Background: Guidelines exist to direct end-of-life symptom management in COVID-19 patients. However, the real-world symptom patterns, and degree of concordance with guidelines on medication use, and palliative care involvement has received limited attention. 

Aim/Objectives: To describe the evolution of COVID-19 symptoms, medication used to alleviate these, and degree of palliative care involvement in the final week of life. 

Methods: This retrospective study reviewed all COVID-19 inpatient deaths across five metropolitan hospitals in Australia from 1 January – 31 December 2020. Outcome measures were collected at day of death, and days 1, 2, 5, and 7 before death. These were COVID-19 symptom severity (measured by the Palliative Care Outcome Scale), and use of supportive pharmacological and non-pharmacological therapies. Palliative care referral timepoint was also collected.

Results: Within the sample of 230 patients, commonest symptoms were breathlessness, agitation, pain, and respiratory secretions. On day of death, 79% (n=181) experienced at least one symptom, and 30% (n=68) experienced severe/extreme symptoms. The use of midazolam, glycopyrrolate, and infusions for symptom management occurred late, less frequently, and at lower doses than suggested in guidelines and other studies. Palliative care referrals were made late, at median 3 days before death (IQR 1-6 days), and for only half of people dying from COVID-19 (51%; n=118).

Conclusion: Symptoms peaked in final 3 days of life. Earlier use of infusional and breakthrough medications should be considered in anticipation of symptoms given high likelihood of dying in discomfort. Earlier palliative care referral for high-risk patients should be considered at hospital admission.