International COVID-19 palliative care guidance for nursing homes leaves key themes unaddressed

COVID-19 mortality disproportionally affects nursing homes, creating enormous pressures to deliver high-quality end-of-life care. Comprehensive palliative care should be an explicit part of both national and global COVID-19 response plans. Therefore, we aimed to identify, review and compare national and international COVID-19 guidance for nursing homes concerning palliative care, issued by government bodies and professional associations. We performed a directed documentary and content analysis of newly developed or adapted COVID-19 guidance documents from across the world. Documents were collected via expert consultation and independently screened against pre-specified eligibility criteria. We applied thematic analysis and narrative synthesis techniques. We identified 21 eligible documents covering both nursing homes and palliative care; from the World Health Organization (n=3), and eight individual countries: USA (n=7), the Netherlands (n=2), Ireland (n=1), United Kingdom (n=3), Switzerland (n=3), New Zealand (n=1), Belgium (n=1). International documents focused primarily on infection prevention and control, including only a few sentences on palliative care related topics. Palliative care themes most frequently mentioned across documents were end-of-life visits, advance care planning documentation, and clinical decision-making towards the end of life (focusing on hospital transfers). There is a dearth of comprehensive international COVID-19 guidance on palliative care for nursing homes. Most have a limited focus both regarding breadth of topics and recommendations made. Key aspects of palliative care, i.e. symptom management, staff education and support, referral to specialist services or hospice, and family support, need greater attention in future guidelines.