A specialist palliative care service in an acute hospital characterized care patterns during the first wave of the COVID-19 pandemic. There were delayed referrals for minoritized ethnic groups. COVID-19 treatments (dexamethasone, anticoagulation, remdesivir) alongside service changes were introduced in the second wave. To examine changes in care patterns and trends in the context of COVID-19 treatments. A secondary objective is to examine differences in ethnic disparity between the first and second wave of COVID-19. Retrospective cohort study comparing patients referred to an acute hospital palliative care service with confirmed COVID-19 infection either at the peak of the first (Mar-Apr 2020, W1), or second (Dec 2020-Feb 2021, W2) wave of the pandemic. Demographic, clinical characteristics, and outcomes data were compared using statistical tests; generalized linear mixed models for modelling of elapsed time from admission to referral; and survival analysis. Data from 165 patients (W1 = 60, W2 =105) were included. Patients in W1 were referred earlier to palliative care than in W2, particularly in the first 10 days from admission. Receiving dexamethasone or anticoagulants, and absence of dementia, hypertension, and fever were associated with longer time to referral to palliative care. Delays in referrals of Black and Asian patients during W1 was no longer observable in W2. There was no association between socioeconomic status and care patterns and trends. The Australian-modified Karnofsky Performance Status (HR < 0.92, 95% CI: 0.88 - 0.95) and phase of illness (HR > 3, 95% CI: 2 - 5) were good predictors of survival. Our findings have the potential to inform strategies that improve palliative care response and equity beyond COVID-19, and in future pandemics or crises. [Abstract copyright: Copyright © 2024. Published by Elsevier Inc.]