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Care and comfort in the time of COVID: Natasha Smallwood takes a holistic approach to health

11 November, 2020
Natasha Smallwood

‘COVID is one of those illnesses that speaks to how much we need a holistic approach to care and comfort,’ says Associate Professor Natasha Smallwood, Deputy Chair of the National COVID-19 Clinical Evidence Taskforce Care of Older People and Palliative Care Panel. ‘We’ve had to think differently and move quickly to find new ways to provide best practice care in incredibly challenging times. Less than 12 months ago, the concept of using an iPad to say goodbye to a loved one would have seemed extraordinary. We’ve been grappling with so many aspects of both clinical and end-of-life care, a large part of which has always involved being physically present and in close contact with your patient or loved one.’

As a respiratory physician at the Royal Melbourne Hospital, Natasha established and leads the hospital’s Advanced Lung Disease Service, which provides specialist integrated respiratory and palliative care. She has not seen a patient face-to-face in the clinic for over eight months now and while telehealth makes much possible, she has found it no substitute for human touch and interaction.

‘Not being able to see, touch and comfort patients is part of this dramatic change and challenge for all clinicians. Prior to the COVID-19 pandemic no one had any real experience in providing ‘virtual palliative care’ and there was no significant evidence base for this situation. The Taskforce has therefore been so important, as it rapidly brought together real time evidence and collective clinical knowledge and experience as they were accumulated from diverse clinical groups. In palliative care for example, bringing together a broad group of clinicians to develop flowcharts for clinical care and communication, not just with patients but also with families and carers, has been invaluable.’

‘This is just one example of everyone’s extraordinary willingness to work together using a genuinely multi-disciplinary approach that is a really unique feature of the Taskforce,’ Natasha says. ‘From the outset there has been so much buy-in and goodwill across the board, with a genuine openness and recognition that we needed to include different groups, specialties and perspectives. As a result, we’ve avoided traditional territorialism and been able to look at clinical questions and evidence with different lenses – which is really quite powerful.’

Natasha is an active member of many peak bodies, special interest groups and guideline panels. She is President of the Thoracic Society of Australia & New Zealand (TSANZ) Victorian Branch, co-convenor of the TSANZ COPD specialist interest group, deputy chair of the Lung Foundation’s National COPD Coordinating Committee, a member of both the TSANZ Acute and Domiciliary Oxygen Guidelines Working groups and an expert reviewer for the COPD-X Guidelines Committee. She sees the Taskforce approach to collaboration and guideline development as being unique and innovative in a number of ways.

‘It usually takes around two years to write a guideline without much support in terms of what needs to be done. Time-consuming literature reviews need to be fitted in around the demands of clinical work. We might work with one or two other groups but not a broad cross-section of clinical groups, and by the time the guideline is published it’s often already out of date. But with the Taskforce it’s completely different. We have this incredible team of evidence experts whose core business is examining data and appraising methods and quality. As a clinician, the evidence is now presented to us ready to review – making the process so much more feasible, efficient and effective. The Taskforce also have a really good leadership structure and governance and relevant panels. I think there are many lessons that can be learned from this living guidelines model and the way the Taskforce has operated so successfully, which could be adopted more broadly for other illnesses and guidelines.’

Looking ahead, Natasha is also keen to see the development of new guidelines that begin to address the immense social, psychological and workplace pressures the pandemic has wrought. To this end, in recent months she conducted a survey of almost 10,000 Australian healthcare workers and their experiences of working through the COVID-19 pandemic. Participants were asked whether they believed they had experienced any mental health conditions since the pandemic began. Over half reported that they had experienced anxiety and burnout, a third experienced depression, and 5 per cent said they had experienced PTSD.

‘We had an incredible response rate, with really rich and detailed answers – in fact we hadn’t dreamed that we would collect so much data so quickly. Along with questions on mental health, we also looked at the relatively new concept of moral injury – which is about being unable to provide care as you would normally because of a change in circumstance. Moral injury has been described in some countries such as Italy and the USA for example, where a shortage of ICU beds meant decisions about which patients had the best chance of survival. In the Australian context, our respondents struggled with the fact that when people die of COVID-19 they die alone – and health workers were really distressed about this.’

Natasha hopes to use the survey analysis to develop recommendations for government and professional bodies on how health workers can be better supported. ‘One simple fix that potentially ties in with the work of the Taskforce would be to have consistent guidelines for personal protective equipment (PPE) across all healthcare settings. That variation is actually really stressful if people work across multiple organisations, they have to remember to do something different every time they go to work. The fact the Taskforce is now partnering with the Infection Control Expert Group (ICEG) to focus on PPE and other critical questions is so positive, and will ensure the Taskforce becomes even more of a one-stop shop for clinicians.’

‘It’s another example of the Taskforce being an open and outward looking collaboration that’s always receptive to broadening the scope. So looking ahead, as countries around the world start to experience second or even third waves, we are really well placed to consider the volume of emerging evidence and the best ways to provide that holistic care and comfort to everyone impacted by this global pandemic.’