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While most infections attributable to SARS-CoV-2 (Covid-19) are mild, a considerable percentage of affected people require hospitalisation and critical care. In European and North American centres, the mortality rate amongst individuals that are hospitalised, particularly those requiring mechanical ventilation, is high [1–3]. Earlier identification of impending severe disease is imperative to reducing mortality from CoVid-19 [4]. Health authorities and others responding to the epidemic should prioritise activities that support this life-saving approach, which includes improving access to health care for persons that are most susceptible to develop critical illness. However, as evidenced in Europe and the USA, maintaining access to health care and prioritising care for the most vulnerable during an epidemic are complex. While resource allocation related to shortages of critical equipment has been heavily emphasized in reports coming from European and North American settings, in African contexts these shortages are more pronounced, and high-complexity care is non-existent in numerous regions. Given underlying issues of access to care in many locations, patients frequently present to African emergency services in an advanced stage of disease suffering from organ failure that cannot be reversed. While the emergency department is not typically an environment associated with the provision of palliative care, we anticipate that the gravity of presentation of certain CoVid-19 patients, particularly those with underlying comorbidities, means that some will be more appropriately treated with informed, symptom-based end-of-life care than aggressive resuscitation. The decision process regarding resource allocation is outside the scope of this paper, but the scale of this pandemic highlights the necessity to implement ethical and compassionate palliative care in settings where it has not previously been considered. Médecins Sans Frontières (MSF) has combined research and fieldbased experience to develop a guidance document for clinicians with limited experience in the provision of palliative care, including those working in emergency services. In this paper we describe how evidencebased palliative care protocols can be adapted to less-resourced contexts at the necessary scale for a rapidly spreading epidemic whilst still respecting the physical and emotional needs of critically unwell individuals and their families.

Providing end-of-life care in the emergency department: Early experience from Médecins Sans Frontières during the Covid-19 pandemic