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DEPARTMENTS: Guest Editorial

The Cancer Nurse as Primary Palliative Care Agent During COVID-19

Rosa, William E. PhD, MBE, ACHPN, FAANP, FAAN; Finlayson, Catherine S. PhD, RN, OCN; Ferrell, Betty R. PhD, RN, FAAN, FPCN

Author Information
doi: 10.1097/NCC.0000000000000886
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Coronavirus disease 2019 (COVID-19) continues to impact the health system and the foundations of human connectivity in countless ways. Regardless of the presence of COVID-19 infection, pediatric and adult oncology patients, as well as their families, face unique challenges in the varied contexts of survivorship, decision-making, caregiving strain, and all stages of grief. As face-to-face clinical relationships are replaced with telemedicine in many settings, it is challenging to provide high-quality primary palliative care in the acute inpatient oncology setting.

Palliative care is a human-centered and interdisciplinary approach to ensuring holistic, engaged care in the setting of serious illness and at the end of life to alleviate health-related suffering.1 Throughout the pandemic, palliative nurses have discussed strengthening their commitment to achieve universal palliative care access on a global scale2 and leveraging their clinical roles in myriad domains of practice.3 Many bedside oncology nurses have had to fill the traditional therapeutic roles of palliative specialists who were more readily available before the resource constraints associated with COVID-19. In the end, all cancer nurses are critical to ensuring the delivery of primary palliative care across the continuum.

Primary Palliative Nursing. Primary palliative nursing includes the management of pain, other symptoms, and treatment adverse effects, communicating patient/family expectations throughout disease trajectory, and assessing patient/family values, needs, and coping abilities.4 Primary palliative nurses (eg, cancer nurses) also support patients/families at the end of life and into bereavement.5 The complexities of COVID-19 have underscored the importance of cancer nurses assuming their role as agents of primary palliative care delivery and advocacy. A key role of primary palliative nurses is to identify the need for specialist palliative care input early in the disease trajectory, upon diagnosis of or admission with COVID-19.

Pain and Symptom Management. Early pain and symptom management can help optimize physical and social functioning, improve quality of life, and minimize discomfort. Patients’ symptoms of insomnia, anxiety, and depression may worsen because of fear of COVID-19 infection and/or isolation during quarantine or distancing measures. For oncology patients who do contract COVID-19, existing symptoms will likely worsen, and new issues may develop, leading to more complex cases requiring urgent attention. Access to symptom management protocols is essential.6 In addition, frontline nurses need additional training to ensure they can navigate primary palliative care needs without typical support services in place, which may include increased nurse autonomy in care management and discharge planning.

Communication and Advance Care Planning. COVID-19 has disrupted “normal” communication across settings. Never before has empathic, therapeutic communication been more important. As patients and families confront the long-term consequences of isolation, the cancer nurse serves as a touchstone of clinical updates, progress, and obstacles. Communication aides can be of great value to help navigate these unprecedented interpersonal challenges.7 More research is needed to better understand patients’ communication needs in crisis and via telehealth.

During COVID-19, patients who avoided discussing end of life in the past may now be ready to talk about it, along with their fears, worries, and preferences. In addition, patients may have new interests in limiting curative treatments or adopting a comfort-focused approach. Helping patients elicit their deepest wishes and values is pivotal to ensuring that care remains human-centered and relationship-based.8 This has highlighted the need for all patients to have advance directives early in their disease trajectory, knowing that illness can worsen at any time.

Cancer nurses have been providing healing and expert care throughout this global health crisis. There are countless educational resources to support the delivery of primary palliative care for all patients and families across settings.9 What would be possible if cancer nurses reframed their daily work and responsibilities through the lens of being a primary palliative care advocate and agent?

William E. Rosa, PhD, MBE, ACHPN, FAANP, FAAN
Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center New York
Catherine S. Finlayson, PhD, RN, OCN
Department of Nursing, Memorial Sloan Kettering Cancer Center New York
Betty R. Ferrell, PhD, RN, FAAN, FPCN
Division of Nursing Research and Education Department of Population Sciences, City of Hope National Medical Center Duarte, California


1. Radbruch L, De Lima L, Knaul F, et al. Redefining palliative care—a new consensus-based definition [published online May 6, 2020]. J Pain Symptom Manage. 2020. doi:10.1016/j.jpainsymman.2020.04.027.
2. Rosa WE, Davidson PM. Coronavirus disease 2019 (COVID-19): strengthening our resolve to achieve universal palliative care. Int Nurs Rev. 2020;67(2):160–163.
3. Rosa WE, Gray TF, Chow K, et al. Recommendations to leverage the palliative nursing role during COVID-19 and future public health crises. J Hosp Palliat Nurs. 2020;22(4):260–269.
4. American Nurses Association and Hospice & Palliative Nurses Foundation. Call for action: nurses lead and transform palliative care. 2017. Accessed July 22, 2020.
5. National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. Richmond, VA: National Coalition for Hospice and Palliative Care; 2020:2018.
6. Center to Advance Palliative Care. COVID-19 response resources hub. Accessed July 22, 2020.
7. VitalTalk. COVID ready communication playbook. Accessed July 22, 2020.
8. Aging with dignity. Five wishes portal home: COVID-19 resources. 2020. Accessed July 22, 2020.
9. End-of-Life Nursing Education Consortium. ELNEC support for nurses during COVID-19. 2020. Accessed July 22, 2020.
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