Webinar Series on COVID-19 vaccine: Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research (ICR), NIH Speaker: Dr. Richard Lim Boon Leong is a Consultant Palliative Medicine Physician and Head of Palliative Care Unit, Selayang Hospital, Ministry of Health Malaysia.

1. COVID-19 Vaccination
in Patients Requiring
Palliative Care
Dr. Richard Lim B.L.
Consultant Palliative Medicine Physician,
Hospital Selayang

2. Disclaimers
•This slide was prepared for the Webinar Series on
COVID-19 session on 3rd March 2021, by Dr
Richard Lim, Consultant Physician at the Hospital
Selayang, Malaysia.
•This is intended to share within healthcare
professionals, not for public.
•Kindly acknowledge “Clinical Updates in COVID-19
http://www.nih.gov.my/covid-19” should you plan to
share the information obtained from this slide with
your colleagues.
Jointly organized by Malaysian Society of Infection Control and Infectious Diseases (MyICID) & Institute for Clinical Research, NIH

3. Content/Outline
•The need for COVID-19 Vaccination in the
terminally ill.
•Recommendation for vaccination in the terminally
ill and those requiring palliative care.
•Prognostication in common chronic conditions.
•Additional benefits of vaccination in those
requiring palliative care.

4. PALLIATIVE CARE
Quality of
life
Comfort
Love &
Family
Pain
Relief
Peace
Suffering
Hopeless
Death
Dying
End of
life

5. Vaccinate the terminally ill?
Wasting
vaccine, patient
still gonna die !
Healthier
patients will
benefit more.
Vaccine will
make them
go faster !
No point, they
won’t benefit
from vaccination

6. CFS 9
NOT OTHERWISE EVIDENTLY FRAIL

8. Scope of palliative care
Source: PCU H.Selayang Census 2020

9. Priority Groups
(adapted from Green Book, Public Health England, Chapter
14a, COVID-19)
Immunocompromised due to
disease or treatment
• Bone marrow/Stem Cell
Transplant
• Hematological Malignancy
• Cancer on active therapy
• Autoimmune ds and those
needing immunosuppressive
treatment
• HIV infection
• Asplenia / Spleen dysfunction
Chronic illnesses
• Chronic Heart / Vascular Ds
• Chronic Kidney Ds
• Chronic Liver Ds
• Chronic Neurological Ds
• Chronic Respiratory Ds
• Diabetes mellitus
• Obesity
• Severe Mental Illness

11. General Recommendation For
Patients Requiring Palliative Care /
Terminally ill
• COVID-19 Vaccination is still
recommended for all patients with
incurable chronic illness where
prognosis is estimated >3 months
• Exclusion:
• Patients who have terminal
illness who are actively dying
• Patients who have terminal
illness with estimated
prognosis of < 1 month
How to determine if the
patient has a prognosis of
1 month or less?

12. Illness Trajectories in Palliative
Care
Lunney J.R. et al. JAMA 2003
Metastatic cancer & CKD 5 without RRT
Cardiac Failure / Chronic Lung / Liver Ds
Dementia / Stroke/Frailty
< 1 Month Survival

13. Illness Trajectories in Palliative
Care
Lunney J.R. et al. JAMA 2003
Metastatic cancer & CKD 5 without RRT
Cardiac Failure / Chronic Lung / Liver Ds
Dementia / Stroke/Frailty
< 1 Month Survival
Most Predictable
Least Predictable
Not Accurate

14. Prognostication
in Advanced
Cancer

15. KPS Criteria
100 Normal. No complaints. No
evidence of disease
90 Able to carry on normal activities.
Minor signs or symptoms of
disease
80 Normal activity with effort. Some
signs or symptoms of disease
70-60 Cares for self. Unable to carry on
normal activity or to do active
work
50 Requires considerable assistance
and frequent medical care
KPS Criteria
40 Disabled. Requires special care
and assistance
30 Severely disabled. Hospital
admission is indicated although
death not imminent
20 Very sick. Hospital admission
necessary. Active supporting
treatment neccesary
10 Moribund. Fatal process
progressing rapidly
0 Dead
KARNOFSKY PERFORMANCE SCALE (KPS)

16. Karnofsky Score / ECOG as predictor of survival in
Advanced Cancer
KPS ECOG
Median
Survival
in days
Average
≥50 3 86.1
2-3
months
30-40
4
49.8
1-2
months /
3-7 weeks
10-20 16.8 2-3 weeks
Reuben DB, Mor V, Hiris J. Arch Intern Med. 1988.
ECOG Performance Scale
0 Fully active with no restriction as
before illness
1 Restricted in physically strenuous
activity but able to carry on normal
light activity (housework, office job)
2 Ambulatory and capable of self care
but unable to carry out any work
activities. Up and about >50% of
waking hours
3 Capable of only limited self care.
Confined to bed or chair >50% of
waking hours
4 Completely disabled, cannot carry out
any self care, totally confined to bed or
chair

17. Karnofsky Score / ECOG as predictor of survival in
Advanced Cancer
KPS ECOG
Median
Survival
in days
Average
≥50 3 86.1
2-3
months
30-40
4
49.8
1-2
months /
3-7 weeks
10-20 16.8 2-3 weeks
Reuben DB, Mor V, Hiris J. Arch Intern Med. 1988.
ECOG Performance Scale
0 Fully active with no restriction as
before illness
1 Restricted in physically strenuous
activity but able to carry on normal
light activity (housework, office job)
2 Ambulatory and capable of self care
but unable to carry out any work
activities. Up and about >50% of
waking hours
3 Capable of only limited self care.
Confined to bed or chair >50% of
waking hours
4 Completely disabled, cannot carry out
any self care, totally confined to bed or
chair
Any patient with Advanced Cancer and a
performance status worse than KPS 50 or
ECOG 4 may not benefit from vaccination

18. Prognostication in CKD 5 / ESRD
Conclusion:
In the 2 months before death, patients reported a
sharp increase in symptom distress and
health-related concerns which may indicate the
patients is approaching death.
Sharp decline in
function and increase
in symptoms

19. Prognostication in CKD 5 / ESRD
Conclusion:
In the 2 months before death, patients reported a
sharp increase in symptom distress and
health-related concerns which may indicate the
patients is approaching death.
Sharp decline in
function and increase
in symptoms
CKD 5 patients who are deteriorating
(KPS 60 and below) with increasing
symptoms (dyspnea, fatigue, pruritus,
agitation, drowsiness, pain) may not
benefit from vaccination

20. • Highly unpredictable in last
6-12 months of life due to high
incidence of sudden death
(25-50%) and continually
evolving standards of heart
failure therapies.
• 1 year mortality
– NYHA Class II : 5-10%
– NYHA Class III: 10-15%
– NYHA Class IV: 30-40%
Reisfeld & Wilson 2015
Prognosticating in Cardiac
Failure
Independent factors worsening
prognosis:
• Recent cardiac hospitalization
• LVEF <45%
• Anemia, hypoNa+, Cachexia
• Reduced Performance status
• Se creat >120umol/l
• Treatment resistant ventricular
dysrrythmias
• SBP <100 , HR >100
• DM, depression, COPD, cirrhosis, CVA,
Cancer, HIV

21. • Highly unpredictable in last
6-12 months of life due to high
incidence of sudden death
(25-50%) and continually
evolving standards of heart
failure therapies.
• 1 year mortality
– NYHA Class II : 5-10%
– NYHA Class III: 10-15%
– NYHA Class IV: 30-40%
Reisfeld & Wilson 2015
Prognosticating in Cardiac
Failure
Independent factors worsening
prognosis:
• Recent cardiac hospitalization
• LVEF <45%
• Anemia, hypoNa+, Cachexia
• Reduced Performance status
• Se creat >120umol/l
• Treatment resistant ventricular
dysrrythmias
• SBP <100 , HR >100
• DM, depression, COPD, cirrhosis, CVA,
Cancer, HIV
In patients with severe cardiac failure
NYHA Class IV and having multiple poor
prognostic factors, pros and cons of
vaccination should be discussed

22. (Celli et al ; NEJM 2004)
•Hospitalised patients with COPD
• PCO2 >50mmHg on admission:
10% die during admission, 33% die
in 6 mths, 43% die within 1 year.
(Connors et al 1996)
• Previous mechanical ventilation,
failed extubation or intubation
>72hours have reduced short term
prognosis.
• > 48hours ventilation 1 year
survival 50% (Nevins et al 2001)
Prognostication in COPD

23. (Celli et al ; NEJM 2004)
•Hospitalised patients with COPD
• PCO2 >50mmHg on admission:
10% die during admission, 33% die
in 6 mths, 43% die within 1 year.
(Connors et al 1996)
• Previous mechanical ventilation,
failed extubation or intubation
>72hours have reduced short term
prognosis.
• > 48hours ventilation 1 year
survival 50% (Nevins et al 2001)
Prognostication in COPD
Outpatient Care

24. (Celli et al ; NEJM 2004)
•Hospitalised patients with COPD
• PCO2 >50mmHg on admission:
10% die during admission, 33% die
in 6 mths, 43% die within 1 year.
(Connors et al 1996)
• Previous mechanical ventilation,
failed extubation or intubation
>72hours have reduced short term
prognosis.
• > 48hours ventilation 1 year
survival 50% (Nevins et al 2001)
Prognostication in COPD
Outpatient Care
COPD patients seen in outpatient
settings should be vaccinated.
Hospitalised patients with history of
mechanical ventilation and raised paCO2
should still be considered.

25. Prognostication in Chronic Liver
Disease
MELD > 30 has over 50%
mortality in 3 months

26. Prognostication in Chronic Liver
Disease
MELD > 30 has over 50%
mortality in 3 months
Chronic Liver Disease patients
with MELD scores over 30 may
not benefit from vaccination

27. Prognosticating in Dementia
•FAST (Functional
Assessment Staging)
identifies progressive steps
and sub-steps of functional
decline.
• Stage 7 (hardly able to talk
and walk) + one or more
demetia-related
comorbidities:
•Dementia related
co-morbidities
• Aspiration
• Upper urinary tract infection
• Sepsis
• Multiple stage 3-4 pressure
ulcers
• Weight loss >10% within 6
months
• Persistent fever
(Luchins et al 1997)
MEDIAN SURVIVAL
= 6.9 MONTHS

28. Prognosticating in Dementia
•FAST (Functional
Assessment Staging)
identifies progressive steps
and sub-steps of functional
decline.
• Stage 7 (hardly able to talk
and walk) + one or more
demetia-related
comorbidities:
•Dementia related
co-morbidities
• Aspiration
• Upper urinary tract infection
• Sepsis
• Multiple stage 3-4 pressure
ulcers
• Weight loss >10% within 6
months
• Persistent fever
(Luchins et al 1997)
MEDIAN SURVIVAL
= 6.9 MONTHS
Patients with severe dementia (FAST Stage 7)
should still be vaccinated unless having
on-going and persistent medical
complications

30. Autonomy and Informed
Consent

31. Autonomy and Informed
Consent

32. Additional benefits of
vaccination in this group
•May enable easier access to care
•Reduce need for isolation
•Allow family and friends to spend
more time together
•Allow more freedom to spend the last
months of life with better quality

33. For those unable or choose not
to vaccinate
•Ensure we advise family and carers that
they should vaccinate
•Avoid visitation by those who have NOT
been vaccinated

34. Email
•limbl@selayanghospital.gov.my