Page 23 - Palliative Care, Trials and COVID-19 Tribulations: First-hand experience shared by the experts at ground zero

Figure 14: The eight parameters used for non-verbal assessment in patients with severe
COVID-19.

With these eight parameters, you can have a total of 16 points. How do you use it? Let’s say,
if you have a score of 6 or more, this patient is not comfortable enough. This patient is
actually kind of distressed, and you need to start addressing that appropriately and titrate your
medications until the patient gets more comfortable. Normally, that would be a score of less
than 6.

Dyspnoea Management

For those who can still swallow, the management of dyspnoea would be to use an Opioid
(aqueous morphine) would be the primary or mainstay is 2 - 3 mg, 6 - 8 hourly, and PRN.
You can gradually titrate that to 4 hourly and PRN. But many patients when they are very ill,
they might have difficulties swallowing, so you can use subcutaneous Morphine, at half of
the dose, 1 - 2 mg, 6 - 8 hourly, and PRN, gradually titrate it to 4 hourly.

Sometimes in the wards, the nursing staff can also be very overwhelmed, so it is not easy to
give four-hourly medications always on time. Hence, if you want, you can actually use a
continuous infusion of subcutaneous/intravenous morphine, and typically we use about 10 -
15 mg over 24 hours.

Now, for those with renal impairments, you can use fentanyl instead of morphine. You can
dilute the Fentanyl and make an infusion of 4mcg/h. You can titrate that by increasing the
infusion by 2 mcg/h every 6 hours until the patient is more comfortable, and normally you
would not need to use more than 12 mcg/h.