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Palliative care on the front lines of COVID: Podcast with Darrell Owens



Many of us with clinical roles are waiting for the other shoe to drop.  Today we hear from Dr. Darrell Owens, DNP, MSN, head of palliative care for the University of Washington's Northwest campus, a community hospital in Seattle.  The UW Northwest hospital has born the brunt of the COVID epidemic in one of our nation's hardest hit areas.

Darrell has stepped up the the plate in remarkable, aspirational ways.

First, he is on call 24/7 to have goals of care conversations with elderly patients in the emergency department under investigation for COVID who do not have an established a code status.  On the podcast Darrell walks us through the language he uses to speak with these patients about the poor outcomes of CPR and ventilation among older adults with COVID.  We note on the podcast that the Center to Advance Palliative Care recently put together Toolkit for COVID including a thoughtful communication guide spearheaded by Tony Back and our friends at VitalTalk.

Second, Darrell has established an inpatient palliative care service at his hospital for patients on exclusively comfort measures.  Darrell and his team admit and are first call for these patients.  This service off-loads the hospitalists so they can care for other patients.

Darrell talks with us about the challenges of titrating medications for symptomatic patients when you're trying to minimize using protective equipment going in and out of the room, and the challenges of returning home from work to his family after treating patients with COVID all day.

By closing let me repeat two things from the podcast.

First, we too can and should step up to the plate.  By engaging patients in goals of care discussion at the time of admission we are likely to help patients reach different decisions than they otherwise might have made had discussions occurred with rushed and less skilled clinicians (i.e. the usual code status discussion).  Before we get to rationing, we can and should engage patients in the highest quality informed goals of care discussions.  The results of these informed discussions are likely to decrease the need for scarce ICU beds and ventilators.  That is why Darrell is specifically on call for these conversations.  Simply put, we do it better.  We have the best skill.  Further, like Darrell, we too can create or expand inpatient palliative care services to provide the best possible care for these patients and free up hospitalists and others to meet the growing clinical needs due to the pandemic.

Second, Eric and I have never been prouder of our fields.  Every day we hear stories of geriatricians, palliative care clinicians, and bioethicists rising to the occasion to meet needs of this moment.  As Eric notes, we will found out a great deal about ourselves and what we stand for these next few weeks and months.

Thank you for all that you do.

-@AlexSmithMD



  


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TRANSCRIPT

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: And we today, we have joining us from the state of Washington, Darrell Owens, who is section head for palliative and supportive care for the University of Washington, Northwest Campus. Welcome to the GeriPal podcast, Darrell.

Darrell: Thank you very much, glad to be here.

Eric: So we're going to be talking about your experience with COVID in Seattle, part of our COVID series. So for those who haven't seen our first podcast on basics of COVID or rationing during pandemics which is our second podcast, this is the third on our series.

Eric: Darrell, before we go into the topic, we all start off with a song request. Do you have a song for Alex?

Darrell: I do. I would like the song, "I Believe."

Alex: Great. Thank you for introducing me to this song.

Alex: (singing)

Eric: Darrell, can I ask why you picked that song?

Darrell: That song came to me based on I had a patient last past November that was planning her own memorial service. And it was a very special song to her, so I went and looked it up and it really rang true for me and I just really loved it ever since.

Eric: I wanted to start off because I think a lot of, in places like San Francisco where me and Alex are at work, we're waiting for that other shoe to drop. They're in the midst of it, a good several weeks ahead on that epidemiological curve. I just want to get a sense, what are things like for you right now?

Darrell: I'm part of the University of Washington health system. We're a three-hospital system. The University of Washington Medical Center is a two-campus system. So I'm on the community hospital campus for there and we currently have the highest number of COVID cases within the university system, and the second highest within the Seattle area.

Darrell: This morning, the daily census show that we had 24 COVID cases in-house, four of whom are in the ICU. And so it certainly is not business as usual. The census in the other hospital has otherwise gone down for the traditional ... We're not doing any surgical cases, no elective cases and we have no visitors so it's a very eerie and weird place.

Eric: What is it like for the palliative care service right now?

Darrell: So the palliative care service is just myself and a registered nurse. We underwent a downsizing some couple of years ago. And when this was coming and we started to see what was happening at the nursing life care center across the lake from us, I decided that with our leadership that palliative care needed to pick ... and so what that meant was looking at data for who was doing well, who was not and how I could best support our hospitalist. We are the smaller team.

Darrell: And so it's an integral palliative care. I'm an integral part of the team here, part of the hospitalist team, part of the ICU team and have been an active part of the COVID response.

Alex: What are the major changes that you've made in place to handle the clinical workflow and to deal with the COVID response?

Darrell: So the first thing that we did was implement an emergency room palliative screening process. So together with the emergency room folks with the hospitalists, we looked at the data that we have available from Italy, from China and from what the CDC has to see what those outcomes look like for those who are not surviving.

Darrell: And so depending on the data you looked at, it's generally the 60 to 65 and older with underlying health conditions. What those underlying health conditions are, we still seemed to have a lot of uncertainty but because those are the ones who are at greatest risk for perhaps non-beneficial treatment such as CPR at the time of death or intubation. And again, for frail folks to begin with, anyone over 60 underlying health problems who presented to the ER needed a palliative care screen.

Darrell: And so if someone presented to the ER already and they're code status was documented as DNR/DNI then they go on to a screening list that's a watch, an observe and watch. And for those who were determined to be full code or a lack of code status documented which has been a painful experience just seeing and being reminded of how often it's not documented for frail elders anywhere.

Darrell: And so if they're full code, then that requires an immediate screen and then I see them in the emergency room. And we have an abbreviated goals of care discussion at that time. It's very proscriptive. I explained to them that we don't have the results back. This is where the suspicion is. The emergency room physicians have already told them this, and we talk about the outcomes for heroic interventions in the event that they are determined to be COVID positive and so we talk about what we can do and what we can't do.

Darrell: To date, I have screened 39 folks through the emergency room. Not all of those required a conversation because they came in already with their code status fully addressed as DNR/DNI. But probably 25 to 30, we've had that conversation. It's a 24/7 access which has been somewhat draining but incredibly helpful because, one, we're addressing code status for a group that has overall poor outcomes for heroic interventions anyway such as CPR or less so perhaps with mechanical ventilation.

Darrell: But people are very thankful and thoughtful about their answers and their responses and thus far our ICUs have been available for people that need them. We have the capacity and that has been a really critical aspect of this response is that integrating palliative care into the ER. And that works here because we're a community branch.

Eric: And how long ago did you start that?

Darrell: About five years, it feels like. Really, I think it's been about 10 days. Maybe close to 14. I have lost a little track of time there but it's not more than two weeks.

Eric: What motivated you? What was the thing that you said, "I need to do this?"

Darrell: Because we have a pretty valuable role to play and I am very close with our hospitalists. And I was also very concerned about utilizing resources for people at the right time and we already struggle with a system that is a see-more, do-more, bill-more system and that model doesn't work. It doesn't work for the frail elders to begin with. And it doesn't work in general.

Darrell: And I thought we need to have upfront conversations but these conversations can't be the traditional, "Now, tell us what you'd like to do if your heart stops, if that stop working?" This is not the time and so while hospitalists and emergency physicians are all used to having these discussions and we all know that they come with a varying skill set and their ability to do them that why not have the people that do them routinely help out their team by having these conversations because this is what we do.

Darrell: And so I really felt like this was a way to ensure that we had to the extent possible bed space for those who would need it and their patients and families would be informed about what was going on and what the choices that they might make could may or may not help them or may actually harm them. So that's the first thing.

Darrell: The next thing that I did is take over the care of all comfort care patients. So we have stopped admitting inpatient hospice patients. We work with our community hospice providers to do general inpatient hospice on a time but right now, we just can't convert those people to inpatient hospice that brings in another set of staff to our hospital that brings in outside hospital or outside hospice staff. That means they're using our PPE. That means more exposure.

Darrell: So right now we're not admitting hospice patients. And generally, the palliative, I admit all the hospice patients anyway, but what we decided to do is anyone who's transitioned over to comfort care for any reason will be managed by the palliative care service.

Eric: That means you're going to be writing orders for them, you're going to be doing the day-to-day rounding on them?

Darrell: That is right. That is right. And I already do that for the hospice patients. I'm the admitting provider for the hospice patients. We manage them anyway. And so to offload the hospitalists and free up more time on their panels, then palliative care folks can manage comfort care patients. We can do that in our sleep practically not to minimize it, but that's what we do.

Darrell: And so to say, all right, well, the comfort patients come on to my service. That's daily rounding, that's daily orders and that frees up the hospitalists to be more available to handle sicker other patients. And that's the second thing we've done here.

Eric: Can I ask you? Let's go back to sleep. What do you do when you're asleep? Let's say you go home, are you signing these patients out to other teams that you're managing or you're just taking everything by call? And who else is helping you?

Darrell: And so, after-hours calls, there's the night hospitalists by routine will take any of those calls but I think that you know that after-hours comfort care patient calls are pretty minimal. If you're managing in the daytime, that's a pretty minimal call at night other than if there's any ... They call if there's a death.

Darrell: So that's not much work, but it is daily rounding. And right now, because visitors can come in for comfort care patients, we do allow two visitors to come in. Some have opted not to so that is a daily call. So the registered nurse on my team is making the daily calls and while she works here in the hospital with us, she's a 10-year seasoned hospice nurse so she's quite comfortable with these conversations. She's quite comfortable so families are getting an update every day because of the fact that many of them just don't want to come to the hospital, they're afraid. And so that's also been a help.

Darrell: Additional support, well, I am now taking Mondays off so this Monday, it will be the first day that I will take off out of the hospital. We have a couple of very experienced surgical nurse practitioners that are currently not doing anything. They are not working, one of which has many, many years of experience in neurosurgery with goals of care classification, those kinds of things.

Darrell: And so she's going to round for me so I don't have to come in to do rounds. And the pager will be forwarded to the registered nurse on our services pager so that she can kind of triage those incoming calls. And then if there's an emergency department screen issue that comes up, we'll sort through and see what that looks like.

Alex: This will be your first day off in quite a while then?

Darrell: About 30 days.

Alex: Whoa. I just want to reiterate just for our listeners, summarize the major changes so they can think about starting these in their own institution. And the first is that you go in, you're on call 24/7 to have goals of care discussions for people with suspected COVID or COVID positive seen in the emergency department who are older and have chronic conditions and have not engaged in these discussions previously or do not have an established code status.

Alex: And then the second piece is that you basically ramped up your service obligations for those people who are hospitalized on comfort care where you were the primary team caring for them. And, yeah, does that about capture it, Darrell?

Darrell: It does. It absolutely does. And again, it doesn't feel ... I mean, again, we're not a UCSF or we're not our main Montlake Campus. We're 150-bed community based hospital and it works. It works for us. The volume is not, for me, I have ... Today, we started the morning with four comfort care patients. We have one last hospice patient. That will be our last one until we decide to bring hospice patients back in again.

Darrell: I've had two deaths this morning and so that's a discharge summary and that's rounds. That's call to the family, and then you have your routine palliative care consults which are down during this time period because our census is down in the hospital. So is it a stretch? Yes. Is it a significant stretch? No, not right now. And that's why we keep thinking, "Well, when does the other shoe drop?"

Darrell: We have occupancy ability. We have beds available but the important thing is we have staff ready. We have hospitalists ready because they have more capacity because palliative care of myself is picking up the patients that we can manage that frees them up.

Eric: I'm not sure if you thought about this already and I certainly hope it doesn't happen, what's your plan if you get sick?

Darrell: So one of my colleagues from the Montlake Campus, so that's our other campus, has gotten emergency credentials here of palliative care position who's been credentialed here, oriented here. Even though we're one hospital, two campuses, we still have some integration issues, but yes, there's a backup plan. He would assume the responsibility here.

Eric: And for the COVID patients that you're seeing, are you doing anything differently? I heard some people are thinking about using video conferencing into the rooms or maybe deciding that they don't have to see them every day? Are you doing anything different?

Darrell: So I would say that it's brief, the encounters are brief. I'm still going into the room to see them because for our hospital, they're behind wooden doors. So there's not a window that we can ... In the ICU, obviously, it's a different story. But when they're out in the acute care, they're behind wooden doors.

Darrell: And so I feel like going in is an important piece. That's probably more my need than theirs. I openly admit that, but we are very strictly supervised. We have what we called Dofficers. These are nurses who have been redeployed from surgery, recovery room, et cetera that what you don and what you doff your protective wear. And you have to buzz in and out of the room and it's a very strict and good process. So I feel okay about that.

Darrell: I did struggle early on with our first two people with COVID that were transitioned in the comfort care. We were utilizing heated high flow for them which does require airborne precautions. So that's an N95 or a PAPR process. And so the issue was now we're going to wean them off of the high flow and we're going to do this with them behind the wooden door.

Darrell: So normally, we might follow up, let's start with the nurse will be in the room. We'll give some PRN. We'll see how we do. We'll start a slower titration but that's really exposing a nurse every time you go in and out for one to try to get PRN medication. Two, you can assess as frequently because they're behind the wooden door and one of them was an opioid-naïve patient, so I really struggled with that.

Darrell: And I talked to my colleagues over at Evergreen Hospital, my palliative care colleagues over there. They took the brunt of the initial life care center patients and said, "I feel like we have to start a low-dose opioid on these patients continuous infusion," because the risk is, one, I send a nurse in there repeatedly with increased exposure risk, and two, the patient has a terrible death because we don't assess them enough.

Darrell: On normal circumstances, I probably wouldn't start a low-dose opioid drip for titration of a high flow but we made the decision to do that at a very low dose hydromorphone infusion and it actually worked very well. And the patients were able to be very comfortable. But it was a struggle for me to start an opioid-naïve patient on a hydromorphone infusion. But the risk is that they die terribly.

Darrell: So we looked at it and we're treating it as if we were doing a ventilator withdraw and that kind of made it more sense.

Eric: Are you changing any of how you're managing symptoms like that based on trying to minimize the amount of times that nurses go in and out of a room? I saw one place where the infusion machine is actually outside of the room and the tube is just running under the door and through the ... Are you thinking about that?

Darrell: I'm not. I don't know if anybody else is.

Eric: No, not that part but just thinking about changing around how you deliver or dose medicines.

Darrell: Yeah. So there's a lot more scheduled, the schedule of medication versus PRN. I tried to space it Q4 to Q6 and then the other thing is that the nurses have kind of blessed me with the code to adjust dosing on the pumps, and you know that's a sacred blessing. And so that if I go in, and the patient clearly needs to be uncomfortable and there needs to be a dosage titration, normally you'd go back out. You tell the nurse. The nurse would go in and adjust the pump. Well, that's an additional exposure you don't need so then I'll adjust the pump right there. If there needs to be a titration, that's one less person going into the room. And now I have the codes to the pump.

Eric: And one thing we're trying to do in our service right now is really very mindful that the lack of visitors and even before this, families frequently feel like they're just not getting enough information. So we're trying to call family members frequently. Are you doing anything differently in how you're approaching family members?

Darrell: So, it's a lot of telephone, because normally you see patients when you round. You see the patients where the nurse will call and say, "Oh, the family is here," and you run over and say hello to them even if you've already rounded. But right now, it's so much more telephonic and we do let ... Again if you're on comfort care, you can have a visitor but again you're super ...

Darrell: If it's a COVID related patient, then they follow the same procedure. We did have visitors come in for the COVID patient but they have to be supervised so we make sure they don't break contact. And so they're supervised. They're assisted putting on their personal protective and then that takes up someone going in the room with them because the nurse is now in the room with them and it's limited to 15 minutes.

Darrell: Other patients who are not on any precautions, we're still limiting to two visitors and that seems to be ... All visitors are funneled to the front. They have to have their name listed. They have to give the screening so that hospital is essentially locked down and everybody is funneled through the front.

Eric: Are there like any really important lessons learned over the last 10 days, like, "Wow, I wish I knew this 10 days ago"?

Darrell: So not necessarily a new lesson but a reminder that, again, people don't document code status anywhere. And so you spend so much time looking through the chart of this 88-year-old with advanced dementia and there's not a code status conversation or documentation anywhere to be found, or if it is, it's hidden. And so that's been brought much more to light for me. And we all knew that that was a problem but this is really a problem when you're trying to address this now.

Darrell: And I think the other thing that 10 days ago I would not have thought that these conversations, that people are so open to these conversations when we have these advanced care conversations and it kind of flows as part of a consult. But people really are open to them.

Alex: Darrell, I wanted to pick up on that thread about the communication, the conversations. I think it's just truly remarkable, Darrell, that you stepped up to the plate in having these conversations in the emergency department, and this is sort of reflecting on our last podcast with Doug White about rationing ICU beds. Before we get to rationing as we said in that podcast, there are so many steps that we should be taking to ramp up the supply, our surge capacity, to engage patients in advanced care planning in the community.

Alex: And what you're doing here is really engaging patients right when they're seriously ill and presenting in those goals of care conversations that are so vital because as you know, patients are remarkably open to these conversations and when you present them with information, they may make different choices than they would if it was just sort of ... If your heart stops, you want us to restart it or if you're short of breath [crosstalk 00:23:42] ventilator in the worst .

Alex: CAPC today released communication guide. They released a whole packet about toolkit for COVID-19. And one of those pieces that was led by one of your colleagues, Tony Back at the University of Washington, is a communication guide that includes a number of different aspects including how to respond to questions about, am I being rationed? Is it because I'm older? Is this because of my race or ethnicity? I encourage our listeners to look at that communication guide. We'll include a link.

Alex: I wonder if you have any tips, how do you approach a communication with the older patients that you're seeing in the emergency department? Is there a particular language that works well for you? How are presenting the prognosis?

Darrell: So after they call me and they get screened, these are all either confirmed or they're ... I've had a couple of confirmed positives and then the rest are rule outs. So I go in. I explained that I'm from geriatrics and palliative care and that I'm part of the hospital's COVID response team. And so I'm here to kind of talk to them about how COVID may or may not apply to them. And I acknowledge that you've been tested. That's what they came in and tickled your brain with that swab, that they put up your nose. And here's what we know.

Darrell: And I said, "I wish I wasn't having this conversation with you. It's a very difficult conversation and I don't mean to scare out by the fact that we're having this conversation, but we really need and here's why, that what we know from the people, in experiences of the people in China that people have the experiences in Italy and what we know in the United States is that you are in an age group with some underling health problems that if you are tested positive for corona, that there's a very high risk that things will not go well. And we know this because four people in the other population, sometimes depending on what you read, up to 80% of the people who did die from this disease were in the same category you're in."

Darrell: "And so I want you to know that we are going to continue to do everything we're doing now that we don't know if you're in this category or not but we are going to take care of you, but in the event that something catastrophic happens, our ability to have success with things like CPR at the time of your death is really minimal. And so at this point, it's not really something we recommend because it's not something that we know thus far will be successful in helping you to continue to survive."

Darrell: And then it's the same thing with the respiratory issue that, "If you have trouble breathing or you start to struggle and your breathing starts to fail, we will keep absolutely take care of you. We'll absolutely give you oxygen but if we have to put this tube down through throat and into your lungs and attach you to life support, those are the people we also know have not done very well in terms of survival and in fact, very few of them have survived and the ones that have, have been younger. And so we should talk about what your preferences are."

Darrell: And that's how I say it and it's ungodly because you're in a mask behind a shield. They're at a mask. It's a reverse air flow room in the emergency room, so it sounds like you're outside with a jet engine running and these are frail elderly people that have hearing problems. I have hearing problems, so it's less than ideal but it's been incredibly successful because that's what people hear.

Darrell: I think what we've seen in our other institutions is that it's a two-step process. Palliative care has to step up but your colleagues have to be willing to let you step up. So this represents a change in practice because I am to be having the goals of care. I'm the one that's supposed to be having these conversations if you screen positive. And this has come from leadership that really in this situation, we want Darrell from palliative care to be having these conversations because he's got the scripted language. He's got a very supportive way of doing it and it's just better all the way around for the patients and families.

Darrell: And so that's the struggle for some hospitalists and for some emergency medicine physicians to say, "Well, I do goals of care. I've always done goals of care. Why would I not?" And then you were also getting the, "We're going to rule them out for COVID but I think it's very low likelihood, so we don't need to have Darrell see them." It's like, no, we're seeing people that I would have sworn looking like death were going to be COVID positive and we're not. And other people who were just ... They had a little bit of diarrhea, maybe a fever once are positive.

Darrell: So we don't have good predictive value about ... Sure, their chest x-ray has got the ground glass and there are some other things. But that's not the way to do it. Your gut reaction of ... I don't think it's a low level. I think that more reflects our colleague's discomfort when having these conversations than it does because nobody has enough information to be able to predict if someone is going to be positive or not.

Eric: How long has it taken you to see a test result there now?

Darrell: I think it depends on the day of the week, like I got a test result back this morning from somebody last night. I have somebody from yesterday afternoon at three, I still don't have the test results back. So, I don't know. That's a good question. It's no more than 24 hours but why are some longer than others, that's a good question.

Eric: That's great. A lot of places ... I know somebody who just got tested and they got a word back that it would take five to six days for it to come back. So it's so variable right now.

Darrell: Inpatient is different but I mean, I don't know about outpatient. I only know inpatient, and that's 12 to 24 hours.

Eric: I got to say, when I hear your story, I feel so very proud to call you a colleague and to think about all of the amazing things people are doing out there right now during this time of crisis. What's it like to go home after doing all of these? Are there other people at home that you're worried about? How are you navigating that?

Darrell: So, my husband is a police officer. We have a 17-1/2-year-old who is not going to school right now. And so he's used to what dads do. He's used to our jobs and that but there's questions. So immediately you go home. You take off your clothes in the garage. I go right in. I take a shower and I change into other clothes. Do I need to do that? I don't know, but I'm doing it. And then we have family dinner every night and with the 17-year-old, my day was fine onboard which is pretty good. That's just much as you're going to get, COVID or no COVID crisis

Darrell: And it's interesting because he has said, "Are you careful, dad? Are you safe, dad?" And of course, I am, but then I watch TV but we're social distancing. He's in his own world doing his own thing anyway. And then we actually are sleeping in separate bedrooms and I think in part because I never know when the phone is going to ring and wake people up, but maybe it's just my piece of mind.

Darrell: I've had friends of the family have baked cinnamon rolls, three dozen of them. One of my son's prior school teachers that I've brought into the different units here and other family friend baked cookies. So I just put a sign on them that says these are donated by friends. I've seen their kitchen. I know it's clean and then people eat them all.

Darrell: But I can't really say what this is going to be like. Do I really wind down? I don't think so. The first time the other day was the most difficult time. A gentleman, he's under the screening age, and lots of family members that were positive and the ER felt like it was a good idea for me to see anyway because of the high risk. And it was a horribly tough conversation that it was one of those where I'd literally walked out and I felt like I wanted to throw up.

Darrell: So I mean I think that's ... Yeah, I don't know. Like I said, we're all waiting for the other shoe to drop. We have capacity, and I think it is because we're prepared. We are prepared. We have that space.

Eric: Given that, if there are two or three things that every palliative care team out there should do right now to prepare, do you have two or three things?

Darrell: Yeah. You, one, expect that it's not business as usual. Very first thing, you're going to have to do things differently, so be open to that. Be totally open-minded. Now the old, "We're not an admitting service or we don't do that and we don't do this," don't start with what you don't do. Start with what you can do, what's your capacity. I think that's important.

Darrell: Next, make sure you've got working relationships with whoever is a primarily admitting and managing COVID patients. This has come up with one of our sister hospitals where they've done ... The palliative care did some work in the emergency room and then pulmonary critical care said, "Well, why on earth would we make this person DNR/DNI? We've got plenty of resources right now. And those are the patients that if they crash and you tube them, you're going to consume resources and be committed to consuming those resources for a long amount of time. You had 70-something year old, pulmonary fibrosis, now COVID positive on a vent.

Darrell: So our colleagues have to think differently too. We have capacity right now but if you start not screening and you wait until you're overwhelmed and then decide to involve palliative care, that's not good. So you should have a solid relationship with your intensivist and your hospitalist.

Eric: Yeah, I like that point. I mean it just highlights also the fact if you have these conversations even outside of pandemics, people often ... Not often ... People frequently may not want the default that medicine defaults them to. And even in the states of non-rationing, like you're in right now, you're not actually rationing healthcare, lifesaving treatments. It's still important to have these discussions and to create structures like you are to actually do this proactively.

Darrell: Yeah. And you know the sad thing is that while there's been no resistance from the patients when we've had these conversations, the resistance has come from some of the colleagues, "Well, why would you make them DNR?" It's like, "Wait, they're okay ... Whose need are you meeting here? Why do you need this person to be full code? We need to address what your issues because the patient is okay with it." So I think that that's the challenge too. And so I think people come to the table with who they are.

Alex: Yeah. I want to ask ... I have one more question. My last question is, one the topic of rationing, the greater good of society, the public health ethic saving the most lives at this time in this state of emergency, does that ever come into individual conversations? And my question is, do you ever bring it up or do patients ever bring it up in the sense that are you doing this because I'm old or you're rationing? Or do they ever say, "Hey, save that ventilator for somebody younger and healthier. I've had a full rich life and I know that I ... I understand I won't do very well, on a ventilator," for example?

Darrell: So I think part of the conversation is always that people in this age category based on the evidence we have, have not done well. So that's a pretty global kind of piece, people in your age category, I should say. I have never said to this point where we feel like it's probably a good idea we conserve these resources first. I've never had to say that but I had someone, a person in her 90s who clearly after having these conversations said, "Well, why in the hell would you do that to me anyway," a whole kind of, "I don't want that."

Darrell: So she was along the full lines and I've had one other person say, "I would never want CPR if it was going to risk exposure of me getting someone else sick especially if I had died and they were doing CPR to try to bring me back." And he brought that up on his own because we know that CPR would be a horrible exposure, that you're going to increase your risk of staff exposure during the cluster of what is the code. And so only two people, one in her 90s who was somewhat joking kind of saying, "What, are you kidding me? Why would you do this?" And the other one who is much more altruistic saying, "No, I wouldn't want to expose anybody for that."

Eric: Darrell, any other things that you'd want to say to other palliative care teams right now?

Darrell: That Again, when you step up to the plate, it depends on your relationship with your hospital. But not everybody is going to be ready for you to step up to the plate. So you may have to be a little more assertive in saying we do have a role here to play and here's how we can help you with that. So I think people should realize there will be some resistance in some institutions. I am blessed there has been none at this campus. But I know that within our own system, there has been and I anticipate there will be.

Eric: Last question from my end, for those patients that you used to admit for hospice, do you know what's happening with them right now?

Darrell: They just stay on comfort care. I mean these were conversions. They were in the hospital and they would convert to hospice. And so now, they just stay on comfort care.

Eric: Okay, I get it. So instead of having a hospice team come in, they're staying on comfort care.

Darrell: Yeah. And for the sole purposes of really decreasing exposure to hospice teams and PPE conservative.

Eric: Well, Darrell, I want to thank you very much for joining us. Again, I am just I've never been prouder just to be part of this community hearing what people are doing. I want to thank you for that and all the amazing work you and your team are doing and your hospital is doing too.

Alex: Yeah. Thank you for sharing your story, Darrell.

Darrell: Yeah. And I can't say enough. I work with the most incredible group of people. It has just been ... They're just awesome. I'm proud of them as well.

Eric: Well, maybe Alex can sing them a song. Alex, do you want to give us a little bit more of that?

Alex: (singing)

Eric: Darrell, again, a very big thank you for joining us. To all of our listeners, please be safe out there and really, if you're part of a palliative care team, think early about how we can actually step up to the plate and follow leads like Darrell out there. I know I'm thinking about that. And thank you to the Archstone Foundation.

Alex: Thank you, Archstone Foundation.

Eric: Goodbye, everybody.

Alex: Thank you, Darrell. We appreciate it. Take care. Stay safe.

Darrell: Yes. Thank you very much.



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