Tuesday, April 17, 2018

Integrating Palliative Care in the Emergency Department with David Wang

This is the last in our series of GeriPal podcasts on Geriatrics and Palliative Care in the Emergency Department.  In this episode we talk with David Wang, an emergency medicine and palliative medicine physician and director of palliative medicine services at Scripps Health in San Diego.

We talked with David about how palliative care can join forces with the emergency department to improve care for the serious ill.  This conversation was motivated in part by a recent expert consensus statement on key knowledge and skills standards about hospice and palliative medicine for emergency medicine providers.  What should the core training be?  How do emergency providers feel about palliative care?  How can palliative care services that are typically available bankers hours work with the emergency department, open 24-7?

Key Excerpts:
Actually, with the American Academy of Emergency Medicine, we did an internal assessment of our 3,000 or so emergency physicians. What we found was the greatest cited barrier for implementation of palliative care in the ED was a lack of time on shift. Almost half of respondents said that was a significant barrier. But, their second cited issue was, for about a third of respondents said that it was just absence of coordination with their palliative care service that prevented them from better delivering palliative care in ED. Interestingly, lack of interest was not on the list. Less than 3% of people said that they weren't interested in implementing palliative care or incorporating that into their practice.
There's that sense of, "I'm here to save lives" and it's not uncommon. I remember walking to an ED, one of the ones I work in as per diem. And they said, "Oh here comes the morphine doc, everyone hide your patients". And unfortunately, that's probably not an isolated narrative to me. Other ED and palliative care trained docs probably have that same experience, but I do want to think that that attitude is changing. There's still quite a bit of conflation between palliative care, hospice and comfort care. And sometimes, we are on the other side of spectrum, or DNR patients get less care than they should. More often than not, there's still a fear of legal ramifications of doing less than the most possible for patients in those moments of uncertainty.
When I talked to a lot of other palliative care docs about engaging the ED, that's one of the first things that comes up, which is, "I want to do the right thing for patients, but these are the hours I'm at work, and I'm not going to be available 24/7 like the ED is". I'll start by saying right off the bat that I don't think the ED expects palliative care to be available 24/7. I mean, if your service is already 24/7, wonderful, but if not, I think it's about creating kind of a culture of expectations around that. Many services that the emergency physician will call or interact with won't be available all the time.

So, for us, for instance, we are seven days a week, but we're not night coverage. And so, they will call our consult number and leave us a voicemail. We have assured them that we'll see the patient within 24 hours of their call that they don't need to expect a call back from us and wait for that, because that is one of the cardinal sins in the ED, to make one of their docs wait. But at the same time, if they have something of urgence during the daytime, we will prioritize that consult, and we'll come as soon as we are reasonably able to, and that has worked well. I think being an emergency physician myself, as long as that communication is clear and I know what to expect, so I don't ask for more than that, I'm not disappointed by not getting more than that, then that is acceptable.

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

Alex: This is Alex Smith.

Eric: And Alex, who do we have with us today?

Alex: Today, we have David Wang, who's joining us from San Diego, beautiful country down south, where he is an emergency medicine physician, palliative medicine physician and director of the palliative medicine service at Scripps Health. Welcome to the GeriPal podcast, David.

David: Excited to be here.

Eric: Great, and I'm excited for the topic of how to work with emergency room physicians and clinicians to integrate palliative care. I think we had a better title that we came up with, but that's the one that I remembered. But before we get into that topic, David, do you have a song to lead us off on this podcast?

David: How about a Take Me Home?

Alex: Take Me Home, Country Roads.

Eric: Are you going to sing with Alex?

David: I think we're going to be singing together.

Alex: All right. Here's the chorus. [Singing]

Alex: Well we inverted some lyrics, changed some chords, but we got the general idea.

David: I'm just following you.

Alex: It's a good start to a GeriPal podcast.

Eric: So, why that song? Any particular reason? Just like it?

David: I love that song.

Eric: All right.

David: Every time I see a street performer, I just got to like stand and watch that.

Alex: Yeah. Instead of Country Roads, that was Take Me Home Country .... yeah, well. The song is called Take Me Home Country Roads in defense, but the lyrics go, "Country roads take me home."

Eric: This is how we roll on GeriPal podcast.

Alex: That's right. This is how we roll.

David: A little dyslexia is okay.

Alex: Yeah, it's all right.

Eric: So, what was that official title that we agreed on? It was the ...

David: Joining Forces with The ED.

Alex: There you go. Joining Forces with The ED: How to Improve Palliative Care and Emergency Medicine Integration. Integration? Co-management? Something.

David: Collaboration.

Alex: Collaboration.

Eric: You got to look up the source.

Alex: Something like that.

Eric: We're going off track with this podcast. Let's start off right after the song again.

Alex: No, that was good.

Eric: No.

Alex: We're going to keep all of that. What are you talking about? That's the best. David, you trained here, right?

David: I did.

Alex: Where were you before you did? And by training here, you did your palliative medicine fellowship here?

David: Yeah, fellowship here, and I was at residency at Stanford.

Alex: At Stanford. So, you've been in several different health systems.

Eric: Scripps, Stanford, UCSF.

David: Yeah, and then a med school at UMass.

Alex: At UMass. So this is a bunch of different health systems, and you've had the opportunity to work in palliative medicine and emergency medicine in these different environments?

David: That's right, yeah, and Kaiser as well.

Alex: And Kaiser, too. So, tell us about how that background piqued your interest in this integration of palliative medicine, emergency medicine.

David: Well, it's kind of cool to see, over time, how things have really evolved in this dialogue and the ED around the perceptions of palliative care. When I started down this road maybe about 10 years ago, really, nobody was talking about this. You'd get some raised eyebrows and maybe a real puzzled look or maybe more colorful remarks. And starting about five years ago, the American College of Emergency Physicians, as part of their first set of choosing wisely initiatives, put palliative care on the map for the ED. And since then, things have really taken off. Everywhere I've gone, the question has really changed from, "Why should we think about this?" to more, "That makes sense, but how do we do that? How does that make sense for us in the ED, not just bringing your upstairs knowledge here, but really making it actionable for the daily practice of emergency medicine?".

Eric: So, why should we do this? Why is it important?

David: It's hugely important. Everybody comes into the hospital through the ED. The ED is a major gateway into the health care system. I think something like three quarters of people come to the ED in their last month of life and at least half in their last six months of life. What happens in those first few hours, maybe even minutes, really changes their trajectory of care. You know, whether they get committed to an ICU, when they get introduced into the palliative care continuum.

Alex: So, were there any like particularly motivating stories of patients you've cared for that made you realize, sort of crystallized for you, you know, "this is important. We need to do a better job of this?"

David: Oh absolutely, and this is like a daily occurrence in the ED. I remember even as a med student having patients with unsurvivable brain bleeds, being brought to the ICU, where there's really no dialogue around anything but the overly optimistic scenario. Or even as a resident for intubating an ALS patient their first intubation, and the emotional weight of that understanding, what we might be coming downstream of that. In those moments, it's tough to really think about what sort of downstream care and experience you're committing a patient and a family to in the ED, but in many ways, we are really kind of like the gatekeepers of that decision and what that's going to look like for them in the months to come.

Eric: And, do most ED clinicians have extensive training in palliative care during their residency or other training period?

David: It's very variable.

Eric: Oh that was better than I thought.

Alex: Yeah.

Eric: I thought you'd say no.

David: Can't say, "No."

Eric: I'll take variable.

Alex: It used to be none.

David: It used to be none. I think though, like I was saying, more and more people are asking, "How do we do this?" And it's always easy to train a new generation than to train everybody else who's already out there in practice. That being said, we recently actually just published a paper in Academic Emergency Medicine Training about palliative care milestones for ED resident education, also, for continuing education, for current providers, part of our LSA. Last year, one of the five articles that every ED doc was asked to read by the American Board of Emergency Medicine was about palliative care and the ED.

Alex: Really?

David: So there's definitely attention being paid to this, but, as we all know, culture change takes a while.

Alex: We should have a link to that article. Who wrote that article? Do you remember?

David: Jan Shoenberger, down at USC, was the lead author.

Alex: Great.

Eric: What was in the article? What did they talk about?

David: Mapping out ... Well it was expert consensus panel on what milestones, based on the ACGME milestones for different residencies, what those would look with a palliative care lens, for the ED. It was written all by practicing emergency physicians, also with experience in palliative care.

Alex: That's great. I didn't know we'd come so far. I used to do research in this area. Actually, that study you quoted about half of patients seen in the emergency department, in the last I think it was six months of life, that was one of my early pieces of research in this area.

Eric: It's still there.

Alex: It's still there.

Eric: I always remember Alex studying for the palliative care boards and a question came up that you got wrong on the boards, and the citation was one of your articles.

Alex: Yeah, it's like, "No. Smith et al."

Eric: You got your own question wrong.

Alex: Well if I can forget the song lyrics to Take Me Home, Country Road, which I've sung only a billion times, I could definitely get my own research backwards too.

David: Well you convinced me on it.

Alex: So I'm glad to hear we've moved beyond the why is this important, and there's buy-in from the professional societies. So, I remember back when I was doing this research, there were training barriers. There was lack of training. You're saying there's more training now, but there are also sort of like attitudinal barriers that a lot of people who'd gone into emergency medicine said, "I went in to cure, to act, to save people, to rescue in that moment". And when somebody comes in, and they're DNR, or they're enrolled in hospice, or their plans are aligned with comfort, then I don't know what they're doing in my emergency department.

David: There's that sense of, "I'm here to save lives" and it's not uncommon. I remember walking to an ED, one of the ones I work in as per diem. And they said, "Oh here comes the morphine doc, everyone hide your patients". And unfortunately, that's probably not an isolated narrative to me. Other ED and palliative care trained docs probably have that same experience, but I do want to think that that attitude is changing. I know what you're talking about, and I think there was a paper maybe about five years ago that was trying to tease out what palliative care meant to emergency providers.

There's still quite a bit of conflation between palliative care, hospice and comfort care. And sometimes, we are on the other side of spectrum, or DNR patients get less care than they should. More often than not, there's still a fear of legal ramifications of doing less than the most possible for patients in those moments of uncertainty.

Alex: Yeah, that's key, the legal aspects, the fear of litigation, because emergency… Is there some data, like, what are the most sued medical specialties? I would guess emergency medicine is up there near the top.

David: I think that unwanted crown goes to OB/GYN, unfortunately.

Alex: OB/GYN. Okay, but you got to be somewhere up there, close second. So, I can understand why that habituation, being sued would make ... it's the chagrin factor reacting to your last bad experience. It's sort of like it trains you to act cautiously. In this case, that means erring on the side of prolonging life, acting aggressively. Is that sort of the implication?

David: There is part of that. When there's uncertainty, when so for instance, how does a DNR patient end up intubated in the ICU? When you think about the cascade of events, at least that was a POLST or MOLST form ever completed? If it was completed, did EMS ask for it? Did EMS bring it? Did the emergency physician then asked EMS for it, did the emergency physician interpret it correctly? So many things can happen in those few minutes that leads to a completely awry kind of trajectory of care. That being said, what I've noticed, at least in my own experience talking with a lot of younger emergency physicians is, while of course we collectively practice under a dogma of common sense and understanding that we live in a highly litiginous environment, at the same time, people are very motivated to want to do the right thing for patients.

There's very few celebrated resuscitations of elderly people, with significant comorbidities. And so, the comment I usually hear is, "When can we stop doing this?" or "Why does this keep happening?", not, "I don't understand why shouldn't we just intubate everybody who comes in critically ill".

Alex: So are there any studies of barriers to implementation of palliative care in the emergency department?

David: Actually, with the American Academy of Emergency Medicine, we did an internal assessment of our 3,000 or so emergency physicians. What we found was the greatest cited barrier for implementation of palliative care in the ED was a lack of time on shift. Almost half of respondents said that was a significant barrier. But, their second cited issue was, for about a third of respondents said that it was just absence of coordination with their palliative care service that prevented them from better delivering palliative care in ED. Interestingly, lack of interest was not on the list. Less than 3% of people said that they weren't interested in implementing palliative care or incorporating that into their practice.

It was more of a question of, how do we get from here to there? How do we actually do this given how busy we are in the environment we work in?

Eric: Well that's a hopeful result right there.

David: I think so. I think times are changing.

Alex: Now, when you say lack of time on shift, do you mean that they felt like, "I want to do more in this area, but I just don't have time to have that extensive goals of care conversation with this patient, given the time pressures of the shift work and the other patients that I need to see"?

David: That's definitely part of it. I think there's this perception that maybe that to have an effective goals of care conversation, you need to talk for a long, long time. But actually, what I've seen play out in my own practice, as well as observing some of my colleagues and mentors, it's really not the amount of time you spend having the goals of care conversation, it's how you do it, how much time you've been listening, what questions you ask. We know this, but as a real paradigm shift for the more telling or talking based conversation that often happen in the ED.

Eric: That's great. So, we just had a podcast, which we published last week, with Kei Ouchi, on prognosis after emergency department intubation. If I remember the data right, a third of older adults, after emergency department intubation, did not survive the hospitalization, and 50% of those greater than the age of 90 years of age did not survive hospitalization. These are pretty shocking statistics for intubation in the emergency room for older adults.

David: It's unfortunately a daily occurrence I think in every ED across the country. I'm thankful for our major academic institutions to kind of put numbers around this and look into it, but that sense of maybe prolonging death or not returning people to the life they previously had is definitely shared by emergency providers.

Alex: So, let's talk about the integration of palliative care in the emergency department. There are kinda two angles to this. One is training of emergency medicine providers in palliative medicine skills, so, primary palliative care. The other angle is secondary palliative care in the emergency department, or consultants coming in, who are specialized in palliative care, to the emergency department. We've touched a little bit on the first. Is there more that you want to say about training emergency medicine providers in palliative medicine, or should we move to the second?

David: One other thing I would say is, if an ED provider tells you that they're interested in learning more skills, there are different avenues through which they may enhance their own practice, beyond doing a fellowship. There is workshops like EPEC-EM, which is a two-day course. There's EM Talk, which is a derivative of Vital Talk, to learn more about communication, strategies. So, there's ways for emergency providers who are wanting to improve their own skillset without transitioning clinical environments.

Eric: And as far as specialty teams are concerned, so probably the most basic model is, I have an inpatient consult team. I get called by the ED. I go down there and see a patient. Rarely happens, but it does. Are there other models ... You were just at AAHPM, right?

David: Mm-hmm sure was.

Eric: At the annual meeting you probably heard some cool models. Are there are other models besides that model that we should be looking into?

David: Yeah. We actually presented on this at AAHPM. I mean, the sky's the limit. It depends on what amount of resources you're willing to commit to that acute care experience for patients. It can range from patients who are actively dying and being able to structure a better experience for them in the ED, maybe circumventing an emission, direct to hospice discharges. It can also be a pipeline to your inpatient palliative care unit, your outpatient clinics, earlier consults on your consult service. And so, it really depends on what the goals, whatever initiative you want to design are and whether you have the bandwidth to create infrastructure around that.

Eric: Can you give me a couple of concrete examples of what some of these pipelines could look like?

David: So generally, I think for most palliative care programs, you're starting off with a consult service, it tends to be the lowest hanging fruit. And having a early identification of patients process, a trigger system, is one way in which you can really engage specialty level palliative care earlier. That can involve EMR triggers. It can involve using different criteria like the P-CaRES one that was published in 2015 or some derivation that maybe is simpler, which is what we're using down in Scripps Health right now. The goal of that would be, you can design that for high specificity or high sensitivity just to create more consults for your service or, I know many palliative docs are nervous that opening that box might result in them being at work 24 hours a day and sleeping in the sleeping bag in their office, you can decide with more specificity such that you're really just trying to move your time to consult much sooner in the patient's course.

Eric: So what do you actually do at Scripps?

David: We're using a very streamlined set of criteria to trigger inpatient consults.

Eric: Which include?

David: One, the presence of an incurable, serious illness. Two, the patient is now mainly limited to being in a bed or chair. So, about a PPS of 50%. There's something to start the conversation. This disease has actually changed their life.

Eric: Are these and-?

David: Yes and criteria. And number three would be, if the emergency physician thinks it would not be a surprise if the patient dies during the hospitalization.

Eric: The surprise question.

David: The good old surprise question, which, as you guys know, is not a bad use. It's probably on par with quantitative models. But it's probably the most sustainable to use in the ED, because it's simple, and it's effective, and it's simple.

Alex: And you modified it to be would not be surprised if they died during this hospitalization.

David: Right.

Alex: Which is a much shorter timeframe from the original surprise question.

David: Right.

Eric: So it sounds like maybe more high specificity. You don't want to unleash the floodgates at Scripps.

David: Right, because for us, I think our consult service is fairly mature. We're probably operating at our optimal bandwidth. And really, what we're wanting to do is just get the patients earlier, especially our patients who skip the ICU, who are already, you know, DNR/DNI, but perhaps end up getting a series of interventions or diagnostics that don't really make sense or don't make an actionable difference.

Eric: Any tips for collaborating with the emergency department, like how you did it, or things that other palliative care consult services could model?

David: Well it takes a village. I mean, the criteria is simple. As you saw, a lot of it is making sure that everybody is on board with that. So, making sure you have good buy-in from your ED. You got to have a champion in your ED. You have to have good representation in your hospitals and ICU groups. It's always helpful to have someone from administration who backs this. For us at Scripps, we're leaning in towards more of an ACO model of care. So, there's system-wide interest in building these collaborations. Some places maybe are still more in the fee-for-service world and don't necessarily want to do a lot of this, so it's about figuring out how do you make this kind of a win-win-win for everybody involved.

Alex: I want to go back and underscore one of the points that you raised about sleeping in the office in a sleeping bag, which cannot be emphasized enough. As a practicing palliative care consultant, I think it's great to collaborate with the emergency department during business hours.

Eric: If only patients followed these rules, don't come in after hours.

Alex: This is a real issue, and this has been identified from the earliest studies in this area. The sickest patients, the most complex patients come in often in the middle of the night and on the weekends.

How can we restructure or provide the best care for those patients, including palliative care in the emergency department, given this constraints of most palliative care services and the real need to not overwhelm services who are often already working a fine line of work-life balance, and the real needs to have time away from work, for people whose schedules are pretty set and don't have that shift work mentality of emergency medicine work. Any thoughts?

David: Yeah, I think that's a shared fear. When I talked to a lot of other palliative care docs about engaging the ED, that's one of the first things that comes up, which is, "I want to do the right thing for patients, but these are the hours I'm at work, and I'm not going to be available 24/7 like the ED is". I'll start by saying right off the bat that I don't think the ED expects palliative care to be available 24/7. I mean, if your service is already 24/7, wonderful, but if not, I think it's about creating kind of a culture of expectations around that. Many services that the emergency physician will call or interact with won't be available all the time.

So, for us, for instance, we are seven days a week, but we're not night coverage. And so, they will call our consult number and leave us a voicemail. We have assured them that we'll see the patient within 24 hours of their call that they don't need to expect a call back from us and wait for that, because that is one of the cardinal sins in the ED, to make one of their docs wait. But at the same time, if they have something of urgence during the daytime, we will prioritize that consult, and we'll come as soon as we are reasonably able to, and that has worked well. I think being an emergency physician myself, as long as that communication is clear and I know what to expect, so I don't ask for more than that, I'm not disappointed by not getting more than that, then that is acceptable.

And in the same lines, there's certain lingo differences in emergency medicine that's important to know. For instance, if a palliative care doc gets called for a consult and says, "I'll be right there after my family meeting. I'm stepping into a family meeting. I'll head there right after." It's important to clarify that that family meeting is not a five-minute meeting, that that might be an hour north of that, because that may be something that the emergency docs aren't familiar with. Goals of care conversation in ED can happen in five minutes. So, that notion may be a little bit foreign.

Eric: Other lingo issues? So we got one really important pearl, which is don't let them hanging on the consult request. Another is ...?

David: I have a couple more. One would be to help your ED colleagues out, help clarify the consult question right off the bat. So, you might get a call saying, "This is a 90 year-old guy. He's pretty demented. He looks like he's got a really bad pneumonia. I think he'd really needs palliative care." So, what does that specifically mean? Is this an emergent goals of care clarification? Is there some other advanced directive we should review? Or maybe he's not that bad and you just think he maybe will survive this and at the hospice. Like, what does, "He needs palliative care," mean? So unpacking that a little bit on the phone and kind of crystallizing what their ask is, because they may not necessarily know specifically we're in the dimensions of palliative care, the need is, but they know that they don't want to give him like the full resuscitative course. The third thing I would say is, as much as possible, when presenting recommendations on the phone, use if-then statements. So, for instance, if you're called for a refractory malignant bone pain, try one milligram of this, and if it doesn't work in 30 minutes, give another dose or double the dose and if that works, he can go home with this altered regimen.

Eric: So almost like a flow diagram of what to do.

David: Right, and then, you know, AB statements, as close-ended as possible as it can be for the ED doc. They would appreciate that, because the emergency physician wants to understand a little bit of everything but don't have the ability to go really deep in some of these fields. And so, while we in palliative care dwell a lot in the uncertainty of various patient situations, as simple and closed-ended as it can be in our recommendations to the ED, the more helpful that would be.

Alex: That's great, because among many emergency medicine treatment algorithms are sort of protocolized and like an algorithm of, "If this, then that. If this, then that," so that the recommendations should follow that format to be optimally received.

David: Right. One of the things that I think is also very frustrating for emergency physicians is, when the disposition is unclear. So, the patient maybe who is pending discharge for hospice or maybe it's going to go to hospice but needs a brief time in observation and control their symptoms, that uncertainty around who manages the patient or where they're supposed to go from the ED, can be really challenging. While doing the right thing for the patient, giving the best care possible is always the goal, two pressures that the ED faces is one, med legal as we talked about. And the other is patient flow and disposition being the most important metric that a lot of emergency physicians and departments are held accountable to.

Alex: I've heard of some patients being discharged from the emergency department or from OBS to hospice, enrolling in hospice directly. Is that something that you have experience with in the Scripps health system?

David: Yeah, and actually, there are patients that directly discharged to hospice from Scripps. One organization that does it very well is Kaiser, and you can imagine more of it in a vertically integrated model. They're really able to ensure that those patients get good follow-up immediately. For that to happen, at any ED around the country, there has to be a good case management and social work presence in the ED, to make sure all those lines are connected, all the DME that they have, they need, insurance issues. What's often challenging for the hospice discharge is, as we talked about just now, the patient who needs to stay just a little bit to get their symptoms controlled, and what that temporary admission observation stay in the ED or through the internal medicine service would look like, the service agreements around who manages that patient.

Eric: I'm also wondering if we can go back to different models of integrating palliative care. Are there other models that you've seen or you've talked about at the annual meeting that are more integrated too, where palliative care is in that department, not just the consulting service?

David: Yeah. Over at St. Joe's in New Jersey, they have what's called the LMSA program, where they have I think a palliative care nurse who actually basically trolls around the ED for patients and looks for patients at where they may have an active intervention on for symptom control, also for patients who are actively dying. There's nothing that pleases an ED doc more than saying, "Hey, I'm here, and I can take over the care of the patient". And so, they are actually physically embedded into the ED. For some ED docs who've done palliative care training, they will, depending on what health system they work for, if they can fund that position, they specifically sit in the ED during daytime hours, and they actively solicit those patients to clarify, to do things like clarifying goals of care, addressing family discord, hospice discharges, if those are possible. There was one ED, I think it was ... I can't remember, but they got a pilot study to fund a palliative care nurse to be in the ED five days a week, just daytime hours. They saw a profound impact on just the amount of patient touches they had, and they were very valued by the EDs having that service, to provide that service.

Alex: That's great. We'll provide links to these studies in the post that's attached to this podcast.

Eric: Okay. So maybe to end this podcast for our listeners, can you tell us maybe three very practical things, besides listening to GeriPal podcasts, that palliative care services could do to better integrate with their emergency department colleagues?

David: I think a good starting point, the first thing you should probably do is take a look inward at yourself, at your own service. What is your hope of this project? You know, engaging the ED. Are you trying to treat more consults? Are you trying to funnel patients into your clinics? What do you have the bandwidth to actually handle? And then you should design your initiative to create the impact that you want to meet those goals. There's an almost innumerable number of things you could do either through primary palliative care education or secondary palliative care utilization, but you got to know what you're driving at first, otherwise it might make your own team frustrated.

Once you have a sense of what that is, I think the next most important thing to do is identify an ED champion, someone who has called you before, who is somewhat understanding of palliative care needs of the patient and understands a bit of what palliative care has to offer, because you'll need an insider voice to really be able to champion any sort of culture change or a new project. And then once you have that, you know what you want, and you know somebody in the ED who will help you champion that, I think they should start them with a needs assessment of the ED. What is their understanding of the palliative care service? What do they think would be most useful to them? And then build from there.

It would be probably ineffective to try to take something that's worked somewhere else and copy it, ceteris paribus to your own hospital. It's much better to understand what's been out there, the realm of possibility, but then figure out what you guys specifically need where you are and then to target your resources and program development from there on.

Eric: Wonderful. I want to thank you for joining us on this podcast.

Alex: Thank you, David.

David: It's been fun to be here. Thanks guys.

Eric: Shall we end with a little bit more of Take Me Home, with edited lyrics by Alex?

Alex: Let's see if we can do a better job.

David: Are we doing our version or the right version?

Alex: We'll do the right version this time. We're going to start from the top.

David: All right. [Singing]

Eric: Thanks for everybody who listened to our GeriPal podcast. We look forward to having you on next week with us. Have a good day.

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Wednesday, April 4, 2018

Elder Abuse and the Role of Emergency Medical Services (#EMS)

On todays podcast, we will be talking with Brooke Namboodri and we have Tim Platts-Mills from the University of North Carolina at Chapel Hill about their  new article in the Journal of American Geriatric Society (JAGS) on "Elder abuse identification in the prehospital setting, an examination of state EMS protocols." 

We talk with Brooke and Tim about the state of EMS protocols in the US and how often the mention elder abuse in them (spoiler alert: not very often), how this compares to mentions of child abuse, the role EMS should play in elder abuse identification and management, and the role of potential screening tools for elder abuse.

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Eric : Welcome to the GeriPal Podcast, this is Eric Widera .

Alex : This is Alex Smith.

Eric : And Alex, and who do you ... ahem, blah, blah, blah, blah, blah.

Alex : Blah, blah. Who do you have ...

Eric : So Alex, who do we have with us today?

Alex : Today we have two special guests who are joining us from the University of North Carolina at Chapel Hill. They're both in Emergency Medicine. We have Brooke Namboodri and we have Tim Platts-Mills. Welcome to the GeriPal Podcast, Brooke and Tim.

Brooke : Hey guys, thanks so much for having us.

Tim : Thanks.

Eric : So we're going to be talking about your new article in the Journal of American Geriatric Society, or JAGS, on "Elder abuse identification in the prehospital setting, an examination of state EMS protocols." But before we go into that, we always ask our guests if they have a song request for Alex.

Tim : Oh, yeah, if you could play "Old Man" by Neil Young, that would really warm my heart, and my daughters would also appreciate that.

Alex : We're going to give it a try here. I'm just going to play a little snippet at the beginning, and the rest will be at the end of the podcast.

Eric : You just learned that one this morning, didn't you?

Alex : I just learned that one in the last ten minutes.

Eric : Alex actually had financial abuse committed to him.

Alex : I was the victim of abuse this morning. I got a call from a collection agency saying I owed Sprint $5,000. And fortunately, I had the means and wherewithal to call the police, track this down, go to the Sprint store all before this podcast this morning. I actually got off the phone with the police because I said, "I have to go to work." I did not say, "I have to go learn a song and get on a podcast."

Eric : That's work.

Alex : You see, priorities.

Eric : Yeah, priorities.

Alex : But other, older adults do not have the ... you know, many of them are victims of elder abuse of one form or another, including financial abuse, very common. And that's what we're going to talk with Brooke and Tim about today.

Eric : So many before we get into your JAGS paper that was just published, how did you both get interested in this subject of elder abuse?

Tim : I might try to take that on. So, I've been interested in the care of older adults in the emergency department for about eight or nine years, and I mentored a woman named Tarshona Stevens about six years ago. And she wanted to do a project, we sort of decided we'd do a project on the non-medical problems faced by older adults and we got a little bit of data on elder abuse as part of that. And we found that seven percent of older adults reported elder ... in the emergency department, reported elder abuse in the past year.

And then my mentor, Sam McLean, who has a lot of funding to do ... has an R01 to look at persistent pain after a sexual assault, met with somebody with NIJ named Carrie Mulford. I got connected to Carrie, and that let to both funding from NIJ. We submitted for a grant, and received funding to develop an emergency department based screener. And so we're sort of in the space of elder abuse.

It was a sort of a twisted route, but that's how it goes.

Alex : And when you think about elder abuse in the emergency ... so how did you transition from thinking about elder abuse in the emergency department to thinking about it in the prehospital setting?

Brooke : Yeah, great. So, we saw that elder abuse was this pretty common condition that older adults were coming into the emergency department with. However, a lot of these emergency physicians aren't able to see some of those observations that EMS providers can so readily see when they visit a patient in their home environment. They're able to see how the condition is with their home, are they taking ... you know, are there empty medication bottles lying around. What are their interactions with their caregivers, in this often unexpected medical condition that shows up.

So we kind of saw an opportunity with EMS providers to act as someone who can implement a screen in the prehospital setting in order to identify victims of elder abuse. So we saw kind of a partnership between emergency providers and EMS providers as a great next step for identifying elder abuse.

Alex : And some of this ... you know, you make the point that we need ... it's so helpful to have the eyes and ears in the homes of older adults who might pick up on elder abuse, but I think the other point you're making is that often they're not called in for the elder abuse itself, is that right? And that this is incidentally either discovered by prehospital providers, or reported in the emergency department, though it may not be the presenting issue at hand.

Brooke : Right, exactly. A lot of these older adults are coming in for some ... you know, for a fall, or some other condition. And then they're, like you said incidentally finding elder abuse, that they've experienced elder abuse in some way, shape or form. So we're hoping that EMS providers can kind of fill that gap of being another set of eyes and ears directly in the patient home, to validify if these patients have actually experienced elder abuse and what that abuse looks like for those patients.

Tim : The point I would make is that in contrast to child abuse or domestic violence, where a lot of times there are clinical findings that are pretty obvious that are causing the patient to come to the emergency department. Like the patient has a black eye, comes into the emergency department after getting hit by their boyfriend, let's say. That's not so hard to figure out. But in elder abuse, a lot of times it's not staring you right in the face. It's a little bit below the radar. It's still present, it's still really hard on the patient, and has a lot of consequences for health outcomes, but it's a little more subtle.

So yeah, as you're saying, it's not necessarily the chief complaint that brings them in, but it's there for sure.

Eric : Do we have any data on how often it's actually picked up by EMS or by emergency medicine physicians?

Brooke : So there's no data specifically about EMS providers, however, there's just a dearth of data in this area in general. However, we do know that about less than five percent of all cases are reported to the authorities, whether that be from an emergency provider, another kind of provider. It is about less than five percent, which is a pretty ghastly number.

Alex : And you know, just to pick up on this point about using prehospital EMS providers for this service, it's not actually what they were designed to do, as far as I understand. Like, they are the first responders for emergencies, but this is really asking them to fulfill a public health mission at the same time of screening the elderly population for elder abuse.

Brooke : Yeah, that's a great point. Actually, EMS roles have begun to kind of develop into being some of these people that are able to go into people's homes and identify social problems like elder abuse. A lot of these programs are that people are naming community paramedicine programs for EMS are coming into homes and identifying social problems beyond elder abuse. Some things like malnutrition, heating, and they're acting kind of in that social worker role. And doing things like health preventative, and checking up on patients who were discharged from the emergency department, and need help with taking their medications and stuff.

So, we're hoping that as that role evolves, that we can identify elder abuse as a really important next step to bring into that role for EMS providers.

Tim : I would add that the mind of the emergency position is gradually evolving on the issue of the role of the emergency department in public health. And I think we've come a long way. I think a more traditional view is like, hey, we just deal with the emergency issue. But of course, we update people's tetanus even though they don't have tetanus, so that's kind of public health role.

And oh yeah, it turns out that if you want to deal with the HIV epidemic, you should probably be screening for HIV in the emergency department. Because some of those high-risk people are only really contacting the ED.

And so, there are places which we see, oh, in emergency medicine and in prehospital care, there are these public health roles that frankly, you can't deal with those problems except by leveraging the opportunity of the emergency department visit.

Brooke : And even more than that actually, in studies that have surveyed the EMS providers to kind of assess their willingness to do things like that, EMS providers overwhelmingly say that they not only identify some of these cases of elder abuse or social problems in a prehospital setting, but they really want to do something about it. So like Tim was saying, this is a role that is evolving, and something that EMS providers are really ready to take on.

Eric : So, that kind of leads us to your study describing whether or not there are protocols relating to the identification, management, and reporting of elder abuse in EMS protocols. Do you want to tell us a little bit about what you did?

Brooke : Right. So for this study, we examined publicly available state-wide EMS protocols and other accompanying documents like system protocols, procedures, and guidelines. So we really tried to limit the search to documents that were specifically intended for and available to EMS providers.

So we searched these documents via three different ways. There was an appendix of a paper that looked at EMS protocols. It was by an author Kupas And then, we looked at emsprotocols.org, and then also each state's public health website. So essentially we went and looked at all 50 states and tried to find any publicly available EMS protocol that was out there.

More specifically, these protocols are written mostly for BLS providers, which is the Basic Life Support, or Advanced Life Support. And we were really willing to kind of take either of those ... either document because ultimately we didn't really care if it was a ... the level of training that these EMS providers had, as long as they were able to identify elder abuse.

And then after we were able to identify each of these protocols, we searched the protocols for terms like abuse, neglect, mistreatment, and looked for the associated qualifiers, like elder, senior, geriatric. And then tried to identify protocols that A, mentioned elder abuse, defined elder abuse, listed any indicators of elder abuse, so a things like bruises, or fractures, those physical indicators, or psycho-social indicators like they're not making eye contact with their caregiver, or environmental indicators like the house is cluttered.

And then we also looked to see if the protocol described patient management, if they were to identify a patient experiencing elder abuse. And finally if the protocol mentioned about that this elder abuse should be reported, and if it was mandatory in their state or not.

Eric : So what did you find? Is it in many protocols?

Tim : Yes, so, there are not ... not all 50 states have state-wide protocols. So for example, we're not going to talk a lot of trash about California, because California doesn't have a state-wide protocol, and has basically county based protocols. So but of the 35 states that do have protocols, only 14 mention elder abuse. So you're kind of already less than half even have content in elder abuse. And then if you look in terms of what do they provide. So ten out of 14 give a description of indicators, eight out of 14 describe patient management. The majority of the ones that do, 12 out of 14 provide instructions for reporting.

So the minority of states, among states which have state-wide protocols, only like less than half, 40 percent, have protocols which address elder abuse at all.

Alex : On its surface, this is really concerning, and probably it is so. But a couple of caveats. One is ... so a state like California where the EMS providers tend to be regionalized rather than state-wide, is that part of the reason that there is no state-wide protocol in California. As opposed to a state like Oregon, where my understanding is they're able to have a POLST registry in Oregon, because they only have one EMS provider for the entire state.

Brooke : So I think that how the EMS providers system works really just varies state-by-state based on laws. So I think ultimately it boils down to if the lawmakers decide that EMS protocols should be mandatory state wide, and that every single county should have the same exact protocols. Or if they want to give their counties a little more space to move around and make their own protocols, which is the case of California. This might be influenced how many EMS providers, or how large the state is, and things of that nature. But it is mostly a regulatory issue with the EMS providers, and that's why it just varies so much, state by state, region by region.

Alex : You notice how I came to the defense of California there for a second.

Tim : I see, I see where you're going with it.

I think at the end of the day, there are a lot of protocols out there that don't include elder abuse as a description, and our findings are also consistent with when they've done interviews, qualitative work with paramedics and EMTs and they say, "Hey, how do you feel about identifying elder abuse?" They say, We'd like to, and we see it, but we just don't have any mechanism for describing it, and there's not a clear pathway for reporting it to providers, and the emergency providers will sometimes ignore us.

And so I think there really is something that could be improved here.

Eric : Do we have any ... if you had to compare this to child abuse, do we have any data on the ... is it similar as far as number of protocols that have information ... like what EMS should do in those circumstances, or what to look for?

Brooke : So this was something that we were really interested in as well, and so we a similar ... with a similar mechanism we searched child abuse. We search child abuse in protocols as well. And what we found is that twice as many protocols actually mentioned child abuse, and all those different metrics that we were talking about, defining elder abuse, finding indicators, instructions for management and reporting. There was about twice as many of those metrics found for protocols with regards to child abuse.

We hypothesized that this is due to several reasons, one of which is that there's just a lot more research surrounding child abuse. So child abuse is just one of those things that has been talked about a little more frequently for a little longer. And so it's been integrated into these EMS protocols just because it's kind of been out in the open for longer than elder abuse has. And we're hoping that we can kind of forge a similar path with elder abuse that ... follow that pathway for child abuse with elder abuse, since the pathway has kind of been forged.

That being said, we were shocked that not every protocol mentioned child abuse. So there were only 80 percent protocols that mentioned child abuse at all. And the fact that 20 percent of these protocols that we were able to find didn't mention child abuse I think demonstrates that there's still a lack of fully understanding abuse, and how to identify it, and how to really leverage the role of EMS providers in identifying any kind of abuse in the prehospital setting.

Alex : You know, backing up a moment, I think should talk about why are we talking about protocols? Why can't they just tell the EMS ... why the EMS providers just say, "Hey, guess what I saw in the home setting?" I think, Tim, you alluded it to somewhat, just a moment ago, protocols are the way in which, the structured way in which this information is transferred, but why this emphasis on protocols?

Tim : That's a good question. The truth is, if it's not in the protocol, it doesn't technically keep an EMS provider from doing it. And so they're certainly ... there are states, for example, Idaho doesn't have a protocol when we searched. As of the time that we searched, their state protocol doesn't talk about elder abuse. But there are certainly EMS providers who recognize elder abuse and tell EMS, and the emergency physicians about it.

So it's not just, like absolutely ... you know, if the protocol is there it happens, and if the protocol is not there it doesn't happen. However, the protocol really does support the activity. And EMS is a very protocol driven system, so basically, the response to every paramedic or prehospital provider is just do what the protocol says. That's always the answer.

And so, if the protocol's there and supports it, it becomes sort of like a behavior that they can do, and it's clear what are the next steps, what additional information they should be collecting in the field. And then it's also better supported in terms of communicating with physicians. And I kind of mentioned this earlier, but if you ask paramedics, they will say that they often feel obstructed in trying to report this information to emergency physicians. And it's not, you know, the protocols don't completely solve that, but I think would solve that to some degree.

Eric : So it sounds like there's a potential path forward looking at child abuse protocols, and it sounds like EMS is not only willing but eager to actually have this as part of their job. What's the next step? Where do we go from here?

Tim : Well, our hope is that this article and the related work that's going on in the field of elder abuse will raise awareness by medical directors of EMS systems to change protocols. But it's a little heavy handed to say, "Well, your protocol doesn't have it, and we think it should, and so put it in there." Because the obvious response would be, "Well, what's the data that this is actually the right thing to do?"

Now, you and I might agree, well, it seems like the right thing to do. But if you look at the US Preventative Services Task Force recommendations on elder abuse, it doesn't even support screening for elder abuse, basically, in any setting, or in primary care, which is really what it's focused on. Because there's no data to support it.

So, there's really like ... the research field is really kind of a little bit behind in terms of developing, A, what are the screening tools and instruments in the prehospital setting, and then, B, what's the evidence that this is actually helping patient outcomes?

So there's a lot of actual work to do. Now I personally don't think we should wait for all that research to be done to go ahead and put those protocols in place, and try to develop the capacity of prehospital providers to identify elder abuse. But unfortunately there's still a lot more work to be done.

Brooke : To add on to that, I think on a day-to-day basis, there's things that providers can do, and I think one of those things is really just to listen to what EMS providers come in and say to them. Even with the health care structured protocols screenings in place, EMS providers are most likely identifying some of these things that we're hoping they're identifying. You know, like a cluttered house, or those medication pills everywhere, or a caregiver who's intoxicated. And making those mental notes is really important, and something that if they just are able to communicate to the ED providers would be really big. If you facilitate that conversation, and that exchange of information, you start to get another layer of providers looking at elder abuse, and you know, is that person possibly experiencing that.

So I think opening that line of communication is something that on a day-to-day basis ED providers can do to start to identify this elder abuse more and more.

Eric : Are emergency providers mandatory reporters of elder abuse if they hear about such concerns from prehospital EMS providers?

Tim : In every state except New York, which does not ... New York does not have mandatory reporting, but all other states, yes. So any medical personnel who gets that information is a mandatory reporter. The actual definition of elder abuse in most states is somewhat restrictive. So it has ... basically in North Carolina, in order to be elder abuse, the person has to be dependent on other people.

So for example, if my mom and my dad weren't getting along very well, and they fought, it wouldn't count as elder abuse, because neither of them are dependent in any formal sense. They may be psychologically dependent on each other in a nice way, but they're not formally ... you know, they're not dependent on each other. And so that would be domestic violence, and that wouldn't fall under mandatory reporting.

But if somebody's dependent, like they have difficulty walking, they can't meet their basic needs, or they have cognitive impairment, and there's abuse, then there is mandatory reporting, except in New York.

Eric : So if something like what happened to Alex this morning, somebody steals your Social Security Number, charges $5000 to Sprint, happens to an older adult in North Carolina, that's not considered elder abuse? Is that right? Because then if it's not a dependent relationship-

Tim : If Alex was 70 years old but kind of did everything he normally does, then no, it probably wouldn't technically be elder abuse, it might be a crime, but it wouldn't fall under that.

Brooke : Now, if one of his children, or someone who was taking care of him, had done that, then it most likely would fall under elder abuse.

Eric : So you're saying if it was his cohost on a podcast who bought a bunch of iPhones.

Alex : You stole $5000.

Eric : I just want to make sure.

Eric : Hypothetically.

Alex : Yeah, I came in and said that to Eric, and he said, "oh, hey, I just got five new iPhone X’s from Sprint at my house." Great.

Eric : So I've got a last question. We've talked a lot about screening, and the potential use for screening, and Tim, you also mentioned that there's not a lot of great research out there on really effective screening tools. What do you guys recommend as far as potential screening tools for elder abuse?

Tim : Well, there is the ED Senior Aid Tool, which is submitted for publication as just described by our group. So I'm being a little bit funny, because that is work that we're working on. But I think, let me rather than answer with that, let me see more broadly. I think in the emergency department, a couple principles apply. One is, you really need to screening everybody. Because if you just think, "Oh, I'm going to get the people who have bruises on their arms," you're just going to miss almost everybody.

The prevalence of elder abuse in the population is like, 10 percent amongst older adults. So it's really common. So we should screening, I think, universally. How you do that best is not entirely clear, but it's probably going to be some combination of a cognitive assessment, some really ... a really limited number of questions, because you just can't do a big battery of questions for every older adults who comes in the ED. They're not going to tolerate it, and the nurses or whoever's doing it won't do it.

So it needs to be really efficient and limited, and then it needs to be more expansive for people for whom there are red flags. So if the patient has cognitive impairment, or answers yes, or refuses to answer a question then you need to take a deeper dive.

And we've tried our screen on 250 people, and we've found like 17 cases. And that was among consenting older adults. So we think ... you know, for methodologic reasons we had to get consent. So I think that's an underestimate. That gave us a prevalence of around seven percent. I think the exact tool is sort of up in the air. There are a couple published versions, none of which we think are optimal for the emergency department. But we think it's definitely something that we can ... that's a nut that we can crack, and we can come up with a good tool for the emergency department.

Brooke : And to translate the tool that Tim is talking about, to the prehospital setting, we're really hoping that it becomes more observation based as well. As we were talking about, I think something unique about the EMS provider role is that they are actually going into these patient's houses, and they're able to see the actual condition these patients are living in. And so building in some of these observations into that screening tool is another really valuable part of the screen that we would like to add in.

Tim : Eric, if I could add one other thing, I would like to add thanks to the National Institute of Justice for the support of and funding of our work to develop the screening tool. They didn't fund this particular project per se, but they have supported the Senior Aids tool. The people at NIJ don't ... this work, we're not speaking on behalf of the NIJ in any means. They are funding the work that we're doing.

And I'd also like to thank some of the collaborators on the project, including Sheryl Zimmerman, Sheryl Zimmerman and Bryce Reed, for both have been extremely helpful.

Eric : Alright, are there any other things that you guys would like to talk about, about this paper, or anything else that we should, before we close?

Tim : No, I think I would just echo, we're emergency physicians, but I see us as having kind of strong partnerships with the geriatricians, and we're thankful for that. Brooke mentioned that it's important for emergency physicians to be sort of listening and open to comments from emergency ... from the prehospital providers, and I think that geriatricians likewise there are parallels there in the in-patient setting, for like, listening to nurses who pick up on stuff. I mean I think this is ... I think elder abuse is something that takes a village to solve. And so it's important for us to be good village members, and good listeners, and consider it a team approach.

In some cases, in our system, we've had geriatricians help solve cases for us where we didn't really pick it up, and then they get admitted, and then we find out, oh, they're a bunch of patients from a nursing home, and they all had the same problem, and the geriatrician's the one who figured it out. So it's very much a two way street between emergency physicians and geriatricians in that regard.

Eric : Wonderful. Well with that, we'll maybe do a little bit more of a closing with Alex singing more of Neil Young, but before we do that I just want to say thank you for joining us on this podcast. It was great talking about this.

Alex : Thank you so much, it's a very important issue, and I learned quite a bit about the role of EMS providers in public health, and screening for elder abuse in particular. Thank you so much.

Brooke : Thanks so much for having us.

Tim : Thanks.

Eric : Thanks everybody for listening to our GeriPal podcast. Stay tuned next week for our next podcast.

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Sunday, April 1, 2018

GeriPal needs YOUR feedback!

by: Alex Smith, @AlexSmithMD and Eric Widera, @EWidera

We at GeriPal have enjoyed blogging and podcasting with you.  Improving care of older adults with serious illness is the common cause that binds us together with you, dear GeriPal readers and podcast listeners.

We would like to know: how can we be better?

To that end, we've hired a consulting firm (Cambridge Analytica) that will gather survey information about your experiences with GeriPal and how it can be improved.  How can our writing be clearer?  Are the posts or podcasts too long?  Too short?  More or less singing?

Cambridge Analytica additionally collects a small amount of voting information that will be used purely for understanding who our audience is and how we can better serve you.  We care deeply about your privacy, so we asked Cambridge Analytica to double pinky promise to delete the data once we're done with it.

Here is the link to the survey, collected via Facebook (naturally): https://survey.fbapp.io/geripal-survey-by-cambridge-analytica

Thank you!
Alex & Eric

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Wednesday, March 28, 2018

After intubation in the ED, 33% die in hospital: GeriPal Podcast with Kei Ouchi

Blue - survive and return home; Yellow - survive and discharge to nursing home;  Red - die in the hospital.

In this weeks GeriPal/JAGS Podcast we talked witk Kei Ouchi, an emergency medicine physician, internist, and researcher at the Brigham and Women's Hospital and Harvard Medical School in Boston.  We recorded this podcast in the hallways of the annual meeting.  We talked about outcomes following intubation in the emergency department.

Kei published a paper in JAGS that is notable for several things, but perhaps most of all for the innovative use of color imagery to convey a message.  The image in the @AGSJournal tweet above is from Dr. Ouchi's article - this tweet went viral by the way - and notice what it does: (1) convey the main message that outcomes are worse with advancing age, and are not good in general overall; (2) grab your attention and make you want to learn more.  

Kei is very thoughtful about how these data should be used - not on the spot in the ED, when a patient is gasping for air, and you pull up the color figure on your iphone Twitter app - no, not then.  Better to use this information in advance, when things are calm, outside the ED, for people at risk of going to the ED in extremis.

This is the first in a series of GeriPal podcasts on the GeriPal - ED interface.  ED stands for Emergency Department by the way.


-By @AlexSmithMD


-Prognosis after Emergency Department Intubation

Listen to GeriPal Podcasts on:


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

Alex: This is Alex Smith.

Eric: We are live at the American Academy of Hospice and Palliative Medicine, AAHPM, the Hospice and Palliative Nursing Association, HPNA, and SWHPN meeting in Boston.

Alex: And we have a guest with us today.

Eric: Who is our special guest today, Alex?

Alex: Today our guest is Dr. Kei Ouchi. Who is an Emergency Medicine Physician and Internist and Research Fellow at the Brigham and Women's Hospital, right here in Boston. He was up working until 3 AM last night, but he was kind enough to come join us today on the GeriPal Podcast. Welcome to the GeriPal Podcast Kei.

Kei: Thank you so much for having me here. It's an honor.

Eric: So, I just want to say, I was up till 2:30 last night, but I was not working. We always start off with a song request. Do you have a song request for Alex?

Kei: How about, "Just Breathe"?

Alex: Perfect. Good choice, given the material. [Singing]

Eric: So, that was a very apropos for the discussion we're going to be talking about today, which is, intubation in older adults in the emergency room. So you just published a paper in the Journal of American Geriatric Society, or JAGS, titled, “Prognosis After Emergency Department Intubation to Inform Shared Decision-Making”. And it's like an all-star cast of authors that you have on this article, including James Tulsky, Rebecca Sudore, and Mara Schonberg. Really amazing, but before we go to the article, what got you interested in the subject?

Kei: I've been a practicing emergency physician and internist for a few years and through my training and my current clinical practice, I always wondered, what is the information that clinicians have to communicate to the patients or surrogates about this critical junction of their life and their illness? And I just didn't know how to do it. So I started to look through, what's the available information that's out there about this. Then I realized that, we don't really know actually what really happens to all comers in emergency department. And the data was lacking. And I wanted to learn more about that. That's how this got started.

Eric: So, it looks like what you did is, you took adults, aged 65 years and older, who were intubated in the emergency room from 2008 to 2015, amongst all these different hospitals, 262 hospitals. What did you find?

Kei: So, I think the most important finding that we found is that, we confirmed that in-hospital mortality, after emergency department intubation for older adults, regardless of their comorbidities or the admitting diagnosis, was very high. Which, I think most clinicians knew already, but we put it in numbers. And we tried to come up with ways to better communicate that to the patients or surrogates, by the clinicians.

Eric: So, we'll have a picture of this amazing figure 2 that you included in this JAGS article of older adults and their outcomes. Both survival in returning home, surviving and discharging to a nursing home versus dying in the hospital. Which is broken down to 65 to 74-year-olds, all the way to greater than 90-year-olds. And it's a really impressive graph. What was it, 30…33% of all comers, older adults died ... Wait, what was the statistic? Do you remember?

Kei: Yes, that's correct. It's 33% when you take all comers coming into the emergency department, who are all intubated in the emergency department.

Alex: 33% died before discharge. So, did not survive the hospitalization.

Kei: Yes, that's correct.

Alex: And among people who are older than 90, that number is much higher, it's 50%.

Eric: Yeah and in that group, it's even more impressive, looking at this graph. It's 50% died of the greater than 90-year-olds, 36% survived but were discharged to a nursing home, and only 14% survived and returned home after that index hospitalization. Now, we have no data what happens right after the hospital, right? Is there any way to get that?

Kei: I have really thought a lot about this because the most interesting information is actually what happens to the patients after they leave the hospital, right? So, what is that quality of life like? And things like that. Which is really, it's certainly not in this dataset. I think it has to be merged with Medicare dataset and some other dataset to come up with that, which is going to be hard.

Eric: Yeah, because when I think about like having these discussions with people in the emergency room. You know, going to a skilled nursing facility is generally not the big decision point, it's not ever being able to return back home. So it would be really valuable to know, of these individuals who went to the skilled nursing facility, how many were actually able to return home? I'm guessing it's incredibly small.

Kei: I really want to learn more about that. But unfortunately, I haven't had an opportunity to work with the dataset that has all that information yet. I think as clinicians we all know, anecdotally, what happens to some of these patients that we're taking care of. But as a whole big picture, it's still slightly unclear.

Alex: Now, other than age, were there other factors that helped you identify patients who are at greater risk of dying before leaving the hospital?

Kei: Yes. So, there are. But the answer is, for example, metastatic cancer, having the comorbid diagnosis of metastatic cancer or admitting diagnosis of stroke or intracranial hemorrhage. And remember, these are people who are all intubated in emergency department. So, intracranial hemorrhage with intubation in the emergency department. Those are, yes, they would increase your chance of not making it in the hospital for sure. What was striking to me was that, none of these things all combined, they still don't predict the in-hospital mortality with this good discrimination. It wasn't all that surprising to me for me to find that. Because we know, all the patients are all very different, and it's very difficult to risk stratify them. That's why you need a clinician to kind of, take in all their information together to decide that. And I think, at least in this claims dataset, there's really not enough information to account for that kind of accuracy. And we really need more information about patients’ functional status and things like that.

Eric: So, you also cite a recent JAMA IM article talking about rates of intubation for older adults and how dementia, I think was outpacing all other diagnoses by a factor of four, as far as the increasing rates of intubation. Do you have any data around cognitive status in these individuals? And was that a factor?

Kei: Yes. I agree and I think that probably a very important factor. Unfortunately, in this administrative dataset, there is no variable that accounts for cognitive status. Even the diagnosis of dementia is not well documented. I mean, they are, but it's hard to figure out how accurate that is, compared to things like diabetes or heart failure. So, yes, that would have been lovely information to learn more about, but we just don't have that information in this dataset.

Alex: So, here's a question. Do you have information or if not, what do you think would happen to similarly sick patients, who are not intubated, who are in the emergency department, but not intubated?

Eric: Are there similarly sick patients? It's intubation. These people are ... that's a marker of sickness.

Alex: Well, I guess my point is, if they weren't intubated, then mortality probably would've been 100%, right? No. Okay, Kei.

Kei: So, we know from some prior studies on this type of issue, they usually take one disease group or one phenomenon, like sepsis or something like that. Then they follow the outcomes. And we know that patients who go to ICU, if they get intubated, their rate of in-hospital mortality jumps dramatically, as you can imagine. So we know that, intubation itself, is certainly associated with in-hospital mortality and people who are not intubated, are less likely to die in a hospital. But that's just the nature of their illness itself.

And one more comment about people who are not intubated, but they should have been intubated, but they were not, for one reason or another. It could be that they had terminal illness or had some kind of conversation that led to that. There's really no good information about that, other than a case series studies. And it's actually not true, not everyone dies in these case series studies. Some people survive. You know, these people who come in with DNR, DNI orders, and they are not intubated, but they go to ICU or hospital, they survive. And we don't really know exactly how much, because these are all very small numbers.

Alex: So that's interesting because it helps put this in context. If a different decision were made, what might happen? I guess I'm getting to the implications of this and how you see it as being used in clinical practice. Like for example, do you see emergency providers taking these figures to surrogates of seriously ill patients in the emergency department and saying, "You know, intubation is one option here. I'd like you to have accurate information about what might happen, based on national study of people, like your loved one, who are sick and were intubated in the emergency department".

That tells one piece of the story. The other piece of the story is, what happens if we don't intubate them? Maybe a little bit from you about how you see this being used clinically or is it ready for use clinically?

Kei: I think all my mentors would say that this is not ready to be used immediately, clinically, because this is the first iteration of this type of decision aide. And that's correct. This has to be tested on different clinicians and different patients to see how they understand this for sure. But, one comment that I'd like to make is that, we hope that this information is helpful when a clinician is synthesizing all the information that you see in front of you. Their vital signs, their lab values, their clinical status, and having this conversation with the patient or surrogate. We hope that this information is somewhere back in their mind to share with them about the baseline risk of mortality for older adults, but it certainly does not speak anything about patients who decide not to get intubated, what happens to them. Because we were unable to look at that information.

Alex: So, do you have any examples from your clinical practice that you could share with our audience, in a way that's anonymized enough to protect the confidentiality of the people you've cared for? Where this sort of issues come up and you wish there had been more information available to make a decision about this.

Kei: Can I just clarify one thing before I talk more about that? What I want to clarify is that this type of decision aide, to communicate the probability and likelihood of some event happening, is only useful for goals of care conversations that happen in a subacute setting, I think. And what I mean by that is, people who are really about to get intubated and they're hypoxic and hypotensive, and when their family arrives and they are crying and yelling at you like, "Why can't you put my dad on breathing machine right now?" That's certainly not the time to bring this decision aide and say, "Hey, look at this, don't you understand this probability?" That's not what this is meant for. Our hope was that this was meant for people who are more subacute and have time and emotional status that's controled to think about cognitive issues like this, like the probabilities.

I think there are two types of conversations in the emergency department like this. One is hyper acute, like what I just described. People who have their emotions super high, and they are unable to process this type of numbers, unless their emotions sort of handled in a way that they can. The majority of my patients are people who are very ill and they're going to get admitted to the hospital. But they're not at that point yet and they can still, either converse with you or their surrogates can make this decision, near term decision, going forward. Our hope is that this is used for those patients where, I'm worried that your dad is getting sicker and he might have a chance of having to have to go on a breathing machine, during your hospitalization somehow, today. Have you ever thought about this? And if they're in the right state, in terms of their emotional status, then perhaps these numbers could be helpful for these patients to understand.

Eric: But the numbers we are looking at here, people who get intubated in the emergency room, do we have data on what happens to those people once they get admitted from the emergency room. Are the numbers worse or better, as far as survival or discharged to a skilled nursing facilities for older adults?

Kei: That's correct. There are prior studies on patients, when they look at patients who are intubated in the hospital, rather than the emergency department. And the numbers are fairly similar. But they don't, they don't usually, they didn't really describe how many people would go to a nursing home or how many would go home, after the hospitalization, but in terms of in-hospital mortality, it's fairly similar. And that's one of the important findings that this paper brought up. Because those prior large studies excluded people who died in emergency department. But actually, those are actually rare. And the numbers are very similar to people who are intubated after hospitalization.

Alex: Is there a specific clinical case that comes to mind, when you think about this issue?

Kei: So, I had one patient, maybe a month ago, who, let's say, his name is Mr. C. Who was 85, had metastatic lung cancer with pleural effusions who are coming in with hypoxia and hypotension. And the patient was actually on home hospice service and the daughter called 9-1-1 because he didn't look very well. Of course he arrived in the emergency department. Of course, the patient has no ability to speak for himself at all, because he's huffing and puffing and he's on BiPAP and he can't really make this decisions. But, now this decision is made with the surrogate, who's the daughter, who arrived with the patient. And she is crying and yelling, "Why can't you put my dad on a breathing machine?". So this is actually a common, it's not a common, but it happens frequently in emergency department. And then, when I think, back to this paper, that's really not the time for you to bring up this decision aide. Actually, these items can be used, but in a different settings.

So, for example, I watching my trainee go through this conversation, next to him. And when she says, "Why can't you put my dad on a breathing machine?", he starts to talk about, "Well, the probability of surviving this hospitalization, if he were to go on the breathing machine is, I don't know what it is," which I know, "I don't know what it is… Blah, blah, blah". He starts to explain about the numbers of why this is important. That's a perfect example of when this decision aid should not be used. Because I think, in my mind, what that daughter was asking is, "Can you please help my dad?". So, this is an important point. The numbers are very important for clinicians to know, but you have to choose the right moment to use this type of decision aid.

Eric: So, let's talk for a second, when you are in that situation with a resident and maybe they're starting to talk about numbers. And you're feeling that this is not the right place. Because it sounds like, you're thinking maybe this happens even before the emergency room. But this is still important in the emergency room, at least it sounds as well. So obviously we want this to occur as early as possible. But when you're in that situation with a resident, they're talking about numbers, what do you do in that instance?

Kei: I struggle with that, too. And I asked people who are a lot senior than me, "What do you think I should be doing?". And I tried variations of it, to see which one might work. But the last example I had is, I had to stop them and I just said, "Hey, I want to add something. Would it be all right if I interject right now?". And the trainees won't keep going because I'm the attending. And then I kind of start to take over the conversation. So, it's a really hard balance of allowing the trainees to do as much as they want, as well as keeping the patient safe. As the lead clinician, it’s always a hard balance, especially in this hyper acute setting.

Eric: And then do you reverse the conversation to go back to big picture goals, values? You're not actually talking about the numbers, but you're talking mainly making recommendations based on those numbers, is that right?

Kei: That's correct. So, what I usually do is that, I say things like, "It sounds like a very important topic and that number is also important. And I also hear you…" the patient’s daughter, "…that you really want to learn more about this. Now, I don't want to ignore that, but I want to put that on hold. And I want to learn a little bit more about your dad, before I can talk more about what I would recommend in this situation".

Eric: Well, I really want to thank you for joining us today and having a great discussion. It was a really phenomenal JAGS article and I loved the color picture, which we will have on our GeriPal website. So, thank you for joining us.

Kei: Thank you so much for having me, I really appreciate it.

Eric: So Alex, do you want to, since we're talking about intubation, do you want to give us a little bit more of "Just Breath", by Eddie Vedder?

Alex: Yes. [Singing]

Eric: I want to thank all our listeners for joining us this week. Especially live from the AAHPM, HPNA, and SWPHN meeting in Boston. And we will talk with you next week.

Alex: Thanks folks.

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Wednesday, March 14, 2018

Should Concept of the "The Good Death" Be Buried? A Podcast with VJ Periyakoil

On this week's podcast, we talk with the authors of a Journal of the American Geriatrics Society (JAGS) article titled Should We Bury “The Good Death"?  As luck may have it, one of the authors is co-host Alex Smith, and the other is a leader in geriatrics and palliative care, VJ Periyakoil.   Alex and VJ's critique of the ‘good death’ was published alongside a paired commentary from Age and Ageing from the British Geriatrics Society.

So listen in and check out these two great articles:

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

Alex: This is Alex Smith.

Eric: And, we have another host with us today, Lynn Flint.

Lynn: Hello.

Eric: And Alex, who is our guest?

Alex: Today we have VJ Periyakoil who is joining us from the VA Palo Alto in Stanford, just about an hour south of us. Welcome to the GeriPal Podcast VJ.

VJ: Thank you so much for having me, it's a lot of fun to talk with you guys.

Eric: And, we have a really interesting topic today, the topic of the "good death." We'll talk a little bit about what that means and articles that you wrote in the Journal of American Geriatric Society and another article on Age and Aging on the similar subject. But, before we do that, we ask all of our guests, do you have a song for Alex to sing?

VJ: Absolutely, I love Adele so if Alex can sing "Hello" for me because I feel that that talks about ... that has a lot of relevance with life review and other palliative care topics so, Alex, take it away.

Alex: I am not Adele.

VJ: We can hardly tell Alex.

Alex: Just in case there was any question. But, I'll give it a try. [Singing]

Alex: That's a little taste.

VJ: That was amazing. That was amazing.

Eric: Well, there's more to come at the end of the podcast.

Eric: Alex is going to hit the highs.

Alex: We'll see.

Lynn: I thought that song was about somebody's phone not working. I don't know.

Eric: Who talks on the phone though? Is that like a text hello?

Alex: Well, Eric and I were wondering if this is hello from the other side, like a person's died and they're looking back.

Eric: So, VJ, why did you pick this song?

VJ: I love her voice. It has so many layers and it's just amazing so I'm a big fan. But, this song also has, sort of, palliative care relevance, exactly like Alex said, "hello from the other side." There's a lot of regret, which is one of the primary emotions we see with people as they are dying. And then she talks about love and forgiveness so, I felt like it was very appropriate for palliative care.

Eric: I always thought it was the other side of the pond. No?

Lynn: Oh.

VJ: That's right. That was another reason I picked it, because this is a companion article with our colleagues from UK so, I thought picking a UK singer would be appropriate.

Eric: Wonderful. So, Age and Aging for those who don't know is part of the British Geriatric Society, and Journal of American Geriatric Society or JAGS is associated with American Geriatric Society, so this is the perfect song VJ. Well done.

VJ: From now, it's just going to go south, this whole ... my contribution.

Eric: So, let's talk. Now, I'm going to turn Alex no longer into a guest, I mean a host. He's now a guest and Lynn Flint, also from UCSF is going to be co-host cause Alex co-authored a paper with VJ in the Journal of American Geriatric Society on the title ... get ready for this audience, "Should We Bury the Good Death?"

Lynn: Great title.

Eric: Great title.

Alex: Is it cheeky?

Eric: Interestingly-

Lynn: To use a British word.

Alex: To use a British word.

Eric: We're much less cheeky in their title in Age and Aging, It was “Reappraising the Good Death for Populations in the Age of Aging”. I got to say, I think you won out on the title guys.

VJ: And, they won out on the gravitas.

Eric: They did. So, maybe before we get into the topic, how did this come as an interest to you?

VJ: From my side, I have been taking care of patients as you guys have and been at the bed side of patients. I don't think I ever heard any specific patient talk about wanting to have a good death. People want reasonable dying experience. That is all the grief, and the joy that comes at the end of life as people are looking at their life in a whole different way. But, I never had a patient tell me, "please make sure that I have a good death." So, it's more about the dying and so I feel like this is more of a issue for the clinicians and not as much for the patients. I believe that was one sentiment. I'm curious to see what Alex thinks.

Alex: Yeah, I think that's absolutely right and clinically I think we've all had this experience and went through it ourselves most likely. In residency, you often feel like you are torturing patients. You're flogging them. Those are common phrases. And so you develop this concept, not explicitly, but implicitly through this, what they call a "hidden curriculum" that there is a bad way to die. And, you also, at the same time, develop a concept of what a good way to die is and that a good way to die is at home, without having CPR performed, without being in the intensive care unit. And I think many of the trainees that we work with have drank that Kool-Aid and come to training with that zeal for "I'm going to help people experience the good death and avoid the bad death."

Lynn: But not until I've done lots of things and I'm absolutely positive there's no more tests or interventions to do.

Alex: Right, there are different sides to it. There are those who believe that the good death ... that no death is a good death and that they have to do every test, leave no stone unturned and that has driven, in a large part, this sort of conveyor belt as Zitter described it when we had her on our podcast, of technological intervention and increasing medicalization of the dying process. But, there are others who are drawn to geriatrics and palliative care as disciplines who fight against that movement within our system.

Lynn: Well, the point that I was trying to make there was around, I think, attention that both of these articles get at, which is that it might actually be easier to ensure a "good death" if we really focus on it at the very end as opposed to making these big, broad sweeping changes to the system. Or, to the way that we care for patients who are dying and slowing down over a period of time.

VJ: I’d say that there is ... concurrently there is a need for both population health approaches at a very broad level, but also personalized strategies that fit the individual patient right in front of us. And I think that might be what you're getting at a little bit Lynn. In terms of, what is the right thing to do. And then the other question I often find useful in providing care is, at every step of the way, asking something very simple, which is, "who are we serving and what do they need?"

So, if I'm serving myself because I want to do one more CT scan just so I can see, or just so I can be less anxious, that's a different agenda right? Meaning I'm serving myself as opposed to, "what does this patient in front of you need?" And, it might be that they want the CT scan, which is a whole different issue, right. But it comes down to who is the patient at the given time and sometimes the doctor is the patient, meaning they're treating themselves more than treating the patient.

Eric: OK I'm going to take it a step back at this point. If you're gonna argue for burying the good death, how would you define, what does the phrase "good death” mean?

Alex: That's a good question. I think that's part of the problem with the good death, is that people develop ... sort of try to attribute to others what their own conception of the good death is. And one of the points that we argue in our paper and that Christian Pollack and Jane Seymour argue in the companion paper in Age and Aging, is there is no monolithic concept of the good death. The good death is highly individual and is highly influenced by your own personal experiences, your history, cultural attitudes, beliefs and behaviors, your social networks and relationships. And that, when we impose one standard of the good death, the good death is dying at home for example, as has been instituted in the UK, for example, as a quality metric. We actually constrain choice, autonomy and we don't allow for the tremendous diversity of perspectives and experiences that people bring to bear towards the end of life.

Eric: Well, in the UK is the quality metric where you die? Like, your preferred place of death, or is it-

Alex: Oh actually you're right. It's a preferred place of death, yeah. Which is good in a way because it's a match between goals and location rather than assigning it as a home based death. Although there is an increasing focus, I should say, talking to Christian and Jane Seymour about what's going on in the UK on death at home.

VJ: I'd say that even having a doctor ask that question is a huge step forward that we would even ask the patient where might be an ideal place for them to spend the last days, hours. And that then immediately personalizes the conversation and hopefully serves as a gateway for patients to tell us more about what matters most to them in a way that we can serve their needs to the extent we can. And as Alex said, we're really constrained by the system that we are in and to be mindful of that as well.

Eric: So there was another great JAGS article that just came out this week on the "Influences of Care Preferences of Older People”, lead author was Simon Etkind, I'm not sure if I'm pronouncing that right. But, I really like this article because it talked about the different influences on preferences including, they had a wonderful diagram showing that how family and care contacts, individual aspects and illness aspects all influence care preferences and probably one of the strongest influences is actually that family and care contact. So, it may not be enough just to ask people, where would you ... what's your preference of where you would want to die. Cause that may different also than what's possible, what other worries that they have. Because they talk about in this article how patients also, one of their leading things that they're concerned about is not being a burden to their family members as well.

Alex: Right, this is an incredibly important point here. When Karen Steinhauser did her landmark study, she actually titled it, "In Search of a Good Death," right. And then she did a survey, a national survey, of people with serious illness to caregivers and people who worked in hospice palliative care. She found that, yes, people felt it was important to die at home, which is always cited in studies. People want to die at home but there's a mismatch for dying in hospitals.

But, it was the seventh most important factor that patients ranked, right. Seventh most, and above that, factors like, not being a burden to people they love, having a sense of spiritual connection and getting right with God before dying. Those factors were higher, being free from pain. And so those factors might intervene if somebody can't be at home without burdening their loved one, without being in pain, hopefully not with the support of hospice. But you could see how that might lead to decisions that lead a person to not die at home. Because when we assume that the preferred place of death should be the top priority or that dying at home should be the top priority, we impose that decision on people, we're constraining their choice and not allowing for this, I'm just looking at this figure now, this whole larger context that the person resides in.

Eric: And we'll include that JAGS article in our podcast review on GeriPal website. And, going to Alex's point too, if I remember the Steinhauser study correctly, while family members and physicians viewed being free from pain highly important as far as a good death, patients valued being mentally clear more than being pain-free. Is that right?

Alex: That's right. I also believe that dying at home was ranked more highly by clinicians than by patients.

VJ: I think that as people get sicker, and we have data nationally that show that people's functional status declines significantly in the last two years of life right. And at that point, to me this individual view of what they want or your own personhood, sort of, becomes a little bit more translucent, if you will, and we ... at least in my experience I find myself providing care for a care unit. So it's not just about what the patient wants, it's also about what the family can support. And so this concept of a good death being at home sort of disintegrates, then, if is culturally a taboo for someone to die at home or the patient feels that this is a burden that their loved one just cannot do at this point because they're working and there's just one person working at home and therefore, they want to be some other place, be in the hospital or in the nursing home. So, I think that the care unit, to me, determines what is a reasonable course of action, as opposed to the individual by themselves, which is very different I think from when you and I are healthy and our choices are our choices. I don't know what you guys think about that.

Lynn: Well I have a question, this is all ... this is all really complicated. I'm looking at the figure, there's a lot of words and arrows and there's context and patients, and families and we talked a lot about trainees in the beginning, if we take away this concept that there is a good death, are we really expecting people to suddenly absorb all this complexity and take care of these really complicated patients?

VJ: I'd say, Lynn, that actually why the diagrams and the research might be complicated, to me it all comes down to something very simple. It's what matters to you. Who is in your life, who's providing care for you and for the doctors to know that, that social history that was recently on Twitter, that little meme that talked about the death of the physical exam. I think that the social history, the physical exam, the being at the bedside just, it's again, back to the basics and it's just the very simple stuff. We jump to the PET scan and the MRI and I think in that rush we sort of lose the very basic things. So to me, it's not at all complex. It's just very ... actually it's on the other end, it's very simple

Eric: And I'd add to that to say that, I'm not saying that physicians or trainees should abandon their moral responsibility to guide patients toward care that aligns with their goals and their values. And that often times patients may, unintentionally often, because they're on this treadmill of medicalization, believe they have to follow a pathway of care that includes highly intensive, aggressive measures, tests, treatments. And that we actually, we do have a moral responsibility to say, "hey, I worry about where that will lead, you said that, it was important to you to be with your family members, to be able to interact with them as much as possible, to get home, to work in your garden. Those things are what matter to you. Having this test, having this treatment, they don't really align with those goals”. So I think we do have a responsibility but it's a more nuanced responsibility.

And I agree with VJ, a lot of this is re-training people to be less like, oh you have to ask about each of these individual domains to actually thinking about it, you need to be more like a taxi driver or a barber who will just ask you questions like, so who are you? So where are you from? So what do you like to do? What's important to you?

Eric: Okay, so there's a lot of talk in the field of palliative care and in geriatrics of measuring what matters. There's actually a white paper on measuring what matters in palliative care. I'm hearing that the concept of the good death as a monolithic thing is not something we should be aiming for. What's the opposite of monolithic ... polylithic, is that a thing?

Alex: I don't know.

VJ: That sounds like a new religion there.

Eric: Polylithic good deaths. Do we have to throw the whole concept away because what I'm hearing is that there is good deaths but it's individualized. And how, is there a way to measure that? That we're doing a good job in following people's values.

VJ: I think before going into measurement, I feel like we need to think a little bit more about the process. And to me, going back and layering on what Alex was talking about, it's going back to the basics and practicing not just high-tech medicine but also concurrently high-touch medicine where you know who you're treating. And then this other, the moral obligation and the ethical obligation that Alex was talking about. To me, if I don't have that ethical responsibility to my patient, that's the day I'll get replaced by a computer algorithm, right. And so, to me, it's really important to separate out the options that patients have available to them. And separate the options from the opinion that we have. What is our expert opinion based on, clinical practice and conferring with other colleagues and people come to us for our expertise. So if we withhold expertise and let them do their own thing in an unformed fashion, I don't think you're doing anyone any favors. But I'm curious to see what you guys think about that.

Eric: Well I mean, I think that's great. Medicine, though, is ... in palliative care, we're moving more and more towards measuring things so if it's high-touch, next week there'll be a quality metric on how many times I touched the patient. Be constantly touching them.

Lynn: Ew.

VJ: Hashtag MeToo.

Lynn: Exactly.

Alex: Let me say this, I think the holy grail that... from putting on the researcher hat. And the research community in palliative care is developing a metric for goal-aligned care. We don't have this metric. We don't know how to develop it. We don't know how to assess it. But I think that's what everybody's after because at its heart, right, as Diane Meyer's says, palliative care is about lining treatment with goals. But how do you measure that? I think that's a challenge for our research community at this time. But you can see how that goal is very individualized.

Eric: I'm just going to go back to the article, sounds like the UK is a little bit ahead. Even if the metric of preferred place of death may be suboptimal because it's just one thing and I think we can argue about preferred, in the context of their care and everything else, but at least it's something that we can see, is the care aligning with their preferences?

Alex: Yeah.

VJ: I'd say that it would be hard to compare UK with US because of the health care system being so different. So a preferred place of death might make a lot of sense where they have universal health care whereas, though we have the affordable care act, there is much more work that needs to be done here, so it's very easy to ask patients what their preferred place is but it may not always be feasible. For example, many patients will tell you when they are, especially when they are of the young old, right, from 65-74, they'll be like, "I never ever, ever want to be in a nursing home". But then we know that reality is not always that easy. So in one sense, unless until we have healthcare systems in place and we want people to be able to die at home, how are we going to support them? Where is the workforce that is claimed to be able to do that? That's a whole separate issue and without that, it's almost unfair to compare ourselves to the UK in the sense that we don't have that infrastructure, the way seem to do.

Eric: Well I was actually shocked in your article that more people in England die in the hospital and die in nursing home ... more people die at hospitals, not in nursing homes than in the US. What's going on there?

VJ: Alex and I had the "ah-ha" moment, that was exactly right so we actually reached out to Christian and Jane and asked, "is this really true?". So, Alex, if you want to talk a little bit about what you did after that?

Alex: That’s absolutely right. We were surprised about that too and they said, no, this information is correct. There are a high proportion of people who are dying in hospitals in the UK and I think that's part of the driving factor by making preferred place of death a quality metric because so many people prefer to die at home. But as we've said earlier, they may have other priorities that are higher. The system is aware that deaths at home are less expensive than deaths in the hospital.

VJ: I think you put your finger on the most important point here, Alex, in the sense that the elephant in the room is, what is the cost, right, of all these procedures? The cost of providing care at the bedside, the home health aide cost and who is going to foot that bill. Because we look at ... every year, now you have this report that comes out saying the health care costs are escalating and so there is this collective national anxiety of who's going to pay the bill. And listen, until we take a good hard look at where's all this money going, and where should we redirect it in a way that we can provide preference sensitive care, I think it'll be hard to solve it. You know we could think about metrics but unless there's a system change, what we measure is going to keep telling us that what we are doing is not exactly ideal.

Eric: Yeah, the last thing I have, just that I want to hear your opinion about, is this like the good death also seems like, to me, is a concept rooted around, ways people died 20 or 30 years ago. Where death was rather quick versus now where, we have an aging population, where multi-morbidity plays a larger role. Where neurodegenerative diseases like dementia, where people ... the process of dying is no longer over days or weeks, or even months, it may be over years. And just focusing on one thing, where someone died, misses the whole point. Like Joan Teno's work on how the hospital, our medical system just churns people through. We can get the home but they may only be home for like three days. So, I just want to hear your opinions on that.

VJ: Two comments. One is to think about, when does dying begin? Right, what does that mean? When is that process for a given patient and are we prolonging life with quality or are we prolonging the dying process and then bringing the patient into that. So, that's one aspect of it. And then, the work that MedPack is doing with post acute care, looking at all the aspects of on all the organizations that provide care, so when hospitals discharge patients quicker and sicker, where do they go and making everyone sort of accountable, I think that's a great step in the right direction.

Alex: Yeah, and just to build on that ... I think actually, the Age and Aging editorial does an even better job than we do at hammering on this point, that the demographics of dying and the end of life have changed. And the system, as you said, is antiquated and is constrained around this old sort of dying trajectory of cancer. People have an acute illness and die. But, it is not, it is not set up for older adults with multi-morbidity, with frailty, with disability, with dementia, cognitive impairment who are experiencing a much more prolonged trajectory of symptoms, of suffering, of need for assistance with daily activities. And that we need a massive reorganization of services to deliver palliative care to the population that needs it most and our systems, as they're currently set up, for providing care to those patients are wholly inadequate.

Lynn: I'm still thinking about the trainees.

VJ: Someone has to Lynn.

Lynn: I'm thinking about it because I think they're the ones who end up feeling this tremendous stress of our system that can't deliver the things that they really want for their patients. And I worry, a little bit, that if we sort of take away this idea that there can be a good death, that they'd need more concrete guidance. The people who are doing the front line care, at least in the academic hospitals, need to have a little more simplicity and sort of, what to be focusing on for their patients.

An example being, an intern can have a patient who is on "comfort care" in the hospital and they can really easily know how to avoid tests and interventions for that person. But I observe them really struggling with the patient who might be in the hospital and have frailty and ADL, need for ADL support and maybe they have pneumonia and they want to try to get through it but they don't want you to do too much to them. Keep them as comfortable as you can doctor while they're here. People really struggle with those in between situations where, in fact, the preferences are really personalized and unique. And I find that that's really hard for learners.

Eric: Response?

Alex: Well, I'll respond by saying ... I think med students are capable of tremendous complexity and-

Lynn: I'm not saying… they're simple minded.

Alex: But I think our system has trained them to appreciate complexity in immunology. Complexity in neural function and cellular pathways. But we haven't done a good enough job of teaching them the complexity of social interactions, individual preferences and how to communicate with patients in order to elicit those goals, values, and preferences to align treatment with those goals. And how to align treatment when those goals ... when it's complex. When the focus is on preserving function, not preserving life at all costs or preserving comfort at all for all costs.

Eric: Well said.

VJ: Yeah really well said. I would add to that and say, I mean Lynn I think you raise a really good point in how does one teach this in a way that people are not really confused. And how do you teach this to a medical student who is taking care of a patient in the medicine wards for the first time. To me, it's a zoom in, zoom out approach. I think we do really well with zooming in. You know, chase the pathology, get the blood cultures. Give the right antibiotic, look at the map and send the patient to the ICU.

We do really well with zoom in and intensity. But I think what we don't teach as much is the zoom out and put this patient in the context of their life trajectory. For example, things like, how old were your parents when they died? Who do you know in your family who has lived beyond a certain age. Some very simple questions that will allow us to do some prognostication and then be able to say okay, for this particular episode we will zoom in. But then I also want you to give me a zoom out plan in terms of what you want to do and when there's conflict between the zoom in and zoom out, that's where the uncertainty is. So, I don't know if that answers your question at all a little bit, but ... and I'm glad to redo this if I need to Eric, but tell me if that makes sense.

Eric: We never edit any of our podcasts.

Alex: Yeah what are you talking about?

Eric: Well, with that VJ, I just want to thank you and Alex for being on this podcast.

Alex: Thank you VJ.

Eric: As well as the authors of the Age and Aging paper, Christian Pollack and Jane Seymour and my co-host today Lynn Flint.

Alex: Thank you Lynn.

Lynn: Thank you.

VJ: Thank you.

Eric: Alex, do you want to send us off with a little song?

Alex: Sure thing. [Singing]

Alex: Alright, that’s enough of that.

Eric: Well, I want to thank all our listeners for joining us on the GeriPal podcast. This podcast is coming out during the American Academy of Hospice Palliative Medicine, AAHPM, HPNA and SWHPN Meeting in Boston. So we all look forward to seeing everybody and on Thursday, if you're in Boston, we have our annual Pali-Med-GeriPal party that starts at 9 o'clock. You can hashtag HPM party to see where we are at.

Alex: Bye folks.

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