Indian Journal of Palliative Care
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  In this Article
 »  Abstract
 » Introduction
 »  The Current Covi...
 »  Why Do We Need a...
 » Managing Concerns
 » Control of Symptoms
 »  Anticipatory Mea...
 » Reassurance
 »  Emotional and Sp...
 » Conclusion
 »  References
 »  Article Tables

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Table of Contents 
Year : 2020  |  Volume : 26  |  Issue : 5  |  Page : 95-98

CARE: A holistic approach toward patients during pandemic: Through the eyes of a palliative physician

Department of Onco-Anaesthesia and Palliative Medicine, Dr Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi, India

Date of Submission23-May-2020
Date of Acceptance26-May-2020
Date of Web Publication30-Jun-2020

Correspondence Address:
Dr. Sushma Bhatnagar
Department of Onco-Anaesthesia and Palliative Medicine, Dr Bhim Rao Ambedkar Institute Rotary Cancer Hospital, All India Institute of Medical Sciences, New Delhi - 110 029
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJPC.IJPC_175_20

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 » Abstract 

Words pandemic and panic, if cannot be used synonymously, can definitely be exchanged metaphorically. Pandemics are outcome of an unanticipated crisis, therefore it is always associated with panic and hence it requires a comprehensive approach to get resolved. On the contrary, during the event of an overwhelming pandemic, due to lack of protocols, the entire health-care system faces crisis and it becomes a tedious task to reallocate and reschedule the resource and knowledge for the uninterrupted and smooth delivery of services. Therefore, pandemics need an evidence-based subjective approach toward the patient and family members for addressal and resolution of complex issues arisen due to the disease. A good contingency plan and approach for combating a pandemic is the utmost solution for providing complete holistic care. A comprehensive care approach model is the need of the hour to provide the holistic care during pandemics. In this article, we propose a model of CARE approach that can be useful in providing holistic care during the times of pandemic.

Keywords: CARE, holistic care, pandemic

How to cite this article:
Rathore P, Kumar S, Haokip N, Ratre BK, Bhatnagar S. CARE: A holistic approach toward patients during pandemic: Through the eyes of a palliative physician. Indian J Palliat Care 2020;26, Suppl S1:95-8

How to cite this URL:
Rathore P, Kumar S, Haokip N, Ratre BK, Bhatnagar S. CARE: A holistic approach toward patients during pandemic: Through the eyes of a palliative physician. Indian J Palliat Care [serial online] 2020 [cited 2020 Jul 7];26, Suppl S1:95-8. Available from:

 » Introduction Top

All doctors are palliative care doctors now rightly quoted by the Washington Post.[1]

The world has seen many pandemics such as Spanish flu (1918–1919), Asian flu (1957–1958), Hong Kong flu (1968–1969), many influenza epidemics, and now, the coronavirus disease (COVID-19) pandemic which have caused severe health crisis leading to great amount of morbidity and morbidity worldwide. The role of palliative care is very crucial due to the uncertain nature of the disease and its devastating effects on health. The role of palliative care will be very crucial in providing symptomatic management and relieving the sufferings of the patients and their caregivers in maintaining their quality of life in the time of pandemic.[2]

 » The Current Covid-19 Pandemic Top

The world is in the grip of COVID-19, an infectious disease caused by the novel severe acute respiratory syndrome coronavirus 2 isolated from the respiratory tract of patients from Wuhan, China, and spreading to almost all the countries globally causing high morbidity and mortality.[3] The WHO identified it as a Public Health Emergency of International Concern on January 31, 2020, due to its ability of human-to-human transmission. Later on March 11, 2020, COVID-19 was declared a pandemic by the WHO. COVID-19 started in China has reached and spreading to almost all the countries globally causing high morbidity and mortality with a global mortality at 3.4% by the WHO.[4]

 » Why Do We Need a Holistic Care Plan? Top

For ages, medical profession has largely been relying on objective management of disease, which only includes care of the disease only. The same has been followed for pandemics also. In recent times, it has been evident that treating just the disease does not cure the patient in a whole.[5] Treating the disease provides relief just to the physical illness and leaves behind the more complex psychological, social, and spiritual concerns.[6] Quality of life of a patient depends on relief from physical symptoms as well as on his sound psychosocial and spiritual well-being. Therefore, a holistic treatment approach is the need of the hour for the complete care of patient.

Pandemics are state of uncertainty which, in turn, creates panic to the society. A sudden surge of cases during acute pandemics puts a huge onus to health-care system for smooth delivery of services. Strong apprehension about the disease makes people think about their illness as a causal link to the pandemic itself. In recent COVID pandemic it is observed that along with symptomatic cases, there are equal or even more number of asymptomatic cases.[7] Therefore, both symptomatic and asymptomatic cases need a comprehensive care plan to be managed, and this is the time we can introduce a holistic care approach.

 » Managing Concerns Top

All the patients should receive care

Managing all patients should begin with a good contingency plan and approach. The WHO has recommended five basic components of preparedness and response for influenza pandemic, which include planning and coordination, situation monitoring and assessment, reducing the spread of disease, continuity of health-care provision, and communications.[8]

The judicious use of resources is very important at these times. Resource allocation will remain the key. Managing and caring of patients should be done in all levels of health-care systems posttriage and priority. Critical ill and symptomatic patients will require expert care in hospitals, whereas majority of asymptomatic patients will require a home-based care. The entire community has to work together to meet the challenges posed by the pandemic. A means of triaging the patients based on severity and comorbidities has to be done to provide a holistic care in each level.

The CARE approach will provide a complete holistic care for each patient taking care of the mind, body, and spirit who are suffering in such pandemics [Table 1].
Table 1: CARE: A holistic approach

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 » Control of Symptoms Top

Patients present with wide range of symptoms ranging from asymptomatic to critically ill and life-threatening symptoms. Management should begin with preventive measures, control of physical symptoms, and finally taking care of the psychological issues faced by these patients at the time of crisis.

Basic preventive measures as suggested by the WHO include: staying up with latest updates on pandemic, performing hand hygiene frequently with soap- or alcohol-based hand rubs, avoiding touching eyes, nose, and mouth, maintaining social distancing from individuals, and seeking medical care if symptoms arise.[9] This is very important to stop the transmission. By strictly following these principles, asymptomatic carriers may also limit the transmission.

Managing the physical symptoms

Due to the vast spectrum of symptoms, evidence-based management is the most crucial step. Constitutional symptoms may be treated conservatively with analgesics and antipyretic cough syrups at home setting, whereas severe symptoms such as pneumonia and acute respiratory distress syndrome will require antibiotics, intravenous fluids, oxygen, and ventilatory support in hospital.

Managing the psychological symptoms

Pandemics tend to cause mental health crisis, especially in vulnerable population, older population, and those with comorbidities. They may experience stress, fear, anxiety, depression, posttraumatic stress disorder. Social distancing leads to loss of connectedness and aggravates loneliness which amplifies their psychological stress.[10] These may require psychological crisis intervention in terms of evidence-based pharmacological and nonpharmacological management.[11] The key role in managing the psychological concerns will be empathetic communication between the health-care worker and the patient.

 » Anticipatory Measures Top

Due to the unpredictable and uncertain nature of the outcome of the disease, anticipatory measures are very critical. Proper counseling, communication, and prognostication are very much required. To involve in patients' future health-care decisions, patients' perspectives should also be well kept in mind.

Anticipating the outcomes in terms of disease trajectory, symptoms, and in patients with advanced chronic disease with comorbidities is useful for triage and proper allocation of resources available. For prevention and mild symptoms, home-based isolation remains the key. For a good and adequate home care facility, integration of home care plan into pandemic care plans is necessary. Anticipatory prescription for mild symptoms can be given such as acetaminophen for fever, cough syrup for cough, lots of fluids along with nonpharmacological home remedies, and breathing exercises. If symptoms persist or aggravates, patient can contact the physician on telephone (telemedicine) or can visit the nearest hospital.

Palliative care is required in terms of controlling symptoms and providing comfort in chronic illness and terminally ill patients who have been denied ICU based aggressive life saving therapies. This should justify the judicial use of resources and should be planned for those who benefit from intensive care and can be saved based on triage.

Prognostication through proper communication remains the key. Correct, honest, and empathetic communication facilitates realistic expectations about the treatment goals and allows the patient and family to express their care choices.[12] In these patients, advance directives and advance care planning are important as it documents the treatment preference according to his goal of care. These patients would not feel abandoned if palliative care is given when life-saving treatment is denied. Proper home-based care educating the caregivers in the care will remain the goal.

Anticipatory prescription in terms of pharmacological drugs for end of life and comfort must be given according to the symptoms expected. Psychological and spiritual care should also be given as to provide a complete holistic care to the critically ill. This, in turn, will relieve the stress and burnout of the health-care workers.[13]

 » Reassurance Top

Health-care professionals have little awareness of the important impact that their presence has in a reassuring patient and family and improving their confidence in caring.[14] Reassurance begins with correct knowledge of the disease, prognostication, and finally communicating the true goals of care plans. Reassurance whether by phone (telemedicine) or in person created a sense of caring by experts among the caregivers in early asymptomatic situation as well as end-of-life care situation. Reassurance results in greater confidence and better mindset to fight the infection which further decreases the psychological stress among the patients.

 » Emotional and Spiritual Care Top

Emotional well-being is essential for physical well-being.[15] Pandemic, particularly a newly emerged disease, has always been a state of confusion to health-care system and to the society. Since there has been no established and formulated protocol for a new disease, it becomes a source of misconception and misinformation. These misconceptions and misinformation lead to the development of fear for the disease. Excessive fear can cause anxiety. Severe anxiety will hamper a person's day-to-day activities leading to the development of stress and, in worst cases, depression also. Thus, emotional well-being should be an essential aspect of treatment plan. Addressing emotional issues of patients helps a quicker recovery, longer survival, and better quality of life.[16] This will also decrease the stress and burnout among the caregivers and the treating health-care workers.

Spiritual care involves the care of a patient as a whole and not just treating the disease. Holistic care of physical, emotional, and social concerns makes a healthy spiritual impact on patient's lives.[6] Studies suggest that there is a complex and nonlinear relationship between spiritual health and quality of life, and this relationship is potentially influenced by emotional well-being of patient.[17] Therefore, emotional and spiritual care should be an essential part of treatment plan.

 » Conclusion Top

The uncertain and unpredictable nature of any pandemic makes the health-care system in a state of confusion regarding tackling and management of symptoms. A drift in the management perspective of health-care profession from objective toward subjective approach is essential and is the need of the hour for comprehensive well-being of patient as a whole. The CARE approach is an effort in guiding health-care workers for the complete care of the person.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 » References Top

Integrating Palliative Care and Symptom Relief into the Response to Humanitarian Emergencies and Crises: A WHO Guide; 2018.  Back to cited text no. 2
Woelfel R, Corman V, Guggemos W, Seilmaier M, Zange S, Mueller M et al. Clinical presentation and virological assessment of hospitalized cases of coronavirus disease 2019 in a travel-associated transmission cluster. 2020 MedRxiv 2020.03.05.20030502; doi:  Back to cited text no. 3
Adams J, Walls R. Supporting the Health Care Workforce During the COVID-19 Global Epidemic. JAMA 2020;323:1439.  Back to cited text no. 4
Schiffman F. Treating the patient, not the disease: Fred Schiff man on humanism in medicine. Oncology (Williston Park) 2017;31:246-7.  Back to cited text no. 5
Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent) 2001;14:352-7.  Back to cited text no. 6
Tao Y, Cheng P, Chen W, Wan P, Chen Y, Yuan G, et al. High incidence of asymptomatic SARS-CoV-2 infection, Chongqing, China. 2020; MedRxiv 2020.03.16.20037259.  Back to cited text no. 7
Recommended Actions Before D. Recommended Actions Before, during and after a Pandemic; 2020. Available from: [Last accessed on 2020 May 19].  Back to cited text no. 8
Advice for Public; 2020. Available from: [Last accessed on 2020 May16].  Back to cited text no. 9
Shah K, Kamrai D, Mekala H, Mann B, Desai K, Patel RS. Focus on mental health during the coronavirus (COVID-19) pandemic: Applying learnings from the past outbreaks. Cureus 2020;12:e7405.  Back to cited text no. 10
Rajkumar RP. COVID-19 and mental health: A review of the existing literature. Asian J Psychiatr 2020;52:102066.  Back to cited text no. 11
Pearce J, Ridley J. Communication in life Limiting illness: A practical guide for physicians. B C Med J 2016;58:262-7.  Back to cited text no. 12
Downar J, Seccareccia D; Associated Medical Services Inc. Educational Fellows in Care at the End of Life. Palliating a pandemic: All patients must be cared for. J Pain Symptom Manage 2010;39:291-5.  Back to cited text no. 13
Dunn L, Byrne P, Lloyd-Williams M. Ring us if you need us: The importance of reassurance to family caregivers providing home-based end-of-life care. BMJ Support Palliat Care 2014;4:119.  Back to cited text no. 14
Stewart-Brown S. Emotional wellbeing and its relation to health. Physical disease may well result from emotional distress. BMJ 1998;317:1608-9.  Back to cited text no. 15
Lamers SM, Bolier L, Westerhof GJ, Smit F, Bohlmeijer ET. The impact of emotional well-being on long-term recovery and survival in physical illness: A meta-analysis. J Behav Med 2012;35:538-47.  Back to cited text no. 16
Akbari M, Hossaini SM. The relationship of spiritual health with quality of life, mental health, and burnout: The mediating role of emotional regulation. Iran J Psychiatry 2018;13:22-31.  Back to cited text no. 17


  [Table 1]


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