High Dyspnea Score, a Trigger for Specialist Palliative Care Utilization-Results from a Cohort Study on the Predictors of High Opioid and Benzodiazepine Use in COVID-19 Patients.

Background: Patients with severe coronavirus disease 2019 (COVID-19) often rapidly deteriorate with severe dyspnea and should receive early specialist palliative care (SPC) as intensive symptom management may be required at the end of life. Currently, there is a paucity of data identifying triggers for early SPC involvement. Objective: To identify risk factors among nonventilated patients with severe COVID-19 who required high opioid and/or benzodiazepines (BZD) use for the control of dyspnea. Methods: This is a retrospective cohort study of nonventilated patients with COVID-19 admitted to the National Centre for Infectious Diseases in Singapore and seen by SPC between January 2021 and July 2022. We collected baseline demographics, comorbidities, 4C mortality score (International Severe Acute Respiratory Infection Consortium-Comprehensive Clinical Characterization Collaboration [ISARIC-4C]), and COVID-19 vaccination status. Clinical and laboratory results, dyspnea by numerical rating scale, and palliative-related treatments were recorded at the first SPC review, when symptoms peaked, and the last SPC review. Patients with morphine equivalent daily dose (MEDD) of ≥45mg and/or BZD use for dyspnea control were grouped as high users, while patients with MEDD <45mg and no BZD use were low users. Results: Among 234 patients, 119 (50.9%) were high users. Multivariate analysis showed that subjects with higher dyspnea (odds ratio [OR] 1.74, 95% confidence interval [CI] 1.45-2.08) and lower ISARIC-4C scores (OR 0.77, 95% CI 0.67-0.88) at first SPC review were predictive of high users. High users also required higher supplemental oxygen and had higher inpatient mortality rates. Conclusions: High dyspnea score is predictive of high opioid and/or BZD use for symptom control in nonventilated patients with severe COVID-19. Such patients with high mortality rates should be seen early by SPC.