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).

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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' 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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