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The State of COVID19 in Boston: Podcast with Zara Cooper, Rachelle Bernacki, and Ricky Leiter

In today's podcast we talk with Zara Cooper, Rachelle Bernacki, and Ricky Leiter about the state of COVID at the Brigham and Women's hospital and Dana Farber Cancer Center in Boston.  While they have flattened the curve somewhat in Boston, they're still seeing huge numbers of seriously ill Covid patients in Massachusetts.  They have 143 out of their ~1000 bed hospital filled with COVID19 patients, including 78 Covid patients in ICU, many of which are followed by palliative care.

This has resulted in the need to drastically restructure the palliative care team, including:
  • Embedding palliative care in the ED.  They quickly found that if they waited for consults, they got not calls, and had to proactively go out and find consults in the ED.  By demonstrating their usefulness, acceptance has increased.
  • Embedding palliative care in the ICU.  These experiences are hard.  Zara Cooper, who works as an intensivist in the ICU (as well as surgeon, as well as palliative care doc, as well as researcher, as well as superwoman) relates the ethical dilemmas and moral distress associated with providing care in the ICU.  Ricky Leiter talks about how hard it is emotionally for the palliative care teams, how the cadence of our usually palliative care consult becomes compressed in these cases, and how their teams are dealing with the challenges of prognostic uncertainty, video meetings, and not being able to see patients in person.
  • Their first instinct was to protect the fellows from COVID19 patients.  The fellows rebelled.  They wanted to be involved, and now they are, and are functioning as an integral part of the response.
All of this and more, including forgiving yourself if due to these extreme circumstances you can't give "gold star" palliative care, but maybe "bronze star" is enough?

Links

1. Pallicovid.app.  Functions as both a mobile app and a website that can be accessed from any smartphone or desktop computer. Salient features include: one-page quick guides on opioid dosing for treatment of acute pain and dyspnea when transitioning to intensive comfort measures conversation guides and videos for difficult conversations across settings (e.g. rapid code status determination in peri-intubation situations, talking about dying in the ICU, etc.) tip sheets for outpatient care, including remote filing of MOLST forms and outpatient resources for elderly and at-risk populations how to have difficult conversations with family members (i.e. "What do you mean I'm not allowed to visit my [mom/dad/grandparent]?") end-of-life nursing care clinical guides and FAQ's and much more!

How to install the www.pallicovid.app as an app on your phone:

  • Android phones: The first time you access the website, you should see a pop-up prompt to install the app to your home screen. 
  • iOS phones: Go to the website on Safari, hit the "share" button, then tap "Add to Homescreen." From there, the app will install and function like a native app 


2. Covid Protocols https://covidprotocols.org/ This document and policies described were prepared by and for Partners HealthCare medical professionals; made available publicly for informational purposes only, in the context of a public health emergency related to COVID-19.

3. Ariadne Labs COVID Response Toolkit https://www.ariadnelabs.org/coronavirus/clinicalresources/covid-conversations/ Ariadne Labs’ Serious Illness Care Program developed a COVID-19 Response Toolkit to support health systems and clinicians in addressing the communication needs of patients in the community and those in the hospital. The toolkit also includes resources for patients to begin having these conversations with people they trust within their support networks.

-@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 is on this call with us? We have a lot of people.

Alex: We have a lot of people. First, we'll introduce our other guest host, Nauzley Abedini, who is a palliative care fellow at UCSF. Welcome to GeriPal Podcast, Nauzley.

Nauzley: Thank you for having me.

Alex: And now we will introduce our guests. We have two returning guests from Boston. First, we have Rachelle Bernacki, who's Director of Quality Initiatives and Palliative Care at the Dana-Faber Cancer Institute and Brigham Women's Hospital. Welcome to the GeriPal Podcast, Rachelle.

Rachelle: Thank you so much, Alex. It's great to be here.

Eric: Were you going to say Dairy Pal? [laughter]

Alex: Dairy? Hey, cows need palliative care too, right? [laughter]

Alex: So then, also returning, is Zara Cooper, who's Director of the Center for Geriatric Surgery at Brigham Women's Hospital. Welcome back to the GeriPal Podcast, Zara.

Zara: Thanks, Alex. It's great to be here.

Alex: And first time on the podcast, we have Ricky Leiter who is a palliative care physician researcher at the Dana-Faber Cancer Institute. Welcome to the GeriPal Podcast, Ricky.

Ricky: Thank you so much. It's a pleasure to be here.

Eric: So, before we get to the subject at hand, we always start off with a song request. Who is the song requester, Alex?

Alex: Zara is the song requester.

Eric: Zara, do you have a song for Alex?

Zara: I do. I do. I would love it if you could play Lovely Day by Bill Withers.

Alex: And could you tell us why you're requesting this song?

Zara: I requested the song, because unfortunately, Bill Withers died recently, and ever since his death, I've listened to this song every morning, and it's helped me get a good start to the day.

Alex: Yeah. All right, I'm just going to play a snippet at the beginning, and then a little more at the end.

Alex: (singing).

Alex: I'm going to stop there. But we'll get more at the end. Lovely Day, Lovely Day, Lovely, Lovely Day. Great choice. Bill Withers, one of our favorites in GeriPal Podcast. We did Grandma's Hands a few episodes back. Wonderful tunes.

Eric: So this is, I think our eighth podcast. We're focused on COVID, and I'm starting to hear a lot more reports coming out of Massachusetts and Boston. Can you guys give us a heads-up? What's happen right now out there, and what are you seeing in your hospital?

Rachelle: Well, in Massachusetts, we have about 32,000 cases, and as of this morning, we had 12,045 deaths. We're one of the top, I think, four states, in terms of cases and deaths. We all work at Dana-Faber, which is a cancer center, and then the Brigham, which is a in-patient hospital that has about 1,000 beds. And today, we have 143 confirmed COVID cases, and 78 in ICU, and 65 persons under investigation, or PUIs, which is odd name. And of those ... Palliative care is involved with a lot of those, so we've actually done a huge amount of restructuring of our palliative care team to meet the needs, and I'm going to tell a story about Zara.

Rachelle: So when we first started, when this first started about three or four weeks ago, Zara instantaneously said, "Oh, my God, this is going to be really hard. We're not going to be able to see our patients and families. How are we going to do this?" And I, very blithely said, "Oh, we're going to be there with you, Zara. We're going to help you. Palliative care is going to help you shoulder to shoulder." And at the time, we literally had no plan.

Rachelle: And a week or two later, after huge efforts on the part of our team, Jane and Emilia, everyone in palliative care department reconfigured. And Ricky is actually the person that was on service with Zara last week, or two weeks ago, and was shoulder-to-shoulder with her at taking care of these patients. So I feel super grateful that I work in a place where that can happen. And it's been really hard to try to figure out how to make this work. We re-imagined ourselves about five times before we came to a stable place.

Rachelle: So the teams that we have right now, we have our regular palliative care consults, where the census is down, and most of that is happening via virtual consults, and there's about 20 patients there. In the ICU, the team that Ricky is leading were embedded in ICU, and were following 35 patients there. So about half of the patients that are intubated at the Brigham Palliative Care is involved with.

Eric: Can I just pause there for a second? So you said 78 ICU patients. So you're falling about a half. How many ICU beds do you usually have? Because that seems like a lot of ICU patients.

Rachelle: Yeah. So we have four ICU teams right now, and it's been climbing linearly, I'd say. And actually, for the last week or so, it's been hovering around 60. But I have to say, the ICU at the Brigham team and the hospitals teams have capacity to take a lot more than that, so we're already ready. We have MD teams at a ready to take more patients. Luckily, the growth hasn't been so ... I mean, we've had a fair amount of time to plan for this, so the growth hasn't been overwhelming. We've been caught off-guard.

Eric: When I look at the IHME model, again, everybody, there's a lot of stuff on whether or not we should trust these models. When I look at Massachusetts, it says that you guys are still two weeks away from the peak. Is that feeling that way, or do you feel like things are settling a little bit?

Zara: I can speak to that a little bit. As an intensivist, I can say that it does not feel like things are settling. They're getting busier. What we've done is, we've actually added five new ICUs to meet the demands of the epidemic. So we do have a huge ICU capacity. We also have a separate building called the Shapiro Center, where those beds are negative pressure beds, and they have the capacity to become ICU beds. And so we've transformed three different floors to become ICUs, to meet the demands of this crisis. So there's been a lot of physical and structural transformation to do that.

Zara: And the approach has been, as far as staffing goes, to actually increase the capacity of each ICU. So the census of each ICU, the limit, went from 10 to 15 and is now going to 20. So instead of opening additional ICUs or adding additional clinicians to each ICU to do that. And that progression has happened ... The rapidity with which that progression is happening is increasing.

Zara: So it is linear in the sense that we haven't gotten this huge tsunami that we have been expecting and prepared for, but it is definitely hard.

Alex: Mm-hmm(affirmative). And Ricky, can you give us a flavor from on the ground, in the ICU? What's it like to consult on these patients? What are the typical issues that you're dealing with, and how is it, day to day?

Ricky: Short answer is hard. I think we really have no idea what to expect when we started there. We're doing a lot of planning behind the scenes, and eventually I said, "Look, we just need to get in there." So one of our fellows and I just started. So we don't know what we're going to do yet, but we're going to embed ourselves. We're going to start talking to the teams, and start seeing patients and how we can help.

Ricky: We're doing primarily roles of care. Some end-of-life symptom management, but I would say, 90% of our consult at this point are for assistance with goals of care. And it's tough. I thing there are COVID-related communication challenges, and also clinical challenges. Communication, as you know, none of the family is there. So every one of our patients is alone in the room, and we're calling these patients' family members over the phone, having really hard conversations where we can't see them.

Ricky: Over the last couple of weeks, we increased our technological capacity, where we can do family meetings over Zoom and FaceTime and what have you. That has its own challenges too. But I think that's really hard in that family members can't see the patients. We can't really see the patients. We're not going to the bedsides. We're trying to preserve PPE. So all that makes it really tough. I think the technology, when it works, it's great. When it doesn't, it's hard. I think Zara and I did the first Zoom family meeting in the ICU, and it was challenging. Multiple family members wanted to Zoom in, they couldn't get on. There's just logistical challenges that ended up with one family member and in here staring at each other, waiting for everyone else to hop on, the first few minutes.

Ricky: So I think it took us a while to get into our groove and how to do these. But I think everything, communication is harder. We're trying to work with an interpreter and we're seeing a large number of Latin Mexican patients who speak Spanish, and so it's challenging to loop in an interpreter as an added ... Just to add difficulty there.

Ricky: And then I think clinically, these are really sick patients, and many of whom weren't sick beforehand. These aren't the patients who have cancer who've been in and out of the hospital for months and families have heard that they've been sick before. We are delivering a lot of bad news, and trying to have goals of care conversations at the same time and that makes it challenging. And then on top of that, I think that the level of trauma and emotion is something that I wasn't expecting. So we've had now two couples who I'm taking care of, married couples, who have both been intubated, doors apart, in the ICU.

Alex: Oh, my gosh.

Ricky: And it's terrible. And I think, talking to the family member, the daughters ... I can't even go there. I can't think about the hard things. And how could you think about the hard things? So I think that was something that surprised all of us, or struck all of us at first, and I hate to say that we've gotten used to it, but we've come to expect that type of story when we're consulting on these patients.

Alex: Wow.

Ricky: Yeah.

Alex: And when you first said that the level of trauma, also trauma, I'd imagine to the providers. I mean, do you worry about how you're going to come out of this, or how other members of the team or the fellows are going to come out of this too? Is this just devastating? New England Journal paper recently about resident experience in Detroit. We've seen more death in the last two weeks than we've seen in our entire lives.

Ricky: Yeah. I think we're all worried about it. We're spending a lot of time in our group debriefing the difficult cases, spending time talking with each other. And I think Zara and I had an experience on that same family meeting once we got it up and running, where the patient's son felt guilty. He's the one who got sick first, and so he felt like he had given COVID to his mother and his mother was going to die and it was his fault. And he said over and over again, "She's going to die, it's my fault. And I'd seen the pictures from New York, with the bodies being put into trucks, and that's what's going to happen to my mom."

Ricky: And there were four palliative care trained people on that call, and I think none of us knew how to respond to that in that moment. So I think it's hard work, and we're all trying to process it together, and I think it's going to be an on-going project going forward.

Alex: Mm-hmm(affirmative). Thank you for sharing that story. Rachelle, I know that you were talking earlier about how you were going to ... how you reformatted the service, and it took you deep into the ICU. Are there other aspects you wanted to get to about the service?

Rachelle: Yeah. So in terms of hospital medicine, I think we've had long-standing relationships with that group, and we integrated with them. We run our list with them every day, and that works pretty well. But the place where I would think it's been the most challenging is in the emergency department. We have really tried to come up with a structure to help them, and we came up with this GeriPal COVID pager to screen patients, and we tried the for a week, and we never got a call. So we were like, "Okay." So Lynn and I work with a really talented PA named Leah Namara, and she is now trolling our emergency room department list for people who are over 70 and maybe came from a nursing home, or have dementia, or have other functional decline, and then we're proactively reaching out to those clinicians in the emergency department and asking can we talk to the family. And that has actually worked pretty well.

Rachelle: We've done about 20 of these so far, and we had I think a really good impact. I think the emergency room clinicians are ... Of all the clinicians, I think they're most stressed. It's been really, really hard for them. By the time they get to ICU the patient already has a trajectory. And after the ED, they're sorting that all out and trying to figure out how we can be most helpful to them has been a work in progress for sure. We did a education session yesterday with the PAs over Zoom, and my first experience doing Zoom rooms, and drills. And it really worked. The PAs said, "Well, I wouldn't necessarily say that emotional response in response to a question about information. And I was like, "Yeah, so why might we think about doing that?"

Rachelle: So that's been really fun, and I think hopefully, meaning full. And yet the challenges of working there are so great that I don't think we ... I just want to be perfectly honest. We don't have it figured out yet, how the best meet the needs there. It's pretty hard.

Alex: Yeah. And you weren't really in the emergency department much before. Is that right?

Rachelle: No.

Alex: This is a frontier area, and you're trying to ramp up the whole service in there. Our first podcast about COVID was with Daryl Owens, and he talked about how he was on call 24/7 for his small community hospital in the Pacific Northwest Seattle area. But he had robust buy-in from his emergency medicine providers. In his case, the challenge was more the hospitalist group had trouble with him having the goals of the care conversation.

Alex: Sounds like in your case, it's the opposite. You get a lot of acceptance in the wards and the floors and the ICU, but the emergency medicine, they didn't call your pager, even though it was called the GeriPal pager, which is a great name for a pager. So it took some work of case finding. You have to be proactive. And maybe that's a lesson for our listeners.

Rachelle: Yeah. Yeah. That should be.

Nauzley: Rachelle, I'm actually just curious, in that same vein. I know you said this is still a moving target to figure out how to be most helpful, but are there some pearls or some key things that you've taken away, in terms of things that you've learned are helpful?

Rachelle: Yeah. So I think emergency department clinicians pretty protocol-driven, so we came up with a guide, and I do think that having structure in times of high anxiety is helpful. So we've been promoting that guide. There's a real tension, because we haven't used it that much, and I don't know if it's actually tested yet, but it seemed to work. I used it on a patient, and it was actually a patient who was around the time of intubation, had the opportunity to talk with her sister, and talk about whether this was really what we wanted. I think one of the lessons for me has been really creating a space to really deeply listen to a patient's family.

Rachelle: So this patient's family said to me, "Dr. Bernacki, I just don't understand why we need to intubate her right now. I don't understand that." And so that really led me to dive in and think about it together with the ED and that patient never actually ended up getting intubated, and is hopefully getting discharged soon. So that's been a real lesson to me, and I think the other piece of that story that I like is, I think when you're working with a new group, instead of trying to tell them what you can do, you have to show it. So you show, not tell.

Rachelle: And so that patient, where I think we were helpful in the emergency department attending, felt like it was very useful, and then communicated that to the rest of their group. So I think that's one lesson for me. I think that's the best way to get in and get recognized. And at the same time, I'm still hearing that there's still difficult situations, where they feel like they could use even more help. Like when someone comes in and they're really short of breath, they've never had a conversation about intubation before, and maybe the patient has a lot of core morbidities or is very frail, and they feel like they can't really have a good conversation if we're not always right there in the ED.

Zara: And I think, speaking of the client, I would say that having Ricky and his team there as the constant presence, or knowing that he was coming at a certain time every day, we were just on the list. And we would run the list, and he would tell me the patients where he thought he cd be most helpful. And I think that really that constant presence that Rachelle over promised in the beginning was incredibly meaningful. When I was in ICU attending, even being somebody who can have these conversations, and has palliative care training, having, as cliché as it is, that added layer of support for us, for the nursing staff, somebody to communicate to the patients more richly while I was running and pruning somebody. It was incredibly helpful. But that constant presence ... The problem with a pager or something like that is, it requires this activation energy that you just don't have when you're constantly running from crisis to crisis.

Zara: And so that's why I think Lynn's approach of really identifying the patients proactively is incredibly helpful. Because when you're just trying to make sure that somebody's not hypoxic, you're not always thinking about that, even though that's what's actually causing everybody the more of the stress.

Alex: You know, we talked to Daryl Owens and Jim Wright. Part of what was heart breaking there is, they were one of two people doing all of these goals of care conversations, and Jim going seven days a week to the ED, just phenomenal that he was doing it. You guys, you have a deeper bench, but I can imagine that sooner or later, that bench starts to thin. How are you thinking about your GeriPal work force in meeting this demand?

Ricky: We've thought a lot about it, and I think ... And this relates to Nauzley's question to, is when we started, every week, so Rachelle mentioned that you kept blowing up the service. So two days later we said, "It's not going to work." We scrapped everything and we did something else. And then we said, "Well, what we're doing now, it's not scalable." So we got really nervous about it. We eventually said, "You know what? That's okay. It's okay that it's not scalable, because it works today. We don't know what the census is going to look like tomorrow or next week, or two weeks later. But if it works now, let's do it as long as it's working, and then think about what we're going to do when the census creeps up."

Ricky: So, the leadership of our group has been just absolutely phenomenal, as Rachelle has mentioned, in thinking through how best to use our bench. So we have ... On the ICU team, we have four or five clinicians, and I'd say three of the five are in-house every day, and then there are two virtual backups, who can do the family meetings from home over Zoom, or over the phone.

Ricky: And that model that in-house people, plus the virtual backups, is what we've done across the service. So our regular consult service, the ones who are seeing the palliative care patients who are still in the hospital, are, I would say 90% virtual right now. They're doing all of their work from homes. And we're really drawing on all the resources that we have and trying to use everyone on our bench as best as we can.

Alex: Mm-hmm(affirmative). It's great. Nice to know. Eric and I are doing ... We are the virtual backup for Colombia in New York, and we're taking care of a very elderly, sick woman in the ICU there and having family meetings with her daughter and granddaughter. Also with a Spanish translator. I want to come back to you, Zara, and talk more about what's it like to be an intensivist, and what sort of challenges you're facing in that role as you're ... You're trained as a surgeon, intensivist and in palliative care. What has this been like for you?

Zara: It's been ... It's a different disease. That's what has really struck me in taking care of these patients. Before I went on the unit, I refreshed about ARDS and all this stuff, and what I've come to appreciate is that there are some nuances here that we really don't understand yet. And that when we were in medical school, we learned about all of these diseases because people before us had all this experience, and then they wrote books about it, and they could tell us, "This is what you expect." And here we are with an entirely new illness.

Zara: And there's definitely stuff that we can take from our prior learnings, but there is also stuff like Rachelle mentioned, with respect to timing of intubation. Over time, we are starting to reconsider that. I think I was one of the intensivists to open up one of the early units, and so we were 2-4-6 intubate. So if you got to six liters after that, we were going to intubate. And now what we're realizing is actually, some of those patients who are on seven to eight liters who are doing okay, they don't need to be intubated.

Zara: It's not pervasive, but it's hard to get a sense of the rhythm of this illness, and so that's been really difficult. And the other issue is that from a palliative care standpoint, the whole thing has prognostic uncertainty, right? I mean, nobody knows. This disease was discovered in humans less than six months ago. So everything we're doing is, we're really all still flying by the seat of our pants, so there's really no data to guide us. But I'm also struck by, from a geriatric standpoint, there's actually a lot of data to guide us, and I feel like we're not using it.

Alex: What do you mean?

Zara: What I mean is that we know that an 85-year-old who has multiple core morbidities, who already had physical disability and functional impairment is not going to do well after they've been on a ventilator, paralyzed and prone for four or five days. We know that. And it has nothing to do with COVID, it has to do with the way that we're treating the disease. And so I think one of the major challenges that I've found, and it actually caused me a great deal of moral distress, is that we're almost forgetting some of the things that we've learned from Loren Ferrante's work and all the great work that's in EL by Tom Gill's group about course of older patients after critical illness. And we need to really, instead of just saying, "We have no idea how this is going to turn out," I think we actually need to apply what we do know about how some of these folks will do, after surviving critical illness.

Alex: Yeah. And apply it in terms of the conversations you're having with family about what to expect if we continue with this current trajectory.

Zara: Exactly. And also in thinking about goals of care. Thinking about goals of care because one of the major communication challenge is, we've said it before that the family can't be there, but it also means the family can't see. And so as an intensivist, one of the things that I struggle with is that the ICU is like a foreign land to people. They really have no idea what to expect.

Zara: And now it's even worse, because they really can't see the machines, and they can't hear the beeping, and they can't see the four or five people coming to turn their loved one. They can't see them in a coma, they don't see all the visual and auditory cues that we rely on to say, "Hey, this isn't going well." We don't have any of that feedback for them. And so it really is having discussions with them in a complete vacuum, which is really challenging.

Alex: No, I can imagine, just talking to others who are in the thick of things, that one of the struggles that we face, doing palliative care consultations is, we generally ... I mean, the mantra is that we don't go into these conversations with agendas, but when you're in the thick of things, when you're in that setting, you see somebody decompensating, you see the people are starting to talk about CVVH and all of these other things in this this person, where the outcomes, while may not be certain, are certainly getting pretty darn close, where ... And that we also are also worried about, not just potentially our safety, but the safety of the teams doing things like CPR, that it's hard to hold on to that mantra of, "Don't go in with an agenda." How are you guys dealing with that?

Rachelle: I think I can take that one. I struggle with this. I just want to name it, really struggled. Our team, especially seeing patients on the floor, it was really hard, because our normal way of doing palliative care consults is to get to know the patient, understand what they want, and then later make recommendations. And there's a way that, in this circumstance that can feel like you should be making a recommendation earlier, potentially, for DNR or not incubating, and this is one of those times when I feel like our team really sat down at the end of every consultation, did this quality improvement process with the conversations, and, "Did that feel right? Was that the right thing to do?"

Rachelle: And so I think where I came to, at the end of, it was just done and pass off the service to Josh this week, is that we did make recommendations. We said things like, "Most patients get better on their own." Because a lot of the patients I'm seeing on the floor and a couple of liters of oxygen, but at the same time, I know they're really frail, because we've done a really good functional assessment, and I'm really worried about their long-term outcome, and so we have been saying this. I hope they continue to do well, but I'm worried that they could get really sick really quickly, and may even die from this, and then sometimes need a recommendation, and what I found, and often like Ricky said, most of our conversations have been through interpreters, adds another layer of difficulty and complication. A lot of the patient family members that we're talking to were saying ... Because a lot of our patients also had concomitant delirium, were saying, "I hear what you're saying, Dr. Bernacki, but they're not that sick right now. And so I prefer to keep them full code or whatever"

Rachelle: And actually, the way I have come to frame that is that we're providing some anticipatory guidance for preparing people for just in time decision making, like Rebecca Sudore talks about. And so we have had a number of those patients. And then later in the course of their hospitalization, they compensate. Some of them have done well and gone home, and that's been great, and some of them have not. And then a part of ... We've been changing the page, or the page has been pretty busy, so every night, we change to a different attending, and a lot of the ... The teams will page and they'll have conversations, and for most of those patients, they've converted to intensive comfort measures. And I think ... I've come to actually talk to my mom about this, but even though these conversations are incredibly hard, I think there's a way that we're helping to prepare people for what might happen. But I have to say, I felt conflicted about it, and I actually reached out to Muriel Gillick this week, because I felt like I just wanted to talk with her about, is this the right frame? Is this the right way to think about doing this? And it was actually really therapeutic to do that.

Alex: Mm-hmm(affirmative). What did she say? We had Muriel on the podcast before, by the way, she's a great thinker.

Rachelle: Yeah. She was so thoughtful, and one of the ... She was really worried about the nursing homes, extremely worried about that, but I think what I also wanted to hear is, I felt like there's a need from a geriatric perspective to feel like you're doing the right thing, you're doing ... And so she offered some fine tuning and things like that, but overall, that felt better, because I think there's just a huge amount of, even though we've done all of these things, we have a deep bench, we have a lot of resources, I just want to name that it doesn't feel like enough. In a rel deep way, that's hard. It's really hard, though.

Nauzley: If I may actually ask a little bit more about that, I've heard now from all three of you that moral distress is really something that's coming through, and being in this uncertain time certainly amplifies that, and I'm wondering ... In some ways, it's almost like we as palliative care have to turn the mirror onto ourselves and palliate ourselves in this process. And I'm wondering, how are you doing that for yourselves?

Ricky: Yeah. I think it's a great question. I think a lot of it is what Rachelle said, and we're doing ... We've done a similar think on the ICU that she's been doing with the hospital medicine and the ED palliative care team, which is regular debriefing. I mean, we've been sitting in a room together having this conversations, each one of us trading off who's leading. And then after each one saying, "Did that feel okay? Did I push too much? Did i go too far? Did I not push enough?"

Ricky: There was one day where I had ... Our team collectively had six hard code status end-of-life conversations in a row, and for t first time, we all walked out shell shocked. And then on my way home, I called one of my mentors and I said, "I don't know if I'm doing the right thing here. Is this right? Am I overstepping? Is this what I should be doing in palliative care?" We talked about each case, and it was. It was appropriate in each case.

Ricky: But I think that Nauzley, you're right. We need to look at what we're doing. And I've been saying jokingly, but I think the message is important, is that those little voices in our heads, that cause us to question what we're doing, are super, super important these days. Because there's so much uncertainty. This is uncharted territory for us, and we should be questioning what we're doing. And I think that will save us from looking back and doing things when we look back two weeks from now, two months from now and say, "Wow, we got that completely wrong, because we were in the thick of things, and we couldn't just come and see our blind spots.

Ricky: So I think the more that we can be very introspective, and then also debrief with colleagues and check ourselves, the more deliberate our practice is going to be at the more ... We protect ourselves against really sticky ethical lapses going forward. But it's hard. It's really, really hard.

Alex: Mm-hmm(affirmative). And just to name explicitly what you're talking about, the moral distress, if I'm understanding you correctly, is primarily feeling like we pushed pretty hard for a DNR in this case, and we're not sure that's the right thing to do, because there's so much uncertainty about the potential outcomes. And we're presenting a very grim picture of what the future might look like for a person who's full code, and I sick with COVID. And yet we don't really know. We have a lot of data that pushes us in that direction. We have data about older adults to a disability, et cetera, that pushes us in that direction. But like you all said, we have that data, and yet we have ... it's still early in the process. Is that what you're talking about?

Ricky: Yeah, I think that's right. I mean, for a lot of these patients, I felt comfortable with the medical outcome. I think for someone who has ARDS, who is not oxygenating well, despite being proned and paralyzed, that has been in the ICU for seven days, getting worse, we have a good sense that CPR would not be medically beneficial for them.

Eric: It's certainly not going to be better than the grim statistics of in-hospital mortality. Like the data coming out of Wuhan is that two out of 100 ... Wait, four out of 120 people were alive at 30 days after cardiac arrest in the hospital. That's a pretty ... Again, it's early data, but it just goes to show you that we do have some, and especially for frail older adults, we have some before COVID that also it can be reasonably applied.

Ricky: Yeah. And I think Eric, you're ... I'll give a shout out to your Twitter story the other day about prognostication in COVID, which we circulated among our group, and among some of the ICU clinicians as well. It was really helpful, so thank you for that.

Eric: And if anybody is interested, we also created on the GeriPal webpage, we have a COVID prognosis page now that includes prognosis for individuals in the ICU, the data that we have so far, and the data that we have with cardiac arrest.

Ricky: Yeah. So I think some of the moral distress is related to uncertainty, but some of it is that we are making stronger recommendations earlier in conversations than we normally would. It doesn't feel like our standard palliative care cadence. It feels a lot more heavy handed than my typical practices, than all of our typical practices. And that's what I think has led to a lot of distress among our team.

Alex: That's a very eloquent way to put it.

Zara: I would say the other side of that, when I was signing the unit to one of my colleagues, I'm signing on our list and he's like, "What are we doing?" So there's a flip side to that moral distress, where Rachelle will get a call from an ICU attending, that, "What are you doing down there in the ED? Why are all these patients coming up full code? Why are they coming that way?" And it's because there are these varying phenotypes. And I think that there's been a lot in the media, rightfully so, about these young people who we see, who have had nothing to precede this, and then they get this life-threatening illness.

Zara: But there are also a lot of folks who have other medical problems that are baseline and are really making it difficult for them to recover. So I think there's moral distress all around that. And then of course there's the moral distress, and I think to what you're talking about, Ricky, is this vacuum where ... Again, as I mentioned, the families are operating without their normal cues, but we're also operating without our normal cues. We can't actually go in and see the patient. We make no connection with them. We don't have that physical assessment.

Zara: "Have you examined my mother? Have you seen my mother?" Well, sort of. Through a glass door for about two ... It's really difficult. And then we also don't have the family at the bedside to help us better understand where this person gets into their social structure. So I think everybody is just feeling really discombobulated right now, because all the things that we normally rely on to tell us where we're standing aren't there.

Alex: Mm-hmm(affirmative).

Rachelle: I had a interesting experience of feeling stuck in the middle, and I'll explain it, but our ICUs, they know me. One of the things that's really important, at least for me, has been having this long-standing relationships. So I'm calling with a transfer to ICU explaining that I had this conversation and I understand that this patient prognosis is really important, but at the same time, at the other end of the phone is this healthcare proxy I'm talking to via an interpreter, and they really feel very strongly that this patient go to ICU.

Rachelle: And so I've never felt squeezed by both sides so much before. It's been ... That piece has felt really challenging. And I can see it from both sides. One of the other things I'd say about these debriefings is, the importance of hard conversations between our tri state colleagues, where someone's really digging in, and I'll just give an example with Josh. Josh and I had a great relationship, but I'm describing this and he's like, "Why are you saying that? Are you worried about resource allocation and ..." To be honest, I'm not really worried about standards of care, but he's pushing me to say, "These are the reasons why I think I think this is the best course of action, and really defend myself, and I actually really appreciate that.

Rachelle: In the moment, it can feel incredibly hard to be pushed that hard, but actually, it allows you to sleep at night, then say, "Okay, yeah, that was really good. I talked it through. And even with that, I still have these nagging ... I have patients where it's just so hard. Had a patient on Easter who was in the hospital, and his wife was ... They both had COVID, and one was dying and they couldn't be there with each other. And the feeling like there's not ... Whatever we do, it's not enough in those kinds of situations. That's the heart-breaking part.

Alex: Yeah.

Nauzley: Yes, I'm hearing you all talk about this. I'm hearing you say that not only is the practice of palliative care right now not feeling normal, but it's also just everything else is not feeling normal as well. And I'm hearing this from experienced clinicians, and putting on my fellow hat, which I wear very well. I'm wondering how it's been for your learners on your teams, and what you're doing to help them think about the fact that this is not normal. Because I could also see it going the other way, where they may be imprinted with this non-normal way of practicing. How are you guys thinking about that, and dealing with that?

Ricky: Yeah, I think it's been tough, and also we're at a stage in the year where they're ready to fly, and I think the inclination at first, about all of us was to say, they're our fellows, they're our learners, we got to protect them from this. We got to protect them from everything that's going on. Let's maintain some [inaudible 00:43:00].

Ricky: And they said, "No, no, no, no, no. You're not going to do that to us. We want to be in there. We want to be in there with you doing this work. And so they're in it with us. At this stage, they're acting like essentially attendings. We talked about how we're deepening our bench. They're right there with us. So I think that they've been on the front lines in all of our services, integral parts, and I think that the fellowship directors, have really taken the approach of, let's show them how this is working. This is like ... I hate to say anything in a pandemic is an amazing opportunity, but there's a way that they could see how a service can restructure, and really dig into that in a way that they wouldn't be able to do in other circumstances. So they've been involved in every aspect of our division's response, right from the beginning. And we're spending a lot of time debriefing with them, checking in with them, and I think that they ... At this stage in the year, they have a sense of what the gold standard palliative care is, and they understand that this is not that, and also how to adapt under these circumstances.

Ricky: I can't say enough about how they've been doing. They are just amazing.

Eric: Well, I'm wondering, as far as the last question is, maybe if each of you have ... We have a lot of listeners who, like in San Francisco, we're waiting. We're waiting for something to happen, potentially volunteering. So if you could give us a tip or a lessons learned, maybe one for each of you, could be either of that. Maybe Zara, we can start off with you.

Zara: I'm just smiling, because I was hoping I would go last.

Eric: I figured Z always goes last. I wanted a reverse alphabet. As somebody whose last name ends with W, I feel-

Zara: Yeah. Well, I guess one thing I would say is, this probably won't surprise anybody, we haven't been quite that introspective with our learners, so that's one thing I've learned in surgery, maybe we should do that a little more. There's a lot of ... We cannot help but use this as a learning opportunity. And I have actually ... It has been an incredibly affirming and valuable and meaningful and rich to be shoulder to shoulder with so many different types of clinicians and learn from them in this very multi-disciplinary way. Because we're all just right there right in it.

Zara: And so I think approaching it with openness and curiosity, honestly is really the best approach here. I think the only way that we're going to get better is if we acknowledge where our gaps in knowledge are. And so I think that's one thing. It's just, don't ... No matter what you read, it's going to be wrong two days later. Whatever protocol you memorize, it's going to be different tomorrow, and so you just got to be prepared to keep up.

Zara: And then I think the other thing that I would say is to try and pace yourself. And I think this is such an emotionally wrought time for everyone. We didn't even begin to talk about the fact that, forget about our professional careers, personally, we are also living through this pandemic, and each of us have our own issues that we have to worry about with this, and everybody that you're with, it's not just you. It's as if everybody that you're working with is grieving. Everybody. At the same time. And so we have to have tolerance, we have to have patience, we have to have respect and appreciation in order to get through this together. And I really think that that is critically important. And I've been really, really, really ... Heartened doesn't even begin to do it justice, but really gratified to see that.

Eric: Wonderful. Ricky, how about you?

Ricky: Yeah. I would say, I sent a text to a colleague in another city, who had [inaudible 00:47:14] like, "Man, can I ... I'm not going to get gold standard palliative care can I just get bronze standard palliative care? Would that be okay?" And I think reframing our expectations of ourselves. And Rachelle mentioned earlier, that it just feels like we're not doing enough. But to constantly remind ourselves that we are doing the best we can, and that's still pretty good.

Ricky: We are still helping families, we are still helping our clinical colleagues. That's okay. We're not going to be able to give the palliative care we're used to giving, but we're going to do the best we can for as long as we can, and that's okay.

Eric: All right, Rachelle. You're talking to 2019 Rachelle Bernacki. Tell yourself what to expect.

Rachelle: So one practical and one sort of more spiritual. The practical is, we have a pallicovid app. It's been so helpful because the number of requests for education and videos is just astronomical. It can feel completely overwhelming, and so that's been super helpful, and we've had a lot already prepared, so that's one thing.

Rachelle: And then the second piece is, at the end of my time ... Madeline wrote this beautiful piece, best response to disaster is resilience. And I just love this quote. When asked about outlook and world affairs, I reply, I'm an optimist who worries a lot. These are not the best of times, but they're not the worst either. It might do well for us to view these abnormal days as an opportunity to ask more of ourselves. And that to me was really inspiring at a time when I felt really tired. And I think it really pushed me through the next teaching session or consult, and so just to be ready for that, the resilience piece, and Zara mentioned it as well, is really important. And then, being forgiving. I love Ricky's bronze standard.

Rachelle: I think we have a lot to offer here, and we are hoping to make this a little bit better for our patients and families and ourselves.

Eric: Mm-hmm(affirmative). I truly want to thank all of you for everything that you're doing, and for joining us on this podcast. I think for me personally, I find it incredibly helpful just to hear what people are going through. It relieves some of my anxiety too. I think the hard part that we face in some of these cities like San Francisco is, it's this waiting. It's this, "Is it going to happen?" And also this feeling of, and we've talked about this before in other podcasts, of the survivor guilt. Of feeling like things are kind of slow here, but elsewhere, they're getting hammered.

Eric: So I really just want to thank you. Maybe Alex, you can end a little bit more with that song.

Alex: A little bit more of this song. Thank you to all three of you. Really appreciate you being on the podcast.

Alex: (singing)

Eric: Thank you, Alex.

Alex: Yeah, need a little of that. I agree, Zara. In times like these.

Eric: I got to say, despite some of the heart-breaking stories that we're hearing from you, you've just made my day that much more lovely, so Zara, thank you for joining us. Ricky, big thank you.

Zara: Thank you.

Eric: Bernacki, it's always great to see you again.

Rachelle: Thanks, guys.

Zara: Yeah, thanks for having us, guys, that was really fun.

Ricky: Thanks so much.

Nauzley: Absolutely.

Alex: And thanks to Archstone Foundation, thank you to all of our listeners. Make sure to like us on whatever app you're using to listen to us, and spread the word. We will see you next time. Thank you.



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