Thursday, March 23, 2017

Quality & Safety Consideration for Patients with a POLST or Living Will

Do We Ask for Permission to Treat First? Or Treat first & Ask Questions Later?

Figure 1: This resuscitation card links to a video by the patient explaining their care preferences:https://vimeo.com/user44599014/review/188926708/25b475b740 The password is: 911.

As we are educated on the ethical & financial concerns surrounding end-of-life care, we are informed by Institute of Medicine that end-of-life care is broken and accounts for $170 billion in annual spending (1). This projection will exceed $350 billion in less than 5 years. To better align patient wishes, living wills & POLST (Physicians Orders for Life-Sustaining Treatment) are necessary documents and processes. Whether you like them or not they are here to stay are we need to assure provider competency.  Additionally, Medicare now reimburses for advance care planning conversations in the office or via telemedicine. In the past, Physicians have tried to embrace living wills and more recently, the POLST paradigm has emerged to the national forefront. POLST & POLST-like processes have grown rapidly, which has outpaced the ability of states to educate to ensure the safe & effective utilization of this process.  Both living wills & POLST have limitations but are good documents with many benefits and are very much required to allow patients to preserve their autonomy (2,3).  How these documents are applied by others, in clinical situations, such as critical illness, has led to the unintended consequences of both “over” & “under” resuscitation.  By way of their success, we have essentially introduced a new patient safety risk which has no quality oversight.  As a result, we now must recognize these risks & act to protect patient wishes and outcomes.

Living wills require interpretation. POLST does not and is an immediately activated medical order set. So can we correctly interpret living wills and can we trust the POLST becomes a question. Most living wills are created by attorneys years in advance prior to the onset of medical conditions.  The POLST are completed by other providers (ex. Social Workers or admission nurses) & signed by physicians who may or may not have been involved in the conversation.  So, how do frontline physicians (such as Pre-hospital, Emergency Medicine, Trauma and Hospitalist physicians) interpret these during a brief interaction? Specifically, Emergency Medicine physicians do not know these patients or families & have no established trusts or report, yet, within seconds, are expected to understand the patient’s wishes to either accept or decline life-saving interventions based upon a form.  Of what is often documented, the “Full Code” appears understood.   However, with a do not resuscitate order, things are less clear.  Further, with POLST, there are many combinations of treatment options, which make the water muddier.

The TRIAD (The Realistic Interpretation of Advance Directives) studies have questioned whether or not providers understand what to do with Living wills, do not resuscitate & POLST orders.   It questions whether we are trampling on patient wishes to better control costs.  We need to figure out who is better off with a living will vs. a POLST.  We need to set quality standards & abide by them universally for both the living will & POLST.   More importantly we need to standardize Goals of Care conversations, so they are balanced & can accurately predict the patient’s wishes.  That information then requires the ability to be conveyed to a totally different & disconnected medical provider in a safe & effective manner that ensures no patient safety risk to the actual patient.

Volandes, Wilson & El-Jawahri have performed pioneering work with clinician to patient video. It has been shown that clinician to patient educational videos can help patients make informed decisions about CPR (4,5,6).   So, could we then utilize patient to clinician video testimonials to help providers make informed medical decisions for patients in a safe & effective manner?   In March 2017, the Journal of Patient Safety released the TRIAD VIII Study.  This was a Multicenter Evaluation to Determine If Patient Video Testimonials Can Safely Help to Ensure Appropriate Critical vs. End of Life Care.   From this work, we can now say that we can do things better to ensure we get it right for patients.    Figure 1 is just an example of how we can bring patients back into the actual decision-making process.

With patient video clarification, we can now hear from patients, in their voice and expressions, when they are critically ill & receive their guidance rather than providers guessing after reviewing a form that may or may not have been completed correctly. We know that forms when not fully completed lead to errors in treatment(8). We know that POLST forms can be discordant with patient wishes (9).  Resuscitations are complex & physicians need to know what to do initially in the first seconds to 15 minutes of an event.  Furthermore, the physicians comfort in the process to trust and act on what is documented is of paramount importance. Paper forms at present do not do this well or provide the necessary level of assurance to Physicians.  We still need POLST & living wills but we also need to hear from the patients to clarify the patient’s wishes. With emerging technologies, we also need to be able to incorporate patient to clinician video in a safe & cost effective manner.

In conclusion, we have a safety problem with living wills & POLST documents. TRIAD VIII presents an opportunity to do better. The traditional treat first and ask questions later approach is already being challenged by the development of malpractice litigation. To do what is right for patients, we need to embrace both living wills & POLST & be sure we set quality standards for their completion & understanding.  We must also investigate patient to clinician video and technologies to allow the clinicians to hear from the patient to accurately guide their care.

References:
  1. Institute of Medicine. Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life. National Academies of Sciences, Engineering, Medicine. September 17, 2014. Available at: http://www.nationalacademies.org/hmd/Reports/2014/Dying-In-America-Improving-Quality-and- Honoring-Individual-Preferences-Near-the-End-of-Life.aspx. Accessed January 3, 2016.
  2. Nicholas LH, Langa KM, Iwashyna TJ, et al. Regional variation in the association between advance directives and end-of-life Medicare expenditures. JAMA. 2011;306:1447-53.
  3. Fromme EK, Zive D, Schmidt TA, et al. Association between Physician Orders for Life- Sustaining Treatment for Scope of Treatment and in-hospital death in Oregon. J Am Geriatr Soc. 2014;62:1246-51.
  4. Volandes AE, Paasche-Orlow MK, Mitchell SL, et al. Randomized controlled trial of a video decision support tool for cardiopulmonary resuscitation decision making in advanced cancer. J Clin Oncol. 2013;31:380-6.
  5. Wilson ME, Krupa A, Hinds RF, et al. A video to improve patient and surrogate understanding of cardiopulmonary resuscitation choices in the ICU: a randomizedcontrolled trial. Crit Care Med. 2015;43:621-9.
  6. El-Jawahri A, Paasche-Orlow MK, Matlock D, et al. Randomized, controlled trialof an advance care planning video decision support tool for patients with advanced heart failure. Circulation. 2016;134:52-60.
  7. Mirarchi FL, Cooney TE, Venkat A, et al. TRIAD VIII: Nationwide Multicenter Evaluation to Determine Whether Patient Video Testimonials Can Safely Help Ensure Appropriate Critical Versus End-of-Life Care. J Patient Saf. 2017 Feb 14 [Epub ahead of print] PubMed PMID: 28198722.
  8. B Clemency et al. J Am Med Dir Assoc 18 (1), 35-39. 2016 Sep 28. Decisions by Default: Incomplete and Contradictory MOLST in Emergency Care.
  9. Hickman SE, Hammes BJ, Torke AM, Sudore RL, Sachs GA. The Quality of Physician Orders for Life-Sustaining Treatment Decisions: A Pilot Study. J Palliat Med. 2016 Nov 1 [Epub ahead of print].

Disclosures:
Ferdinando L. Mirarchi, D.O. has disclosed that he is the Principal Investigator of the TRIAD research series. He has an independent medical practice that focuses on advance care planning. He further discloses that his patients receive an ID Card depicted in this publication.

Kate Aberger MD, was a study site Principal Investigator for the TRIAD VIII study and has no further disclosures.


by: Ferdinando L. Mirarchi and Kate Aberger
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Thursday, March 16, 2017

Navigating end of life issues for those with no known family and friends




Consider the following scenario:

A previously independent 80 yo gentleman develops a catastrophic illness.  His mental status is poor due to strokes during his illness and it is unlikely he’ll recover the ability to meaningfully interact with the world.  However, he also has severe lung disease and he needs a tracheostomy with the ultimate plan of going to to a long-term ventilator facility.  It is unlikely he would ever leave the vent facility.  He has no family members, no friends.

Should he get a trach?

In most facilities, my sense is that the answer is yes.  The logic is that unless we have clear and overwhelming evidence that a patient does not want a specific intervention, death is always the worst outcome and thus must be avoided at all costs.

However, I wonder if this logic is flawed.  If we have 100 patients in this scenario, it is very possible that some of them would want the trach.  But it also seems quite likely that most would not want the trach, feeling that it would prolong a life that they feel has no value.  Our current system implicitly suggests that keeping someone alive in a state they don’t ever want to be in is not nearly as bad as allowing death for someone who values life regardless of their ability to interact with the world.

For me, both errors feel equally egregious.  And the current system which implies that any death is worse than keeping someone alive against their will feels one-sided.

Consider an analogous situation from a very different field:

When a new employee elects to save for retirement, the default option is often a low-risk, low-return money market fund, which experts agree is the wrong answer for the vast majority of new (mostly young) employees.  However, the low-risk option was the safest (prevented lawsuits from employees if a default high-risk option lost money).  However, having an overly “safe” default, contributed to the very predictable problem of most people not having enough retirement savings.

There are increasing efforts to try to create defaults that are more likely to be better choices for most people.  So, a new employee of a certain age will be given a default that is tied to their most likely retirement date (“life cycle” fund).  For young people, these are likely to be more aggressive funds that have a high proportion of their money in stocks.  It is likely that some young people who are very risk averse will end up in a retirement fund that embraces more risk than they are comfortable with.  However, by using what is most likely to work for most people, I believe that this new approach is probably helping more people than it hurts.

Coming back to medicine, I wonder if a “reasonable person” standard would be better than our current default of doing something unless there is clear evidence that a patient doesn’t want the intervention.  Instead of saying, “If we don’t know whether he’d want this, we have to do it,” how about “What would most people in his situation want?”  That way, the burden of evidence is not on one side to say he would not want this, but on both sides to get a sense of what is most likely what this patient would want. In a situation where we don’t know what an individual patient would want, it seems reasonable that we make the assumption that he is an “average” person who would want what most people want.

Just as having an overly safe default retirement option leads to predictable problems, I think our current paradigm of do everything unless we have clear evidence to the contrary, is likely leading to the predictable error of sustaining a life that many patients don’t want. A more nuanced approach where we look at what most people would want would decrease the errors.


by: Sei J. Lee
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The Overlooked Never Event



by: Ryan Van Wert, MD

John’s Story

Since his college days, John was always a runner.  Now at age 65, limping with arthritis, his orthopedic surgeon has recommended a left knee replacement. John completed a consent form authorizing the procedure.  In the operating room, John falls asleep as the anesthetic agent runs through his veins, hearing reassuring words from his nurse that everything will be okay.  When John awakes, it is very clear that something is very wrong.  His surgeon and nurses have gathered around his bedside and have devastating news: an error had occurred.  John had been mistaken for another patient scheduled for an above knee amputation, and the surgical team had removed his left leg.

This is one of the most terrifying scenarios that patients and surgeons fear, a family of adverse events called “Wrong-site, wrong-procedure, wrong-patient errors (WSPEs)”.  At the turn of this century, increasing awareness of these events led to the contemplation of “Never Events”. What ensued was an incredible culture of change in operating rooms to improve patient safety and the implementation of policies to reduce the chance of these devastating errors, including checklists, procedure time-outs, and empowerment of the surgical team to voice concerns before and during a procedure.  Medicare no longer reimburses any costs associated with these events, and WSPEs are medico-legally indefensible.  As devastating as WSPEs are, how often do they occur?  Most estimates put the risk at about 1 in 100,000.  And yet, immense resources have been deployed and fundamental changes to reimbursement have occurred to ensure that John’s story never happens to anyone else.

Susan’s Story

Susan has advanced heart failure; her care team has said there are few other treatment options and her prognosis is limited.  She completes a Physician Orders for Life-Sustaining Treatment (POLST) form – a durable medical order many states use to help patients get the care they want – confirming that she prefers not to have CPR or be admitted to the hospital.  Her preference is to spend her remaining time with family and have her symptoms controlled with medication. One day, she becomes short of breath. She is transported to the hospital and cannot speak for herself.  The POLST form is nowhere to be found and there is no copy in the medical record.  Unaware of her preferences, physicians insert a breathing tube to provide mechanical ventilation.  Her family is reached several hours later, extremely upset to learn that their mother is on life support.  They come to the hospital, order the breathing tube to be removed, and Susan passes away in the hospital several hours later, dying in a way completely contradictory to her care preferences.

Medical Errors Related to Life-Sustaining Treatment

Let’s compare the stories of John and Susan.  Both authorized, in writing, a treatment plan.  Both received procedures that directly contradicted that plan.  Both suffered severe, life-altering consequences of the error.  Both of these adverse events were completely avoidable.  So, why is Susan’s story not considered a Never Event by patient safety organizations?

As an intensive care unit physician, I can tell you that Susan’s story is not uncommon.  There are various factors that expose patients to risks of having an adverse event related to life-sustaining treatments:

  • The healthcare system (defined broadly) has never asked the individual about their preferences, or encouraged a process of systematic advance care planning
  • Documentation of care preferences is missing, or incorrectly documented in the EHR
  • The individual has not communicated their wishes effectively with their loved ones, putting surrogate decision makers in the heart-wrenching position of making treatment decisions with limited knowledge


How frequently do these medical errors occur?

Daren Heyland, a Canadian intensive care physician and researcher has a growing body of work to quantify the extent of the problem both over treatment and under treatment relative to the patient’s actual care preferences.  In a research study published in BMJ Quality and Safety, Heyland’s group performed a multi-center audit of elderly individuals with advanced, life-limiting illness admitted 16 acute care facilities.  Researchers asked patients or their surrogates about their preferences for life-sustaining treatments at the end of life, and then checked their medical record for physician orders related to cardiopulmonary resuscitation and do not resuscitate orders.

Using the medical order or “code status” in the patient record for this study is key, since these are the orders that would be followed by the care team in the event of an in-hospital emergency situation.  The findings were profound: overall, 37% of patients experienced a medical error in documentation of life-sustaining treatment preferences.  Certain sites had an error rate of 67%. Most of these errors put the patient at risk of over treatment.  These patients had clear preferences not to have CPR, yet documented medical orders were to provide CPR if needed. Two percent of patients experienced errors related to under treatment, that is, stated preferences for CPR with a “Do Not Resuscitate” order on the chart. One in six patients (and remember these are all individuals with an existing life-limiting illness), had no documentation on their charts about the use of life-sustaining treatments.

Let’s reflect on the potential consequences of these medical errors. Under treating an individual means near certain death; over treatment is similarly grim. After undergoing CPR – a painful procedure that often results in broken ribs – only 10% of individuals are discharged from hospital with favorable neurological outcomes.  ICU admission exposes patients to higher rates of hospital-acquired complications from delirium (confusion), pneumonia, muscle weakness and blood clots.  It is not uncommon to have many months of rehabilitation after an ICU stay, and long-term negative psychological effects for both the patient and loved ones.  ICU interventions are inherently uncomfortable and include large bore intravenous lines, uncomfortable breathing tubes and other routine procedures that require the use of powerful narcotics and sedatives for a patient to tolerate.

How are the consequences of an unwanted life-sustaining intervention any different than being left without a limb due to a medical error? At the turn of the century, a positive sea change took place in operating rooms across the country to define and systematically eliminate Never Events.  Now is the time for our health systems and patient safety organizations to embark on a similar mission to eliminate Never Events related to life-sustaining treatment.



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Tuesday, March 14, 2017

Code Blue




by: Marcia Glass, MD

I sometimes notice “DNR” on my intern’s to-do list during rounds. It usually means his resident asked why this patient, in spite of being so debilitated from his end-stage cancer, or his dementia, or his heart failure, was still full code.  The patient should be made DNR instead, but doing so involves a difficult conversation with sick patients or desperate relatives, sometimes over hours, sometimes over days. Hence, the DNR on the to-do list and the knowing looks from my team. “How’s the family?” “Do they get it?” “Are they reasonable?” Any possibility of a peaceful death depends on my medical team’s ability to make people we hardly know trust us and then change their minds.

Mrs. J. was different. In her eighties, she came to our hospital in San Francisco with her favorite blanket and a book of crossword puzzles. Her husband, close to ninety, rode two buses in his neat overcoat every day to arrive promptly at 8 a.m. before our rounds started. Mrs. J. had advanced stomach cancer and knew she was dying. She had been on home hospice care and came in only to see if the surgeons could relieve her agonizing intestinal obstruction. They could not. But they did place a nasogastric drainage tube to make her more comfortable. My team adjusted her pain and nausea medications and found a hospice facility where she could be cared for until she died, instead of struggling at home. She was not fighting to stay alive; she only wanted to feel better and enjoy the limited time she knew she had left. She was eager to leave the hospital and spend her last days at the residential facility we had found for her. She had told us not to resuscitate her if she coded. She was at peace.

The one morning her husband came in late, I sat alone by her bed and asked how her night had been. We ask these questions dozens of times a week, but this encounter felt more intimate, chatty. For a moment, I enjoyed a friendly conversation, a rare pause in the day when I could sit next to someone I was caring for with no agenda. For ten minutes, no one came by to clear the breakfast tray or encourage her to sit up for physical therapy or ask her to swallow her every-four-hour pain medication. We could have been in her living room instead of under the fluorescent lights of this hospital. But then the speakers in every hallway came to life, and we heard the urgent call to a code. Code Blue. 10th Floor ICU. Code Blue. 10th Floor ICU. The announcement sounded calm, formal, aseptic. Yet the clean language belied the chaos I relive every time I hear a code: nurses shouting, doctors running, a defibrillator charging, blood everywhere. I looked at Mrs. J. and realized she seemed scared. She closed her eyes, grabbed my hand, and whispered something to herself, too softly for me to hear. These could have been words of relief that she would never go through a code, or words of compassion for the person suffering a few rooms away, or, perhaps, some doubt about her decision to pursue comfort measures only and not cling to every possible second.

I have helped many other patients and their families struggle through decisions about end-of-life care over the years since I cared for Mrs. J. As I have supported them through this grueling process, Mrs. J. sometimes comes back to my mind. I will never know what she felt when she heard someone else’s code blue, but I will always remember what I thought at the time: You made the right choice.



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Tuesday, February 28, 2017

How Low Should We Go with Blood Pressure in Older Adults? A Podcast with Mark Supiano



In this GeriPal Podcast we talk with Dr. Mark A. Supiano about a blood pressure management in older adults in the light of new evidence from the Systolic Blood Pressure Intervention Trial (SPRINT).

In particular, we talk about a recent paper he co-author with Jeff Williamson in the Journal of the American Geriatrics Society (JAGS) titled "Applying the Systolic Blood Pressure Intervention Trial Results to Older Adults."  We discuss issues around the generalizability of the SPRINT trial, whether it applies to a subset of frail older adults, and whether the way we measure blood pressure in a typical office visit influences how we should think about the question "how low should we go?"

GeriPal Podcasts can be found on:




Transcript of the podcast:

Eric: Welcome to the geripal podcast this is Eric Widera.

Sei: And Sei Lee.

Alex: And Alex Smith.

Eric: And before we get to our guest who's calling in all the way from Utah, maybe Sei you can give us a song that can give the audience a hint about what we're gonna be talking about today.

Sei: How about friends in low places.

Eric: Alright.

Sei and Alex sing “Friends in Low Places” by Garth Brooks:

All together now, Blame it all on my roots, I showed up in boots and ruined your black tie affair. I was the last one to know, was the last one to show, I was the last one you thought you'd see there. I saw the surprise, and the fear in his eyes, when I took a glass of champagne. Then I toasted you, said honey we may be through, but you'll never hear me complain. 'Cause I got friends in low places where the whiskey drowns and the beer chases my blues away. I'll be okay. I'll be okay.

Eric: So with that intro of a song, today we have Mark Supiano with us, he's a professor and chief of division of geriatrics University of Utah School of Medicine, and the director of the Salt Lake City grecc and Mark just got published, I think just a couple months ago, is that correct Mark? An article on plying the systolic blood pressure intervention trial or SPRINT trial results to older adults in a JAGS issue that just got published in January.

Mark: Yes, it appeared in the January issue, it was published online early I believe back in November, and I should also acknowledge the co-author with me on this article is Jeff Williamson from Wake Forest where he's the chief of the division of geriatrics there and has been integrally involved in the SPRINT trial.

Eric: I'm gonna just start us off, how should we be integrating the SPRINT trial into our clinical practices?

Mark: Sure, so that question Eric, is exactly what Jeff and I wanted to respond to after the main trial results were published in New England Journal of Medicine in late 2015 and then in May of 2016 the results from SPRINT specific to individuals age 75 years and older was published in JAMA. The questions that Jeff and I were getting from our colleagues in geriatric medicine and primary care providers was how we should be interpreting these results and what sense does it make for patients that we're seeing in our clinics?

So, there are several points to make I'll start with I think the first one really, which is the case with any randomized trial result that you are considering applying to the patient in front of you, is whether or not the patient would have met the eligibility criteria for that trial. So in other words does the trial finding generalize to the patient that I'm treating. So with that in mind there were several important exclusions to SPRINT I can name just several now, and then we can go into some of the details, but importantly SPRINT did not include individuals with a history of diabetes, it did not include individuals with prior history of stroke or had prevalent congestive heart failure, or dementia. Form the geriatrics perspective individuals for community dwellings, so ambulatory community dwelling adults, so not nursing home residents and without dementia at the time of entry into the trial.

So those were some of the important characteristics of the study population that need to be kept in mind when you're deliberating whether or not the SPRINT blood pressure target of 120 would be even something that you would consider applying to a particular patient.

Eric: And real quick overview for our audience who may have read the SPRINT trial over a year ago, what was the intervention again?

Mark: So, SPRINT is a bit unusual it was not a specific medication intervention, it was a single labeled design, the subjects knew, which arm they were in, two blood pressure targets. So a standard arm of a systolic blood pressure of below 140 and an intensive arm to a systolic blood pressure target of less than 120. To accomplish that blood pressure reduction on average required one additional medication, so at the time of entry in to the trial the average number of antihypertensive medications that the subjects were taking was two. And the average systolic blood pressure on entry was just over 140. To achieve the lower systolic target of 120 required on average an additional medication so that at the end of the study the individuals in the intensive arm were on three antihypertensive medications while the standard arm average remained at about two.

That said the separation in systolic blood pressure between the two groups occurred relatively quickly, so within the first six months there was more than a double digit difference in systolic blood pressure and that delta was maintains across the duration of the trial for the 75 and older group the delta ended up being about 11 millimeters of mercury between the two groups.

Eric: And if I remember correctly the mean blood pressure in the intervention group was actually slightly above 120, right?

Mark: That's correct it was, if I'm recalling correctly, it was 123 for the 75 and older population so, half the group had blood pressures above 123 and half were below that.

Eric: So what are we supposed to make of that, so if the goal was less than 120 but still the majority, or the mean was above 120 in the intervention group, how should that play into our clinical thinking?

Mark: Yeah, so that's a good question, there will be additional analysis done to determine the impact or the relationship between the achieved systolic blood pressure and outcomes, as opposed to assignment to treatment arm, right? So at the moment we have the results based on assignment to treatment arm, to address that question whether there was added benefit or potential harm in going based on the achieved systolic blood pressure those analysis have not yet been completed.

But let me take a tangent off on that question to make an additional very important point about measurement, because this is another question that does come up and something that Jeff and I highlighted in the Jags article, is that the protocol that was used in SPRINT to measure blood pressure at the time of entry and then at all of the follow up phys-eds is not the routine office blood pressure measurement that most patients are getting when they go in for a visit with their provider. So the blood pressure measurement details are that an automated blood pressure device was used, it was programed to require that the individual being sitting quietly for five minutes before any blood pressure measurement was taken, the appropriate details regarding cuff size and position of the arm and so forth were adhered to, and then after the five minute rest period three serial blood pressure measurements were taken most of the time without the observer in the room, and the average of those three serial blood pressure readings was then taken to be that clinic blood pressure for that day.

Eric: So that sounds very different, I just had a blood pressure check yesterday, what happened was, I walked in to the room, the nurse was talking to me the whole time, she slapped on a blood pressure cuff-

Mark: Probably over your jacket.

Eric: (laughs) It was actually not over my jacket, but over my shirt and over an undershirt. Throughout the whole intervention maybe it took like one minute to do the blood pressure check, again we were talking and chatting throughout the whole time. Different, it sounds like.

Mark: There's a difference, and the reason it's important is that there's pretty good evidence to suggest that this automated protocol result is anywhere between five to eight millimeters of mercury lower than the blood pressure that you just had done yesterday. Alright so if it was repeated using this protocol chances are your systolic pressure would be five to eight millimeters lower than what you obtained with the protocol that you described. So, the main message here is that if you intend to treat to the SPRINT target of 120, again this was the target as you pointed out earlier not everyone got to that level, but if you're attempting to bring someone's blood pressure down to that range, it really is important that you're utilizing the protocol that SPRINT used to make sure that you're not over-treating and getting someone down even lower.

Eric: And if we don't have a lot of control over the protocol in the short term, I mean this sounds like a great quality improvement project, should we be targeting slightly higher by five to eight millimeters mercury?

Mark: That would be the correct interpretation, Eric, although I want to take this opportunity to push back on your first part of the statement, I think we really should push back in fact to change our work flow and the procedures so that we are measuring blood pressure correctly and accurately. So the excuse that while the blood pressures of SPRINT aren't meaningful in the real world, my response to that is we need to make the real world a better place and utilize the appropriate protocol to measure blood pressure accurately so that we are in fact treating people to the right target. This also mitigates in part some of the white coat hypertension that we see more commonly in geriatric patients and just so I don't lose my train of thought if I can interject one more important measurement aspect because it will relate to the comments that I'm sure we'll get to in a minute about adverse events, but the other critical aspect of SPRINT and critical aspect for treating hypertension in older people, is to make sure that orthostatic hypotension is checked for and monitored.

So, an important exclusion to the SPRINT trial was if someone's standing blood pressure after one minute was below 110, it turns out that for the 75 and older population, ten percent of individuals who are screened for enrollment into SPRINT had blood pressures below 110 after one minute of standing. So this was not uncommon. So, the other take home is that before you entertain a lower target for the patients that you're seeing for their hypertension, it's obligatory that their orthostatic blood pressure be measured to make sure that you're not putting that patient at risk for this more intensive systolic blood pressure target down to 120.

Eric: When I think of orthostatic blood pressure I often think of not just systolic blood pressure of less than 110, but a drop in systolic blood pressure when standing, was that also part of it? Or was it just, if your blood pressure was less than 110?

Mark: So the exclusion was if the standing blood pressure was below 110, that said orthostatic blood pressure measurements were checked at every visit, which is another thing not commonly done in routine clinical practice, but is in fact a standard dating back to JNC 7 actually. So this is not new information, but again not commonly done. But the protocol for follow-up visits in SPRINT was that orthostatic blood pressures were assessed as well as carefully assessing for adverse events of hypotension, dizziness, and falls.

Sei: So first of all, I want to congratulate you on just an amazing study. And I have to say, it was great reading a study that was designed and really led by geriatricians, and I was thinking as I was reviewing it thinking about how it differed from the HYVET study where things that I was so interested in like frailty and cognition were measured at baseline so that I could really make a critical assessment of whether the patients in the trial were similar to the patients that I see. So, first I just wanted to say thank you for supplying us with the evidence to actually be able to say how well the trial data fits with the patients that we take care of.

Mark: Well, thanks for that comments Sei, and I want to give credit where credit is due and I want to thank Jeff Williamson and others on the SPRINT steering committee, but Jeff in particular really went to bat to incorporate the geriatric measures that you just sighted so, the cognitive battery, the gate speed, the frailty assessments that we've been able to report on, those were built into the design of the trial. And I think as geriatricians as you were just saying that we really should applaud finally, that we've been successful in getting these outcomes into a major trial like this because it is so important for the older patients. And let's also applaud the fact that, and it was actually thanks to the ARRA funding that there was an opportunity to augment the recruitment of individuals 75 and older into the trial, and so that population accounted for 28 percent of the entire cohort. So their 2800 individuals over the age of 75 who participated in the trial so we also need to thank the SPRINT steering committee and NHLBI and the other funders, including NIA, for that investment to allow that to happen. Thank the sites it's very difficult to recruit and retain older people into trials like this. And also, most importantly thank and acknowledge all of those participants who contributed to this information and really allowed us to make this kind of report.

Eric: So the other thing I want to thank, is going back to the Jags article that you recently published, you had a section in there called time to benefit. And thinking about medical decisions in the context of prognosis, how should we be thinking about the SPRINT results as far as time to benefit?

Mark: Well thanks for bringing that up Eric, it's something I've given a lot of thought to and again it is geriatricians and for the Geripal audience as you just alluded to, we need to carefully think about any treatment that we're gonna recommend to individuals, particularly frail, older individuals at advanced ages and I think with that said, the flip side of that is, we need to be careful not to under-treat older, frail people, who may derive from more intensive treatment of important cardiovascular risk factors such as high blood pressure.

With that in mind the information that's maybe somewhat lost in this that I will take this opportunity to emphasize is that similar to HYVET, you just brought up the HYVET study so, you may recall that HYVET, like SPRINT stopped early because the DSMB identified a significant mortality benefit in the group that in HYVET had been randomized to active treatment relative to placebo, and in SPRINT similarly the trial ended earlier than anticipated. The trial was designed to go a little over five years, it ended at 3.2 years of follow-up, when the DSMB noted the unequivocal benefit to the intensive treatment group in a mortality outcome, as well as the primary cardiac outcome. So with that in mind the other study that people may not be familiar with is that there was a follow on extension to HYVET that took people who had been in the placebo arm of HYVET and crossed them over to active treatment and the same benefit for the HYVET outcome of stoke, so the same benefit with about a 35 percent reduction in the hazard ratio for stroke occurred in that group that crossed over within the first 12 months of treatment. So, when you think about how high blood pressure develops over time and we think about these risks that accrue over a lifetime.

That said the benefits that we're talking about for reduction in cardiac morbidity and mortality and total mortality are occurring in the space of 12 to 24 months. So for someone with a life expectancy that exceeds one to two years, the potential for benefit is there. I think another point to move to then, and I'll be very interested in both of your input into this, but quality of life for this patient population supersedes, I almost said a different word but I've eradicated that word from my vocabulary given the current events in Washington, so the quality of life may supersede mortality for our patient population and these results are not yet published, they've been presented at a national meeting and the paper is under review but, the quality of life was another outcome that was assessed in SPRINT and the short take home was that there were no deleterious effects in quality of life in individuals randomized to the intensive arm.

And from our perspective for the geriatric population that also held true for the most frail subgroup of the 75 and older population. So these benefits occurred without a negative impact on quality of life, and finally speaking of frailty, we are often somewhat nihilistic about recommending treatment to an older frail individual, but it seems to me that the last thing an older frail individual needs is to develop heart failure or to have a stroke, because if they're already old and frail the morbidity and disability that is incumbent with the development of either of those outcomes could be devastating. So if we can successfully prevent additional disability that would be related to the development of congestive heart failure or a new stroke. It seems to me that that's an outcome that many of our patients would consider as important to them, and if so worth the additional costs and time and so forth that would be involved in one additional medication to get their blood pressure a little bit lower.

Eric: So the one last question from my standpoint then, is when we're thinking about other risks from this, and especially since the trial ended early, sometimes risks of medications and treatment strategies build up over time, and the one that you talk about in the JAGS article that really popped out at me is kidney outcomes. How should we think about the SPRINT trial, because there were increased number of negative kidney outcomes, is that right?

Mark: Correct, so these are referred to as conditions of interest, so the event rates not only acute kidney injury and electrolyte abnormalities, primarily hyponatremia and low blood pressure were more common in the intensive group. That said, these have been found to be transitory, there was no increased rate of renal failure, in fact the number of renal outcomes was very low overall so there was no harm in terms of permanent renal injury that developed. So these transitory adverse events can be modified by dosage adjustments and other things that can be done quite easily, in turn if you develop a cardiac event, that's not as modifiable, right? If you have a heart attack or stroke, you can't go back and change that, so our take home was that these risks although present, are far out raised by the cardiovascular mortality benefits that were identified. The final point though with regard to your question, Eric, is that there are longer term studies that will be carried out in the SPRINT cohort to address your question about longer term kidney outcomes, so this is called the SPRINT ASK study, so aging seniors and kidney I think is the acronym. Geriatricians don't have quite as sexy acronyms as cardiologists.

Eric: Cardiologists are really good at it.

Mark: Yeah, we needed a cardiologist to help us with that, but SPRINT ASK will likely be funded this year, we don't have the definitive notice of award yet, but that's looking very encouraging and if funded that will allow additional follow-up for another year in the SPRINT participants, not only for their renal outcomes but the other area we've not yet touched on and I know we're running out of time but just very quickly, the other outcome of keen interest to all of us is the cognitive outcomes, and whether there is an impact on the development of incident dementia with the more intensive blood pressure reduction. So the SPRINT ASK extension will likewise collect neuropsychological outcomes for an additional year in participants who were in the SPRINT trial. So those outcomes on the cognitive outcomes are still forthcoming and that will obviously have a huge impact on how widely adopted the lower blood pressure target is going to reach.

Sei: How do you think these results should be interpreted for patients of the appropriate age, but patients for whom as a clinician we feel like this is a patient who is more frail than the average 80 year old, a patient for whom it seems they're more frail than the frailty of the average SPRINT participant?

Mark: Good question Sei, and we have to think back to the very first thing I said about generalizability is if in your clinical judgment the patient that you're seeing would not have been eligible to enter the SPRINT trial for the reasons that you've stated, we should be very cautious and thinking about generalizing and applying it to that individual. So one particular example would be, because this question has arisen relatively commonly, is what about residents of skilled nursing facilities or long term care residents. So that's a very different population where, as you're pointing out their life expectancy may be quite low and we need to think carefully about an intervention in that population and we don't want to over-generalize these findings to a more frail population such as you're describing.

Eric: So I want to thank you Mark for really the insightful comments and for writing the Jags paper, which we will put up on our website for our listeners to review.

Mark: Just to add one quick thing in response to Sei's last question, I thought you were also gonna ask what happened longitudinally with frailty, we do have those data and I actually just saw a sneak peek of those results yesterday, but we're preparing to present the longitudinal frailty outcomes at the international meeting of the Association of Gerontology and Geriatrics or the IAGG meeting in July in your home city of San Francisco-

Sei: Yes, we'll see you there.

Mark: So, come to our session, there's a SPRINT session symposium that's been accepted for presentation at IAGG so we'll have some additional data there, and again we look forward to fielding more questions and getting more input about this very important topic.

Eric: And we could have the in-person podcast!

Mark: Fantastic, on the scene right?

Eric: The sequel, we'll have you at that next one, we'll have you sing our closing verse with us.

Mark: Oh yeah, I've warned you not to invite me to sing.

Sei and Alex sing “Friends in Low Places” by Garth Brooks:

Blame it all on my roots, I showed up in boots, and ruined your black tie affair. I was the last one to know, I was the last one to show, I was the last one you thought you'd see there. I saw the surprise and the fear in his eyes, when I took his glass of champagne. And I toasted you said honey we may be through, but you'll never hear me complain. 'Cause I got friends in low places where the whiskey drowns and the beer chases my blues away. I'll be okay. I'll be okay. And I'm not big on social graces, think I'll slip on down to the oasis, oh I got friends in low places.



Transcript edited by Sean Lang-Brown
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Monday, February 27, 2017

Encouraging ACP to support the Older Americans Act


by: Joanne Lynn, MD (@drjoannelynn)

Last year when the Older Americans Act came up for reauthorization, no medical or nursing professional groups provided visable support.  Outrageous.  This is how our vulnerable patients get Meals on Wheels, housing adaptations, transportation, and so on.  Funding has been stagnant for nearly two decades.

If you are a member of American College of Physicians (ACP), please write immediately in support of the Resolution 3-S17 which is reproduced below – comments are due by March 1 – so don’t delay.

Send your supportive comment to astacp@hotmail.com.

If you are not in ACP – consider whether your professional organizations might support the OAA when it comes up next year.  ACP required this process that ends up authorizing their advocacy group to take action – so it takes a year or so to get them aligned.  See what other groups will need to be ready.

If we are not there for our patients in need, who will be?  Most cities now have 6 month waiting lists for home delivered meals.  We do the mop-up for shortcomings like this when elderly and ill folks end up in the ER – but the persons in need suffer and we have to run up the costs.  Let’s break the cycle and feed and support people who cannot fend for themselves.  Support the Resolution!


----------------------

Here’s the Resolution:

Resolution 3-S17. Supporting the Older Americans Act

(Sponsor: District of Columbia Chapter)

WHEREAS, the ACP has a long history of being supportive of efforts to improve the health care for the elderly (who are high-risk for the need for social services) as well as in general for other persons who are at-risk for the need for social services; and

WHEREAS, an ACP Mission is to advocate responsible positions on individual health and on public policy relating to health care for the benefit of the public and our patients; and

WHEREAS, the Older Americans Act (OAA) [1] [2] provides funding for social services to at-risk elderly persons and is up for renewal in 2018; and

WHEREAS, such funding has not increased sufficiently to provide adequate assistance to individuals requiring significant need for social services (e.g, funding for the Older Americans Act has been essentially flat over the past decade though the population 65 and older has increased by over 25% in number in this period of time[3]; and

WHEREAS, individuals who cannot adequately care for themselves without supportive services suffer unnecessarily, spend substantial resources they often cannot afford, and have to rely upon medical care, which is often discontinuous and expensive, occurring in settings such as hospitals and nursing homes; therefore be it

RESOLVED, that the Board of Regents supports the Older Americans Act as official policy; and be it further

RESOLVED, that the Board of Regents will collaborate with other health care professional groups to lobby for the extension of the OAA beyond its current 2018 expiration date, lobby for increased funding for the OAA, and encourage the development of innovative, cost-effective models of care which combine medical and social services in general.




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Monday, February 20, 2017

Jessica Zitter on Palliative Care in the ICU



In this GeriPal Podcast  we talk with Dr. Jessica Zitter, a pulmonary critical care and palliative medicine physician (click here for the podcast).

Jessica Zitter is the author of Extreme Measures: Finding a Better Path to the End of Life (publication date 2/21/17) and is featured in the short documentary Extremis, available on Netflix and nominated for an Oscar.

We talk with Jessica about her experience transitioning from being an ICU doctor to an ICU/Palliative doctor, how she is treated differently when she sees patients as an ICU attending vs a palliative care attending, the Big 3 (CPR, mechanical ventilation, and feeding tubes), and most importantly WHO she is wearing to the Oscars!

Jessica Zitter will be speaking and showing the film Extremis at the HPNA/AAHPM meeting this Thursday 1:30-2:30, and will be signing copies of her book Thursday at 5:30pm in the Exhibit Hall.

Major props to Jessica for being the first GeriPal podcast guest to sing along!  Musical hint: recorded on Aloha Shirt Friday...with an Ukulele...Somewhere...



by: Alex Smith, @AlexSmithMD

GeriPal Podcasts can be found on:


Transcript of the podcast:

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And we have a guest with us today, Jessica Zitter. Jessica is a Pulmonary Critical care doctor, a Palliative Medicine doctor, a feature in a recent Academy Award nominated film, Extremis, that you can find on Netflix, and also now an author of a new book called Extreme Measures. Welcome Jessica.

Jessica: Thank you so much for having me.

Alex: So I thought we'd start off, given the seriousness of the topic of Pulmonary Critical Care, and the weighty tone of the movie with something sunny, because it's Aloha Friday! I forgot my Hawaiian shirt, but usually on Friday we all wear Aloha shirts, so in honor of that maybe a little Somewhere Over the Rainbow. Jessica are you going to join me a little here?

Jessica: A little bit.

Alex: All right. Got the ukulele too ...

Alex and Jessica sing “Somewhere Over the Rainbow” by  Israel Kamakawiwoʻole.

Alex:
Nice, I think that's the first time we've had a guest join for singing on the GeriPal Podcast.

Eric: I believe so.

Jessica: That's gorgeous, thank you. Your voice is really much more beautiful than mine, thank you.

Alex: No, no, no. That was beautiful. Welcome to GeriPal Podcast. It's an honor to have you with us today. I really enjoyed reading your book and seeing the movie. Such deep material, there's so much we could talk about today. I thought it would be interesting to start off by talking about what motivated you to write the book, in particular. Why a book? How did that happen?

Jessica: It didn't happen ... It didn't start out intentionally as a book. It started out as a series of personal journal articles. Journal writing that I was writing in my early days as an ICU doctor, and even my residency in medical school when I was, really looking back, suffering from some moral distress. It was a way of processing what I was seeing and sharing it with my family and friends. And as I found the Palliative Car movement, it became a much more hopeful series of essays and eventually that turned into a book proposal.

Alex: I was struck in this book by how much there's a sense that as you learned and developed, and became interested, and trained, and worked in Palliative medicine, that you had to unlearn so much of what you have learned in Pulmonary Critical Care. Not just in terms of the technical stuff, but in terms of the culture of critical care. I wonder if you could comment on that a little bit.

Jessica: I'm still unlearning and I'm still learning, and I expect that to be the case forever, I hope. We go in and especially in moments of, in environments, like the ICU where there's so much distress and so much extremis and physiologic distress and suffering. It's really comforting to fall back on protocols. It's something that I just did automatically and I didn't really know another way. It was when I learned from a nurse, Pat Murphy, who I write about in the book, who taught me really how to be the doctor that I aspired to be now.

I learned how to do it a different way and come out of the protocols and take pauses, that I started to feel some relief. But it was hard. It's still hard.

Alex: Yeah, Pulmonary Critical Care and Palliative medicine are one of those, just almost ... I don't want to say combustible, but there's something about the cultures of the two that are seemingly in some ways at odds. So, it's just remarkable to read your story as you've gone through the journey of being well trained and accomplished in both.

Eric: What I thought was fascinating is that you mentioned that you're treated differently as a Pulminologist and Critical Care doctor when you do consults. Where your word is, you said, like "God" versus when you're a Palliative Care doctor, sounds like, your word isn't always like "God."

Jessica: Actually, before I answer that. I'm curious to hear what you thought about when you read that as Geriatricians and Palliative Care physicians. What's your response to that?

Eric: Well, my response is that, I feel like our word is never like "God", it's always a negotiation. I never thought about the differences in consult culture, and how people respond differently to different consultants before I read that.

Alex: Yeah, Pulmonary Critical Care is so hierarchical. The structure of ... Right? As you write about it in the book, and Palliative medicine is so interdisciplinary. Each team member is valued in its own way.

Jessica: Yeah, it's really fascinating to me. I actually wrote a piece a while ago called “Collegial Burnout.” It was about the burnout that I think is unique to Palliative Care physicians, maybe other types of physicians too, but certainly something that I had come upon later in my career in trying to navigate my way through as a Palliative Care consultant. It's not the kind of burnout that we talk about with "Oh, you know, so many patients are dying and there's so much suffering." It’s not that burnout, which of course is a real burnout as well. This is a different kind of burnout, and it's the burnout of feeling like you're constantly walking on egg shells.

And like you really don't want to ... You want to adhere to this consultation etiquette. There's consultation etiquette for every consultant, but when you're a Palliative Care physician with this relatively new sub–specialty of medicine and also perceived by many as, touchy–feely, you have a sort of a different ... It's a different dance, and it's very complex I find.

So, I didn't answer your question, but I do notice a big difference. I do feel that when I'm coming in, say, making Pulmonary recommendations or I'm coming in consulting as an ICU doctor on a surgical patient in the ICU, people are like "What, tell me exactly what to do. I'll do this, this, this, this, and this." When you come in as a Palliative Care consultant, people are telling you, "Don't talk to my patient about this. You can talk about this, don't reframe it this way." It's changing, certainly. I really feel a change, but it's been a very interesting discrepancy for me.

Eric: So this book is almost a collection of essays and one of the things that I ... One of my biggest questions is, sometimes I can't even remember what I did yesterday. Do you journal? How do you remember all ... Because it's filled with so much detail. How do you remember so much that you can create these wonderful essays, and a whole book about them?

Jessica: I've been writing for years. I write, I would love to show you my computer. It's basically filled with scraps. A lot of times I'll write a paragraph, I'll come home and say "Oh my gosh, I saw this, this, and this person". Interesting stories, and I'll write a paragraph of them, about each of them. It'll take me 15 minutes, and I'll put their medical record number in so I can back and look up details of the case later. In fact as I was writing the book, I definitely had to do that, or even sometimes call my friends in New Jersey, "Remember that case?" And usually they didn't, but it's tricky. But I have to sort of do some documentation along the way. I've been doing that for years.

Eric: Does that also help with mindfulness, self–care and burnout?

Jessica: I'm terrible at that. This is my big downfall, as a Palliative Care physician is the self–care. I really need to do better at that. I guess in a way it helps with, I wouldn't say mindfulness, but I think with processing and reflection. I guess that's a form of mindfulness. I do feel very revved up, and maybe that's partly my personality, but I feel this sort of burning passion to talk about these things, and when you get me started, it's hard for me to not spread well, “and then this happened, and then that happened." Because I feel that we have, honestly, a public health crisis that we need to manage. I just feel like I want to get the word out to everybody so, I'm not very good about settling down and just saying "I did this and now I'm gonna move it aside and go hang out with my kid." I'm not doing that as well as I would like to.

Eric: What do you think the crisis is?

Jessica: I think people are dying badly, and I feel like I have a front row seat to that in the Intensive Care Unit, which as you know is sort of the place that people get funneled into. If we keep going along, what I call this end of life conveyor belt. I just feel ... And, as we all know, when people are informed, they choose differently. I feel like I'm responsible for carrying out treatment plans that I'm not even sure people want. Because, as you know, by the time they come to us, it's really too late to assess preferences and goals. And we're working with surrogates who are well-intentioned often, but not necessarily able to do really what the patient would want. We just never know, so it's a very tough place to be.

Eric: So, that reminds me of a quote in some of the challenges that we face doing this in the hospital. Is it okay if I read the quote?

Jessica: Please. Yeah.

Eric: "These decisions are difficult in any case, but with secrecy, physical distress, and unclear set of personal preferences, there is no real way to know what to do in the very few moments that are left. All options available, to me, felt brutal. Trying to talk to a dying man in extremis about his mortality. Trying not to talk to a dying man in extremis about his mortality. What would you do?" I think that's often the challenge, is how much distress, and I think you talked about this essay, how much distress do we cause people by having these conversations? And how much distress do we cause by not having these conversations? Especially when there's so much urgency to have them.

Jessica: It's the key to it all, and it's why no matter how good you are, and no matter how much of a support system you have. Ultimately this is very stressful work, because you're dealing with human beings. That case was a man who was very, very in-stage with PCP Pneumonia, who had clearly avoided all healthcare contacts. I really suspected that probably he didn't want us to intubate him. I knew it wasn't really gonna help him, but that's our default path, right?

Eric: Yeah.

Jessica: Respiratory failure, ventilator. And so, I just ... He was really ... We had drawn up the medications to intubate him, and he was so terrified. He was looking at us like, "What are you gonna do? Help me, help me." And I was going to go in, and then I thought, "Oh my gosh, I don't know. Let's just sedate him, intubate him." And then my medical student with whom I had been processing this, said to me "Dr. Zitter, you've gotta go in. You gotta tell him." So I did. I went in and I looked at him, and I said this, "I don't think this is gonna help, but do you want us ..." And he looked at me like a deer in the headlights, and he didn't answer. And I didn't know what to do and he looked more and more anxious, and I said "Okay we're gonna intubate him." We intubated him and he died within a few hours.

My resident said to me the next day, when I wanted to process the case on rounds, and it was a very distressing case, as you can imagine. This one resident said to me as we were going around the group, "Well, Dr. Zimmer. No offense." And those words always strike fear. "No offense, but I'm really kind of uncomfortable with the fact that the last words this man heard were, you're gonna die." I think about that to this day. Did I ... What would you have done? What would you have done? I don't know. I did what I thought was the right thing in those very moments.

Eric: Yes, so these palliate stories are so powerful. My favorite was the fear of being wrong. I'll just read a little bit of this here, "But in my opinion one of the most powerful determinates of physician behavior, is the fear of being wrong. There are a small number of cases that will haunt my practice forever. Their memories stifling my desire to speak the truth as I see it. These were patients whose prognoses I had thought extremely dire, but who against all odds had rallied and survived. Or at least didn't do as badly as I thought they would."

That strikes me as ... rings true to me having just come off service and had some similar experiences there. Where you sort of put yourself out there, and you ... When you are making prognoses, we are putting, you know ... even though we acknowledge the uncertainty, we are putting our nickel down, and saying this is what I'm worried is gonna happen here. And sometimes we're really wrong. In this particular case, this was about a patient named George, as you call him in the book. Who had a massive brain bleed, and you were really worried about what would happen if they tried to take him to surgery. Then he ended up making it through remarkably, right? You want to say more?

Jessica: I really was worried about what would happen if they took him to surgery, but I was also worried, I'm gonna be honest, about if he survived.

Eric: Yeah, what would he be like?

Jessica: I really worried that this man would be very, very debilitated and really permanently confined to a breathing machine in a ventilator facility. I felt that in some ways, I mean again, it's not for me to decide ultimately. But I wanted the wife, I wanted her to have as much information as I had, which is there is a risk that he'll die, obviously on the table, but we already knew there was a risk he was gonna die. But there's a risk that he'll survive, and this is what it will look like. And, he did survive, and it didn't look the way he would've wanted it to, I don't think. Now, would he have said "Don't keep me alive." I don't know. "Don't take me to surgery." I don't know. But she might have made a different decision had she known what it was really gonna look like ultimately, which I tried to tell her.

Eric: So, in the book, you describe the Big Three and how people treat the Big Three differently. But can you describe for our audience what the Big three is?

Jessica: It's the Big Three, it might be the Big Four. They're procedures that the public knows about. That have been sort of immortalized on T.V. Codes, breathing machines, dialysis. These are things people ... not necessarily pressers, right? But certainly codes, dialysis, breathing machines, feeding tubes. So, I say the Big Three, but for each person it's gonna be slightly different ones. The concept is, these are things that people know about and have been revered on television shows or held up as magic pills, and magic solutions.

And so, people think they're going to help. The point that I make in the book is that there are these things that, even if we as the healthcare team, do not feel that they're gonna be of significant benefit, they're certainly not gonna reverse the underlying illness. If a family insists on getting them, we have no choice. If a family insists that they be used, even if we don't think it's in the patient's interest, even if we have some evidence that maybe the patient wouldn't want it, we really are obligated to give it to them. Because we've just built our health system up that way. A neurosurgeon doesn't have to do an operation, they can come in and say "Sorry, not a candidate for surgery." The surgeons can come in and say, "Sorry, ischemic bowel, but we're not gonna take this person to surgery."

But the ICU physician really can't say "Oh, you know, I'm not gonna intubate this patient. It's not indicated, it's not gonna help this person." If the family is saying "intubate," we have to intubate.

Eric: To you think we're obligated? Or do we feel obligated? For instance, for CPR in the VA system, we can't change people's code status from full to D8R. However it's still in the physician's judgment when to call a code, whether it be at 15 minutes 5, or 1 second. And I wonder how much of it is a ... Because I don't know of any legal rulings that say a physician has to do a particular intervention. Rather that it's our risk aversion that makes us feel obligated. Your thoughts on that?

Jessica: Absolutely, and you know, how many times have I picked up the phone and called risk management and said, "Well, what do I need to do here." The reality is, if you actually do call risk management, which I do a lot by the way, they often really just tell you just to go ahead and do it. Those kinds of situations as we all know, usually arise when there's some conflict, and there's some conflict between healthcare team, maybe some family dysfunction. There's conflict, and you've sort of lost the communication line. And it's not about communication anymore. It's not about logic, it's not about truly patient–centered care and assessing goals, it's about something else, but it's being manifested in this way. And again, if they are insisting on it, I don't personally see a real option. Look at the Jahi McMath case, in Oakland Children's hospital. That was a case of brain death, and the fact that that went as far as it did. And she is now ... I don't know.

Eric: In New Jersey.

Jessica: In New Jersey, I mean it's mind boggling for us in Palliative Care and Critical Care physicians who think about brain death. There was not really anything they really could do. They were really stuck, those physicians. I think it's a powerful ... It's a powerful commentary on our societal relationship with technology, that we just are so enamored with technology and we believe in it so much, or this technological imperative. If it's there is got to be good. That we can't even, with all due respect to logic, we can't take it off the table ... Certain parts of it off the table, because they've been so celebrated and they're so expected as a right.

Eric: Maybe we can shift gears and talk about your movie, Extremis, which is up for an Academy Award.

Alex: And you're going to the awards.

Eric: So, the question that I keep on being asked by people who hear you're gonna be on this podcast, is what are you gonna wear?

Jessica: I don't know, and I'm going shopping today for it. It's hilarious, because let me tell you, I was joking before, but I'm currently wearing .. can I describe for the audience?

Alex: Yes.

Eric: You can describe to our audience.

Jessica: Okay, this is a typical ... This is a kind of slightly dressed up for me. I'm wearing a kind of a nice pair of jeans. I'm wearing a shirt that I got at a really nice place, so it was probably like, $80. When I was cleaning off my stethoscope with that bleach, I kind of draped it over my shirt. So, I've got a bleach stain coming down the center. This is nice for me, so I don't really know... My friend emailed me yesterday and said, "Who are you gonna wear?" And I said, "Jinx" who's my dog. And she said "That's disturbing." And I said "No, it's cuddly."

Eric: So tell us where did the idea of the movie come up?

Jessica: When I ... Did you hear about the movie, The Waiting Room? If you didn't you must see it.

Alex: No I don't ever think I had.

Jessica: It came out in, I believe, 2012. Director Pete Nicks, whose wife works with me in the ICU at Highland. She's a speech therapist and she's terrific. And Pete came in and did this film that was mind blowing, about really access to healthcare, county hospital, emergency room. It's sort of 24 hours in the day of the emergency room. We saw it at the Grand Lake Theater, the whole was there, and I saw it and I was blown away. An you must see the movie, just gorgeous and compelling, and just the visuals and ... And I was at this point writing a lot. Writing for the New York Times, and really, people were responding to it. And I said to myself, and I went up to Pete at the end of the showing and I said, "You've got to come in and do a film in the ICU about decision making, it's a really important topic." And he said, "oh uhh, I don't have time. I'm doing this film on the police force in Oakland." Which apparently just came out, and it's supposed to be wonderful.

For the next year, I texted Pete every time I had a really interesting ... I'd text him probably ten times over the next year, "Pete, it would have been great if you'd been here, listen to this family conference. It was so interesting." Finally he got tired of me texting him, and he said "Look, I got this friend whose interested in a new project. Why don't you meet him?" So, we went out to this café, this kind of really hip café in Oakland. I'm with these two directors, very cool guys, and I was not very cool. Anyway, and I was trying to convince this guy, Dan Krauss, why this was such an important topic. And Dan was sort of interested, he's like "I don't know, kind of sounds ... Like it might be kind of sad, or might be ... Why would people want to watch this?" And I was saying this was really compelling, it's actually not sad, it's really inspiring, and we can have wonderful outcomes and...

So, he said "You know, let me think about it." Then, I guess he emailed me a couple days later and said "I'll come ..." I said "Come in round with me." So he came and rounded with me and we had a really tough case right off the bat when he was there. Young guy with kids, and Dan has young kids, and the guy was dying and Dan's like "Oh my God, this is just so awful and difficult." And he said, "I don't know about this." I didn't hear from him for about a month. And then he emailed me and said "You know what. I think I want to come back. I want to conquer my demons on this. I can see it's an important topic, and I kind of want to come back." I said "Great, come on." I was like, "You sure? But okay."

So he came, and he brought his camera with him, and then went on to just start filming. It was incredibly stressful for me. It was one of the most stressful things. I think if I had to say, what was the most stressful thing in my career, I'd say that filming. Because it went on for about three months and he ... People were really weary, as you can imagine. It's an ICU, it's not just an emergency room, it's like an ICU! My colleagues were like "Well, I don't know." I had thought we were all gonna be in it.

People were really reticent and uncomfortable, and felt ... And every time I asked a patient or family if they would be willing to have Dan come in and film them, I felt like I was in some ways, abusing my right. And so I was very ... I felt really stressed. Because my goal is to protect my patients, and yet I felt this was such an important thing. And I would say to them ... And Dan was the same way, he's very, very respectful of people. We both would be like ... I'd say "Please. Most people wouldn't want to be in a film like this, so do not ... If you're interested, think about it and we'll come back." Very few people agreed to be in it. Many of the staff didn't want to be in it. It was very hard, I felt like I was coming in with this film crew ... Anyway, Dan just obviously a genius, made this gorgeous film.

Eric: Yeah, it's amazing.

Jessica: He put it together and I'm just so appreciative. I think he really did a huge service to humanity by putting this film out there in a short documentary format, so people can access it and see it.

Alex: It's on Netflix, we should say. So, all of you out there, it's about 24 minutes long. Short, remarkable film. Captures so much of the crush, the life and death decisions, the extreme ... call it extremis, which I assume ... Is that a word?

Jessica: It's a word we use in the ICU all the time, and I say it a lot.

Alex: He's an extremis?

Jessica: He's an extremis, yeah. I looked up the word, by the way. It means profound physiologic distress before death. Which is what we deal with in the ICU.

Eric: The other important part is that you'll be at the American Academy of Hospice Pal- Medicine (AHPM) annual meeting. You will both be having a workshop and a book signing, is that right?

Jessica: Yes, I-

Alex: Can you tell us a little about that?

Jessica: I hope you'll all come. Yes, and to note it's incorrectly labeled in the program. It says that I'm on Saturday, but I am on Thursday going to be presenting a breakout session, Thursday at 1:30, on Extremis. We'll show the movie and then we will, have not a huge amount of time, but to talk about three points that I want to bring up, based on examples from the movie, about communication barriers and strategies for us overcoming them in the Intensive Care Unit. Hopefully we'll give some people some time to process that, and also then hopefully people will join as at our book signing that evening at the exhibit hall at five–thirty.

Eric: Wonderful.

Alex: It's great and then after that they're gonna come to the GeriPal PaliMed Party, everybody at AHPM, who's listening to this podcast will be there, Jessica included.

Jessica: Yes.

Eric: To learn more about that, you can just go to the GeriPal website. We'll have links to Jessica's book, to the AHPM correct timeslot, and to Extremis, the movie, and how to get on it on Netflix.

Alex: Should we go out with a little music?

Eric: That sounds like a lovely idea.

Alex and Jessica sing “Over the Rainbow” by Israel Kamakawiwoʻole.



Transcript Edited by Sean Lang-Brown
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Wednesday, February 15, 2017

Ain't No Party Like a GeriPal / Pallimed #HPMParty at #HPM17



Come one, come all to the 11th annual GeriPal / Pallimed party during the Annual Assembly of AAHPM and HPNA, and right after SWHPN's conference too!

In keeping with tradition, we will host it on the Thursday of the Assembly (Feb 23rd).  We will start at Lustre at around 8 PM and move on from there to Hanny's at 10pm (and then who knows what).  Like always though, these are rough estimates of time, so if you want to know the details, follow the hashtag #HPMparty on Twitter.

Also, feel free to invite and bring anyone, as this is no exclusive crowd.

Ways to follow: 

by: Eric Widera (@ewidera)





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Wednesday, February 1, 2017

Nate Goldstein - The Role of Palliative Care in Heart Failure



On today's podcast we interview Nathan Goldstein (@drnategoldstein), Chief of the Division of Palliative Care for Mount Sinai Beth Israel. We discuss his experiences and research focused on improving communication and the delivery of palliative care to patients with advanced heart failure, including for those folks with AICD's and LVADs (and other interesting acronyms).



GeriPal Podcasts can be found on:


Transcript of the podcast:

Alex: Welcome to the GeriPal Podcast, I'm Alex Smith.

Ken: I'm Ken Covinsky.

Alex: And we have a special guest with us today, Ken. We have Nate Goldstein all the way from the left coast. Who's Nate Goldstein?

Ken: Oh my gosh, I have been a long-time admirer of Nate. Truly on of the giants in the fields of palliative medicine. So Nate is the one who has really founded the field of palliative medicine within heart failure research.

Alex: I can't wait to meet him. He sounds really great. That's amazing! And there is Nate.

Nate: It's an honor to be here, guys. I'm having fun already.

Alex: So Nate, you have to choose a song to start us off here.

Nate: So as I said to you this morning, Alex, I've been listening to podcasts to try and really do some research here, but it hit me this morning, that this is probably the first podcast after the inauguration. And so I thought, and this is not making a statement about your political sympathies, but I wanted you to play whatever song of resistance you know and that you wanted to play.

Alex: That's good. Okay a resistance song. So, let's see. The first song that came to mind is "Redemption Song," by Bob Marley.

Ken: Oh that's wonderful.

Alex: Is that good?

Nate: That's perfect, yeah.

Alex: I'm trying to remember what key it's in. Oh I remember.

Alex plays “Redemption Song” by Bob Marley:
"Oh pirates yes they rob I, sold I to the merchant ships. Minutes after they took I, from the bottomless pit. But my hand was made strong by the hand of the almighty. We forward in this generation triumphantly. Won't you help to sing these songs of freedom? Cause all I ever had, redemption songs, these songs of freedom."

So, Nate, welcome to San Francisco, we're delighted to have you here. And we want to talk with you about palliative care for heart failure today. And to start us off I thought we... I just wanted to ask if, were there any particular clinical experiences that moved you to conduct research in this area and be the national leader?

Nate: Yeah, there was a very clear clinical experience. I was a resident, a third-year resident on my rotation in the ED and there was a patient with advanced lung cancer who was at home on home hospice who had an ICD, and he came in to the emergency room getting repeated shocks from his ICD.

And he was lying there in the bed totally comfortable and we had him on the monitor and he would sort of... I mean he was dying, so, he would sort of go into arrhythmia, and he would go into V-tach and to defib and his ICD did not know that he was dying of lung cancer so it just kept shocking him and the ICD was doing exactly what it was supposed to do. It was monitoring his rhythm and we were watching on the strip and every time it was supposed to, it shocked him and we eventually turned it off in the emergency department, but he ended up dying in our not-very-private trauma bay, as opposed to in his bed at home, which he and his family had wanted.

And that was sort of like, this feels like a problem that needs to be fixed, and that's how it all started.

Ken: So Nate, what is this ICD thing?

Nate: So an ICD in an implantable cardioverter Defibrillator and the idea is that it monitors the heart rhythm and can send very small electrical shocks to change the rhythm to one that is compatible with life.

Alex: And what's it like going into a new field where palliative care hasn't been traditionally. Like, palliative care really started more with the hospice movement with cancer and it's taken a while to create a foothold in palliative care and heart disease and heart failure in particular and you were one of the first people in. What was that like?

Nate: I love that you think there was a plan. I mean it sort of, it was very much like, this is a thing in front of me, I'm gonna work on the thing in front of me, and then you realize what the next thing is, and what the next thing is, and what the next thing is and suddenly other people are jumping on your ship, and you're totally excited, and now there's all of these people doing amazing work in this field. And I think the field has finally really realized it and begun to welcome us more and more into it and that's been really exciting to see.

Alex: And just sort of trace your own arc here, you started out working primarily on the discussions around deactivating ICDs as the clinical stories.

Nate: That's right, so we started with sort of a retrospective study, and then we did some qualitative work with patients and clinicians and then we did a lot of work in hospice, and we've just finished a big five-year RO1... Alex got really excited, that look on his face was, but we haven't actually analyzed the data yet because it's just now finished coming in. So, sorry.

Alex: I thought we were going to have a GeriPal, new breaking news story!

Nate: And we're trying to figure out kind of what's next, and so it's really exciting. It's so interesting in our fields, this combination of forethought, serendipity, and blind luck. I mean I imagine that you both have those stories, in particular you, Ken. Sort of how you fell into this work and that sort of thing. And the more people I talk to it turns out there's...life is really so much about what happens to be right in front of you and whether or not you chose to take that moment.

Ken: The grand plan is not as grand as we think it is often. Nate can you tell us a little bit about the trial that you're finishing?

Nate: Sure, so, it's a six-center study, we call it "The Wisdom Trial," because you can't have a trial in cardiology without a super-fancy name. And we train docs in the beginning to talk to patients about ICD deactivation which is sort of the stated objective and of course the latent objective was to get them to talk more about advanced care planning. And you know hind-sight is 20-20 and I would never have done the trial the way I set out to do it five years ago, for lots of reasons.

But one of the things that's been most interesting about this trial, and about this field, is that cardiology moves so much faster than we do in geriatrics and palliative medicine. So we started with a set of entry criteria that we had to change because the field of cardiology was changing so quickly that in the very beginning we did not want to include patients who were candidates for ventricular assist devices. And of course that's now everyone. And so we had to completely change the entry criteria and some of the work that I've done looking at VADs we have changed those criteria as well as we've moved because the field moves so incredibly quickly. To me that's actually what's quite exciting about it is trying to sort of stay ahead of it and figure it out and figure out ways that we can integrate better, and integrate to kind of where it's moving, not just where it is now.

Ken: And what are the VADs?

Nate: So a ventricular assist device, the majority of them, are these small implanted devices that actually take blood out of an ailing left ventricle through an internal rotor, and basically dump the blood back in to the aorta. So, the body is still doing the work of oxygenating the blood. These internal devices basically just help circulate it. And there are connected through a drive-line that exits the skin, and is attached to little controller and battery pack so these patients literally plug themselves in at night and during the day they have this little wire that comes out of their skin that's attached to two battery packs that they wear around.

Ken: Wow, so it really is an artificial heart. It makes up for the heart that's not pumping.

Nate: So, the cardiologist would have a stroke, pun intended, if we called it an artificial heart, but us lay, non-cardiologists could call it that.

Alex: I remember at a meeting we were at this summer, where we were talking about different specialties of medicine and surgery, and palliative care, and the research frontiers there. You had a nice clinical pearl, that I thought would be important to share with many of our listeners, a lot of whom are clinical, that "the best palliative care..." what was it?

Nate: Oh right, the best palliate care for heart failure is treatment of the heart failure.

Alex: Yeah, can you say more about that?

Nate: So the best treatment for the short-of-breath patient who comes into the emergency room or is at home or is walking into your practice, is actually not morphine but Lasix, and this is the thing that's so interesting about heart failure is when you sit down with cardiologists, what they say is, unlike in other fields for example, in cancer, they say, "No, no, I know how to treat their shortness of breath. Like I actually know how to treat their lower-extremity edema. What I need help with is having them understand the trajectory of heart failure and where it's gonnna go, and sort of the hope for the best, plan for the worst."

And that is so, so different than cancer, where I think the oncologists sort of say, "No, no, I'll do the talking about goals, we're going to try X, Y, and Z, I want you to really work on symptoms." And I think that can be a frame shift for the generalist palliative care, the generalist geriatrician, clinician in the world because what you need for one disease entity is different that what you'd need for another. And this gets to the whole question of, not only specialty versus primary palliative care, but what is the role of the generalist geriatrician, of the generalist palliative care, clinician, in each of these diseases.

Alex: That is a great question, Nate. What is the role of the generalist palliative care, generalist geriatrician?

Nate: Dr. Smith, that was a hypothetical, not something I was planning on answering. So, one of the things we talk about, at least in our trial all the time, is the "hope for the best, plan for the worst." And particularly, in terms of heart failure, when we think about advanced technologies and particular assist devices and total artificial hearts and where we are in terms of heart transplant and how the number of VADs is unlimited, you just keep churning those out in the factory, but the number of hearts available for transplant has remained flat for the past couple of decades. So, how do you simultaneously sort of work with your patient to really hope for the bridge to transplant, to ultimately the transplant, while also be thinking about the sort of, the what ifs. The worst case scenario.

And I think the other piece that I've really learned in working with all of these cardiologists is in geriatrics and in palliative care we only see the cases that go terribly, terribly wrong. And that is an incredibly small minority of the cases. The vast majority of patients with VADs are walking around, on the street, passing you every day, you have no idea that they have a VAD. They're doing incredibly well. When you ask them, "How's life with a VAD?" We in palliative care and geriatrics expect the answer to be "Oh, it's awful, I'm stuck to this machine all the time, I can't stand it, I have all these problems," but the actual answer when you ask a patient is "Well you know, I can play with my grandkids now." "I can walk across the room." They couldn't do that a month ago, and I think because we aren't as well integrated as we could be, we never see them.

Ken: So Nate, speaking of the primary care issue, I think one issue in heart failure that frequently is tough for the primary care provider is this tension between the physiologic monitoring and the quality of life issue. So that the way a lot of heart failure treatment has gone is you really medicalize the patient a lot, that you get them to weigh themselves every day, you're constantly monitoring blood pressure, but I think on the one hand, you see the sense of that, on the other hand, I often feel that the goal of geriatrics is to make our patients' medical problems as little part of their life is possible. And that a lot of heart failure makes their heart failure as much a part of their life as possible.

On the other hand, maybe that makes sense if it prevents symptomatic exacerbation. So one of the things I struggle with, and I think a lot of providers struggle with, is what is the balance between all this very close monitoring and aggressive management of heart failure, and the needs of patients who often to maybe be de-medicalized and not have this be front and center in their lives all the time?

Nate: So I'll answer that actually two different ways, Ken. One is, inheriting what you said but I think is really important to explicitly state is that the mass majority of folks with heart failure are cared for by either the primary care doc or their primary geriatrician. So it's not the cardiologist and it is certainly not the advanced heart failure specialist that we're seeing in the coronary academic medical centers where we happen to work. I mean those are the sickest of the sick, the most complicated of the complicated, it's the ones where people tend to focus a lot of energy, but that's not where the vast majority of patients are.

The second part to that is, I think, and this is so much what we do in geriatrics and palliative medicine, is the patient will tell you when they're no longer quite so interested. And when you ask them, "so, where are you weights for the past two weeks?" And their answer is, "well, it was my grandson's graduation and it just sort of fell off the radar," there's your answer. We spend a lot of time, I mean we both work in, sort of, really urban centers where we say to the patient, "well you know, did you take your Lasix?" And said, "uh, no, it was more important that I went and bought groceries this week," or "I had to choose between these medicines and paying my rent."

So I think, where the rubber meets the road, is in sort of these day-to-day problems. I think this is not just a problem in geriatrics, I think it's a problem in all of medicine. Which is, we doctors sort of think that the patient's medical problem is the most important thing in their life, and they're gonna let you know that it's actually just a list of things they have to deal with every day.

Ken: Interesting. So really it gets down to listening to our patients.

Alex: So it seems like the pace of change, as you mentioned in cardiology, is just so incredibly rapid. And, you have an in because you work closely with these cardiologists so you have some sense of what's coming down the pipe or what may be changing before our very eyes. What is on the... what are we on the cusp of... what's changing now? What are the things that are going to push palliative care to have to think in new ways, new directions? Or may take cardiologists a step back and that they think this is the new miracle whatever...device, drug, treatment?

Nate: So, this is going to show my age, and I won't say anything about anybody else in the room, but, I remember days when you would walk into a patient's room who had a VAD and you could hear those old pulsatile pumps from outside the door. Neither one of you has to comment on whether or not you remember that, but I really remember that. The devices are incredibly small now, incredibly efficient. HeartMate 3 is the new VAD now that is coming out with this incredible data of no in-pump thromboses, incredibly small complication rates compared to where we were just a decade ago.

So the technology is getting better, it's getting smaller, it's getting much more, much easier to live with in terms of quality of life. One of my favorite stories is the VAD patient that's refusing to go out of the house the first few days because they're so scared about being away, what happens if the battery dies, etc. And then a month later they've left the house without the spare battery because they sort of forgot they even have the VAD. I mean it's really amazing to see that.

The TAVR in sort of all these non-invasive cardiac surgeries or less-invasive cardiac surgeries than what we're used to, I think is the new frontier, because you know, the cardiologists really look for survival and stroke. And the question that we come by and ask is like, "yeah but does it make life better?" And the new outcomes we're looking at is not survival, but days out of the hospital. Those are sort of the new outcomes we'll be looking at. Instead of things like quality of life, things that can still be easily counted, which is, you know, who doesn't end up in the nursing home, ends up going back home, instead of just these gross counts, and I think that's where clinical trials are going.

It's not, how many hospitalizations and ED visits but actually how many days were you out of the hospital? Out of the hospital at home, not out of the hospital in long-term care, but in the hospital at home.

Alex: Well that's a step in the right direction. What about measuring functional outcomes? Is that a big component of a lot of the heart failure studies? Because it wasn't early on. It was combined death and MI, or combined hospitalization and death.

Nate: Traditionally, it has not been an outcome the way we as geriatricians think about it traditionally. There was, does the six-minute walk improve? But not actually how is there function. And now some of the large registries in clinical trials are actually starting to put in those kinds of outcomes.

So it's still very, very new, like you can't go to a giant secondary database and do that research now, we're just starting to collect those kinds of data, but I think it will be soon.

Alex: Anything else you wanna...any shout-outs you wanna give?

Nate: I think the shout-outs that I wanna give, sort of in line with what we were talking about, and sort of in line with the question Ken asked earlier, is, who are the cardiologists out there in the world that have really embraced this? And those are the people that I want to give shout-outs to. The Lynne Warner Stevensons of the world, the cardiologists who are standing up in giant cardiology meetings and sort of saying, how do we incorporate palliative care, and even if it's not palliative care, how do we think about these outcomes that are really important to patients and their families and these kind of outcomes that matter, if you will. Those are the people that I think need more credit, because we can spend a lot of time on the outside sort of shouting, "you should, you should, you should," but it's the change-agents inside those fields that have really embraced geriatrics and palliative medicine that are helping integrate the kind of change that we're seeing more and more. That's the general shout-out I want to do.

Alex: That'll include Rita Redburg here.

Ken: That's right.

Alex: Great. Well we usually end with another verse. This one is, maybe, more appropriate for the Trump time period, we'll see. I'm gonna see if I can get this solo right.

Alex plays “Redemption Song” by Bob Marley:
"Emancipate yourself from mental slavery, none but yourselves can free our minds. Have no fear for atomic energy, cause none of them can stop the time. How long shall they kill our prophets while we stand aside and look. Some say it's just a part of it. You've got to fulfill the book. Won't you help to sing, these songs of freedom. Cause all I ever had, redemption songs, redemption songs, these songs of freedom."

Alex: So why'd you choose that song, Nate?

Nate: You know Alex, I just think it's really important that those of us in healthcare, who have a voice, make sure that we advocate for those in our society who don't have a voice, because I think it's a fundamental right that we have, that we all have healthcare. And not everyone can actually have a voice to advocate for themselves and I think all of us need to make sure that's one of our priories, regardless of what's happening in the world.


Transcript edited by: Sean Lang-Brown

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