Do the clinical management guidelines for Covid-19 in African Countries reflect the African quality palliative care standards? A rapid review

Palliative care should be a component of COVID-19 management to relieve suffering, improve patient outcomes and save cost. We identified and appraised palliative care recommendations within COVID-19 management guidelines in Africa using rapid document analysis. All guidelines of any language published between December 2019 and May 2020 were retrieved through online search and email to in-country key contacts. We appraised the documents using African Palliative Care Association standards for providing quality palliative care. Fifty-five documents were retrieved from 29 out of 54 African countries. Fifteen documents from 15 countries were included in the final analysis, of which eight countries have identifiable PC recommendations in their COVID-19 management guidelines. The other seven countries have statements of recommendations which are relevant to palliative care. Governments and policymakers in Africa must prioritise palliative care within case management guidelines to ensure patients with COVID-19 have access.


Background
COVID-19 was declared a pandemic by the WHO within three months of its emergence. (1) The number of cases and deaths are escalating in African countries. As of 21 May 2020, 95,201 cases and 2,997 deaths have been reported from all 54 African countries. (2) COVID-19 case fatality rates range from 0ꞏ35 to 11%. (3) Risk factors for severe illness and mortality in COVID-19 include being elderly, the presence of pre-existing health problems, multi-morbidities, (4) and being of black and ethnic minority heritage. (5) In addition to these, severity and case fatality patterns in Africa may also be influenced by the lowered immunity in individuals with existing and undiagnosed conditions such as HIV/AIDS, tuberculosis infections, respiratory, cardiovascular, and metabolic conditions. Approximately 14% of patients have been reported to have the severe form of the disease, and 0ꞏ16% to 5% needed intensive care admission to manage severe respiratory symptoms. (6,7) Inadequately resourced health systems in Africa face challenges of providing needed critical care medications and mechanical ventilators for intensive care. (8) COVID-19 patients and their families report distressing multidimensional symptoms and concerns. These range from distressing physical symptoms such as fever, breathlessness, fatigue, cough; (9) psycho-social concerns, and spiritual /existential distress caused by the threat to survival, worry, and clinical uncertainty. (10) WHO recommendations for isolation means families and patients risk additional distress and poor access to social support. (10) Palliative care is a core component of Universal Health Coverage and is required by WHA73.3 resolution as part of member state responses to COVID-19 (11) . However, the neglect of palliative care among the dying and the resulting unnecessary serious health-related suffering is well established. (12,13) WHO's omission of palliative care from COVID-19 response plans has been highlighted. (14) Palliative care must be a component of COVID-19 case management to relieve suffering, improve outcomes for patients and their family members, and save costs. (15,16) Within limited resources, palliative care teams are supporting complex decision making for patients with severe COVID-19 illness. (17) Evidence from previous fatal viral epidemics demonstrates that hospice and palliative care play essential roles including providing protocols for symptom management, training non-specialists, being involved in triage, and providing psychosocial and bereavement care. (18) Given the low coverage of palliative care services and fragile health systems in Africa, health care professionals should be supported to deliver palliative care through clear comprehensive

Design
We conducted a rapid document analysis using a systematic procedure to retrieve and analyse COVID-19 clinical case management guidelines from all 54 countries in Africa.

Search Strategy
We searched the Guidelines International Network database for specific guidelines for the management of COVID-19 cases from Africa. In addition, we searched online sources including government agencies and ministry of health websites. In situations where guidelines were not available online or where documents available do not meet our inclusion criteria, key contact persons (ministry of health official, leaders of national palliative care associations, or palliative care champions) were contacted to obtain these documents. The process was coordinated by the African Palliative Care Association (APCA), the regional body that supports and coordinates the development and sustainability of palliative care. We emailed key contact persons in 39 countries.

Inclusion Criteria
We included guidelines for case management of COVID-19 published between December 2019 and 10 May 2020, written in any language. Our search was restricted to Guidelines prepared by a national government ministry or nationally recognised government body tasked with this responsibility. We included only guidelines prepared by the government as we were interested in assessing whether the government is considering and prioritising palliative care in the delivery of care to COVID-19 patients. Where a country has more than one version of the guideline, the most recent version was used.

Exclusion Criteria
We excluded: guidelines that were regional or hospital-based; guidelines that were prepared by NGOs or national associations not commissioned by the government; High-level strategy documents focusing on National Preparedness and Response Plan; Opinion pieces, commentaries, communique and editorials.

Data extraction (selection and coding)
A data extraction sheet was designed, piloted, and used to extract the following variables: 1) characteristics of each guideline i.e. country, title, date, and version of the guidelines. 2) Verbatim palliative care recommendations and content using related terms such as supportive care, supportive treatment, supportive therapy, hospice care, and end of life care. OA and MAO reviewed and extracted all guidelines together. Any guideline for which inclusion was unclear was discussed with second reviewers (AO, EC, EN, and KN). AO, EC, EN and KN also conducted independent checking and verification of all extracted data so that data extracted from each guideline was reviewed by a second researcher, and any disagreement was adjudicated by a third reviewer (RH). Guidelines in french language were independently forward translated by official French speakers (HA and SB) and their translations were compared for consistency.

Data Analysis
We conducted a narrative synthesis of the extracted data. We analysed the palliative carerelated contents of the guidelines using content analysis. In order to grade adequacy of the palliative care recommendations, we developed a matrix based on Principle 2 of the APCA standards for providing quality palliative care across Africa (19) . The APCA standards document was developed through wide consultation with service beneficiaries and providers to establish a framework for the development of evaluation and performance indicators to facilitate palliative care programme improvement and development across Africa. The document contains 37 standard statements grouped under four main principles including organisational management, holistic care provision, children's palliative care, education and training, and Research and Management of Information. (19) As we were reviewing case management guidelines and protocols, we assessed adequacy with respect to Principle 2 (Holistic Care provision) which has 17 standard themes (Table 1). This principle is most relevant to the direct patient and family care and support.
OA and MAO independently graded and checked the adequacy of the COVID-19 case management guidelines assigning fully met, partially met, not met, or not applicable. EN, EC, AO and KN verified the grading and any disagreement was resolved through discussion. 'Fully met' was assigned when a recommendation in a guideline comprehensively addresses the APCA summary statement for a standard. 'Partially met' was assigned when a guideline's recommendation addressed some or part of the quality standard summary statement. 'Not met' was assigned when a guideline's recommendation was deemed not to have met any aspect of the quality standard. Recommendations were assessed as 'Not applicable' where we could not assess a standard due to the complexity of the criteria and where it is not directly involving patient care.

Role of the funding source
No funding was declared for this study. or referred us to their website for documents (Rwanda). We had no response from the remaining 21 countries after two reminders were sent and we could not identify a key contact in Niger and Sao tome and Principe where. In total, we retrieved 55 documents from 29 countries. Figure 1 shows the process of retrieval and selection of documents. We included 15 documents (11 in

Discussion
Our study set out to critically appraise the case management guidelines for COVID-19 in Africa for their palliative care content and evaluate the adequacy of this against APCA standards for quality palliative care provision across Africa.
The majority of the countries with specific sections on palliative care are in Southern and Eastern Africa. This reflects the development of palliative care in these countries with strong advocacy networks and well-developed services and national policies. (20) Also, these countries named their treatment and therapeutic management sections supportive therapy or supportive treatment to recognize the absence of curative treatment for COVID-19 as against other countries.
While some case management documents made recommendations for some symptoms, there were no recommendations on other palliative care problems that may accompany breathlessness in COVID-19 such as delirium, anxiety, and cough. (21) Also, except for guidelines in South Sudan, Ethiopia, Eswatini, and Uganda, there were no clear recommendations for giving patients and families choices regarding care decisions such as the use of mechanical ventilation. In a continent where healthcare delivery has been known to be paternalistic (22) and palliative care training and education are limited, (20) there is need for explicit recommendations on shared decision making, fostering autonomy of choice, providing psychosocial care, patient-centred referrals to palliative care, and encouraging adequate communication with the patient and families at a time of high anxiety.
The importance of religious and cultural practices around dying in contributing to the spiritual needs of patients and families have been documented. (23) However, most of the guidelines we reviewed did not meet the standards of spiritual and cultural care (2.8 and 2.9 respectively).
While there were sections on managing dead bodies in recommendations from some countries, caring for the dying is omitted in all the case management guidelines. This suggests a lack of priority on supporting the dying phase to reduce distress and suffering. (12) This might also be indicative of the pervasive reticence and taboos around discussing the death and dying in African cultures. (24) There are limitations which may affect the interpretation of our findings. The wording of the APCA standard influenced our analysis. The specific wordings within the APCA standard is However, there is a wider debate that people with other progressive serious illnesses aside from HIV/AIDS and cancer have poor access to palliative care in Africa. This highlights the need for APCA to review and expand the standards to make it more inclusive within the context of wider serious health-related suffering. (25) Our findings are also based on documents that we were able to retrieve online or from key contact persons. We are aware that there might be other guidelines from government and NGOs which address some of the areas that we identified as weak. In addition, we only did forward translation for guidelines in the French language; therefore some meanings might have been lost in translation.
Furthermore, we applied standard 2.6 (the management of medications) by considering oxygen and other medication recommended in majority of the guidelines as serving palliative care or supportive therapy purposes. In the context of poorly resourced health systems in Africa, even oxygen for the management of breathlessness (which many of the guidelines recommended) may be unavailable, and as such might require rationing. In addition, the detailed criteria for this standard are related to medications commonly used in palliative care such as opioids which require proper training to prescribe and use. Therefore, clear guidance must also be recommended on the use of opioids as an additional line of management for breathlessness in patients dying of COVID-19 (21) and systems must be put in place to ensure their availability.
Like the HIV/AIDS pandemic before it, the COVID-19 pandemic might catalyse the development of palliative care in Africa to meet the needs of the non-COVID population. The focus of palliative care is on managing serious health-related suffering (12,25) and this is the only type of care we can offer patients with severe COVID-19 disease while we conduct further research into developing vaccines and curative treatment. There is extensive palliative care evidence on approaches to managing serious health-related suffering. It is therefore imperative for governments, policymakers, and stakeholders in Africa to prioritise the role of palliative care in the management of patients with COVID-19.