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Palliative care in advanced coronavirus disease in intensive care units
  1. Ali Esmaeili Vardanjani1,
  2. Hossein Rafiei2 and
  3. Mostafa Mohammdi3
  1. 1 Department of Critical Care nursing & Management, School of Nursing and Midwifery, Tehran University of Medical Sciences, Tehran, Tehran, Iran (the Islamic Republic of)
  2. 2 Department of Critical Care Nursing, School of Nursing and Midwifery, Qazvin University of Medical Sciences, Qazvin, Iran (the Islamic Republic of)
  3. 3 Anesthesiology and Intensive Care, Department of Intensive Care Unit, Imam Khomeini Hospital, faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
  1. Correspondence to Hossein Rafiei, -, Qazvin, Iran (the Islamic Republic of); Hosseinr21{at}

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Coronavirus disease (COVID-19) is rapidly developing throughout the world.1 Although many do not have severe symptoms, a minority (about 5%) develop an advanced form and are admitted to intensive care units.2 There is no known cure, and a significant proportion die in these units. Iran is one of those countries struggling with the disease.3 Our experience shows that in addition to the therapeutic measures, palliative care is also required.

These patients suffer during the last days of their lives in intensive care units. Severe symptoms, body pain, dry cough, death anxiety, chills, fear of imminent death, gastrointestinal problems and shortness of breath affect patients physically and mentally. In some, the disease progresses rapidly, the patient cannot adapt. As there is no specific cure (and the patient is also aware of this) they becomes stressed and helpless. Our patients usually accepted death during the final stages but suffered from the difficult death that they knew awaited them. They preferred to die elsewhere and under different circumstances. In some, it was more difficult for them to endure the conditions of the intensive care units and their clinical status than death itself.

The family, as a support system, can play a vital role in such critical situations. In advanced COVID-19 hospitalised in intensive care, family relationships are completely disconnected. In a very stressful situation, those with COVID-19 are deprived of this essential support system. Many longed to be with their family and even to see them for a moment before their death. In addition to the family disconnection, patients may not receive the necessary symptomatic care in the intensive care units. Due to the critical conditions, the medical team may undervalue palliative care. Additionally, many hospitals may not have sufficient staff and resources to provide it.

Given that many patients are hospitalised in our intensive care units with COVID-19 (and many are dying) than others affected witness the disease development in fellow sufferers; they see other die and realise what lies ahead. This issue was usually very frightening. Some openly acknowledged death would come to them and their condition would become more difficult. Many requested more anaesthesia and sedation to minimise the consequent distress.

Given the rapid spread of COVID-19 throughout the world and the large number with advanced disease, organisations developing health and care protocols to respond (including the WHO) must consider a comprehensive palliative care protocol for advanced COVID-19. The need for palliative care among these patients is paramount.



  • Contributors AEV: planning, conduct and article writing; HR: planning, article writing, conduct and article submission; MM: planning and article writing.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; internally peer reviewed.