Background: Little is known about end-of-life care among Muslim patients, particularly during Coronavirus disease 2019 (COVID) pandemic, which we report here. Methods: The clinical characteristics, end-of-life care and resuscitation status of Muslim patients who died in the ICU of our tertiary care hospital in year 2020 from COVID were compared to Non-COVID patients. Results: There were 32 patients in COVID and 64 in the Non-COVID group. A major proportion, mainly of Non-COVID patients, already had a hospice eligible terminal disease at baseline (p=.002). COVID patients were admitted to the ICU sooner after hospitalization (2.2 vs. 17 days), had prolonged duration of mechanical ventilation (18.5 vs. 6 days) and longer ICU stay (24 vs. 8 days) than non-COVID patients, respectively (p<.001). Almost all patients were “Full Code” initially. However, status was eventually changed to ‘do-not-attempt resuscitation’ (DNAR) in about 60% of the cohort. COVID patients were made DNAR late in their ICU stay, predominantly in the last 24 hours of life (p=.04). Until the very end, patients in both groups were on tube feeds, underwent blood draws and imaging, required high dose vasopressors, with few limitations or withdrawal of therapies. Family members were usually not present at bedside at time of death. There was minimal involvement of chaplain and palliative care services. Conclusions: Muslim COVID-19 patients had prolonged mechanical ventilation and ICU stay and a delayed decision to DNAR status than non-COVID Muslim patients. Limitation or withdrawal of therapy occurred infrequently. The utilization of chaplain and palliative care service needs improvement.

PURPOSE: We conducted this study to evaluate the characteristics and outcomes exclusively in high-risk coronavirus disease 2019 (COVID-19) tertiary care patients with multiple comorbidities, as very few have reported outcomes in this specific cohort. METHODS: All patients, with two or more risk factors for COVID-19 and Charlson Comorbidity Index (CCI) of >2, who were admitted to intensive care unit (ICU) between March and December 2020 were included. Their characteristics, ICU course, and outcomes as well as differences between nonsurvivors and survivors were evaluated. The primary outcome was all-cause 28-day mortality. RESULTS: Out of 1152 COVID-19 patients, 101 met the inclusion criteria. The patients had an average of 4 or more comorbidities with a very high CCI of 5. The 28-day all-cause mortality was 23% and inhospital mortality was 32%. Among all risk factors, only age > 70 years, male gender, and chronic kidney disease were significant determinants of mortality ( P < 0.03). Admission PaO 2 /FiO 2 ratio and elevated inflammatory markers were same among survivors and nonsurvivors ( P > 0.66). The mean time from presentation to ICU admission (59 vs. 38 h), APACHE II score (20.5 vs. 17), ICU length of stay (25 vs. 12 days), and hospital length of stay (28 vs. 20 days) were all higher in nonsurvivors as compared to survivors, respectively ( P < 0.03). Fifty-four percent of the patients were intubated and had higher 28-day (40%) and inhospital (55%) mortality. CONCLUSION: Tertiary care patients with multiple comorbidities have higher mortality than what is reported for mixed populations. Further studies are needed to determine realistic mortality benchmarks for these patients.

Background It is unclear how COVID-19 vaccines have impacted the behavioral and physical infection control practices of health care workers (HCWs), both in the hospital and community. We conducted our study to explore this issue. Methods A comprehensive survey of 4 sections and 40 questions was administered to 146 HCWs 6 months apart, before and after COVID-19 vaccination. Besides demographics, the 4 sections evaluated the “behavioral” and “physical” infection control practices of HCWs in the hospital, infection control precautions in the community and their emotional stress. Each question was scored on a 4-point scale from 0 to 3. Results One hundred four of the HCWs (71%) completed both surveys. Respondents were mostly female, middle-aged nurses. Only 21% were confident that vaccine would prevent them from hospitalization or death. Despite some statistical improvement in some of the perspectives and practices, the intensity scores remained moderate-to-high for majority of the questions after vaccination. The HCWs remained worried about contracting COVID-19 infection in hospital and community, continued zealous precautionary measures, maintained social distancing both inside and outside of the hospital, avoided touching surfaces, and minimized contact with COVID-19 patients (P ≥ 0.08). Their emotional stress also did not improve after vaccination (P > 0.24). Conclusions COVID-19 vaccines have only a modest impact on the physical and behavioral infection control practices and emotional stress of HCWs. Additional measures are needed to influence HCW “souls” so they can reclaim their life of normalcy.

Background: Both coronavirus disease 2019 and middle east respiratory syndrome (MERS) can cause acute respiratory distress syndrome (ARDS); however, the former is postulated to lead to an atypical ARDS course and characteristics. We directly compare COVID-19 and MERS patients with ARDS to evaluate this issue.Methods: MERS patients with ARDS seen during the March to May 2014 outbreak and COVID-19 patients with ARDS seen between March and December 2020 in our hospital were included, and their clinical characteristics, ventilatory course, and outcomes were compared.Results: Among 1,091 confirmed cases, 133 were admitted to the intensive care unit. Forty-nine and 14 patients met the inclusion criteria for ARDS in the COVID-19 and MERS groups, respectively. Both groups had a median of four comorbidities with a high Charlson comorbidity index value of 5 points (P>0.22).COVID-19 patients were older, more obese, with significantly higher initial C-reactive protein (CRP) level and more likely to obtain a trial of high-flow oxygen and delayed intubation (P≤0.04). The postintubation course was similar between the groups. Patients in both groups experienced a prolonged duration of mechanical ventilation, and the majority received paralytics, dialysis, and vasopressor agents (P>0.28). The respiratory and ventilatory parameters after intubation (including tidal volume, FiO2, and peak and plateau pressures) and their progression over 3 weeks were similar (P>0.05). Rates of mortality in the intensive care unit (53% vs. 64%) and hospital (59% vs. 64%) among COVID-19 and MERS patients (P≥0.54) were high and reflective of their baseline comorbid status.Conclusions: Despite some distinctive differences between COVID-19 and MERS patients prior to intubation, the respiratory and ventilatory parameters postintubation were not different. The higher initial CRP level in COVID-19 patients might explain the greater steroid responsiveness in this population.

The end-of-life resuscitation status and therapeutic interventions in critically ill Muslim patients who succumb to their illness is not well reported. We describe our experience in such patients who were admitted to our tertiary care hospital Intensive Care Unit (ICU). METHODS:Our hospital is a tertiary care center accredited by Joint Commission International and Nurses Magnet Programs and runs active organ transplantation services. The patient population and treating ICU physicians are all Muslim. We collected twelve-month data from the year 2020 of patients who died in our ICU. Coronavirus Disease 2019 infected patients were treated separately and were not included in the study to give true reflection of the end-of-life care in Muslim patients under ordinary circumstances. Patient demographics, characteristics before and at ICU admission, cardiopulmonary resuscitation and DNAR details in ICU, and therapies administered in last 24 hours before death were recorded. Descriptive statistics were used to organize the collected data. Continuous variables were described as median with Interquartile Range Q1-Q3 (IQR), and categorical variables were described as number and percentages, as appropriate.RESULTS: 104 Muslim patients died during the study period. Their median age was 64 years and 51% were male. These patients had a median of 5 underlying comorbidities and a Charlson Comorbidity Index of 6 at baseline, highlighting their moribund status. 56% had underlying illness that would have qualified them for hospice before admission. Patients spent a median of 10 days (IQR 6-15) in the ward before ICU admission, had a high APACHE II score of 23 (IQR 20-33) and lactic acid of 3.7 (IQR 2.2-4.8) upon ICU admission. Their duration of mechanical ventilation (6 days; IQR 4-9), ICU stay (6 days; IQR 2-13) and hospital length of stay (10 days; IQR 6-15) were relatively long. 92% were "Full Code" at ICU admission and the status was changed to 'do-not-attempt resuscitation' (DNAR) in about 67% of the cohort before death. 42 patients had CPR done and 8 were made DNAR after one CPR. DNAR decision was made after median of 13 days (IQR 7-22 days) of hospital admission and 5 days (IQR 2.5-9 days) before death. DNAR discussions were led by Intensivists in 89% of the cases. Until the very end, patients in both groups were on tube feeds, underwent blood draws, had few limitations on therapy or withdrawal of care. There was hardly any involvement of Muslim chaplain and palliative care service. CONCLUSIONS:The concept of DNAR is accepted in Muslim patients even though decision is made near end of life. Many patients with terminal disease ended up in the ICU and role of hospice and palliative care needs to be increased in this population.CLINICAL IMPLICATIONS: DNAR is acceptable in Muslim patients, however, active mechanisms need to be developed to avoid terminal patients suffering undue ICU course at end of life.