services are overwhelmed, as has been suggested as a possibility by our leaders. Clinicians need to know how they would be expected to make the complex ethical decisions about which patients will not be treated when there are more patients than places for treatment.

I do not envy the job of our leaders who must decide when and how to act during this pandemic when the known knowns, the known unknowns and the unknown unknowns mean that it is not possible to be sure of the consequences of their choices. In the absence of outcomes from the choices they did not pick, they will be blamed for the adverse consequences of those that they did. They need our support and understanding for an impossible task.

Palliative care services also need to prepare for the inevitable surge in cases of COVID that are expected to emerge as states open up. Whereas in many other countries opening up was not worse than their prior experience, for Australians who have seen very little of COVID, the numbers will be a big shock from our low baseline.

Two sessions in the recent virtual Oceania Palliative Care Conference organised by Palliative Care Australia highlighted the work of those of our colleagues who have studied their experience of the impact of COVID on a variety of aspects of the delivery of palliative care during the pandemic. This research is vital to our understanding of how we might respond in to future crises of COVID, and for future pandemics with other as yet unknown viruses.

In the light of the predictions that COVID will surge across Australia later this year and into 2022, we will be incorporating the COVID-19 newsletter into the PCA Newsletter. Please send any comments and observations that you think might help the palliative care community to deliver better COVID care to our community.

In the meantime, it is time to consider how each of us can prepare ourselves and our services for what might lie ahead.

• Support advance care planning for all our patients, particularly the vulnerable, and for ourselves
• Prepare your service for the care that it might need to deliver to existing patients and those who need palliative care for COVID
• Ask you managers how you should allocate resources if you do not have enough to provide the care that we expect of ourselves

For an understanding of life for a palliative care clinician during COVID I suggest that you read Breathtaking: the UK’s human story of Covid by Rachel Clarke, a palliative medicine physician and former journalist.

Best wishes,

Dr Will Cairns