Smilow Shares with Primary Care: Palliative Care

Transcript

• 00:00Hi everyone. Thank
• 00:02you for attending tonight. We're
• 00:06excited to have our palliative
• 00:09care team and as part of Smile
• 00:13shares with the primary care.
• 00:15This is a series that Karen Brown and I
• 00:19really have developed and lots of people
• 00:22have helped with to really focus on.
• 00:27The perspective of of of cancer
• 00:30and and palliative care,
• 00:32cancer and cancer and palliative
• 00:36care services for patients.
• 00:38And let's see,
• 00:40let's start with the slides please.
• 00:47And just so you folks know,
• 00:50if you ever, if you or other
• 00:52people want to access these
• 00:54afterwards there's a YouTube link.
• 00:56And actually we've been having lots
• 00:59of folks access those earlier or
• 01:01earlier lectures that we've had.
• 01:03So next slide please.
• 01:08As many of you may know this is a
• 01:11monthly lecture series that focuses
• 01:13on primary care perspectives
• 01:15and cancer and and hematology.
• 01:18We love having our faculty
• 01:21panel with featuring featuring
• 01:23primary care and our smilo.
• 01:25And other experts and we try for Tuesdays
• 01:29the first Tuesday of the month, 5 to 6.
• 01:33Again, you can access these afterwards.
• 01:36And while there are lots of
• 01:38different venues that can teach
• 01:39you about cancer topics,
• 01:41this is really a case based
• 01:44discussion that highlights key
• 01:47key understandings and advances
• 01:49from the primary care perspective.
• 01:54Next slide, we are going to
• 01:58do some introductions and then
• 01:59we'll jump into our cases.
• 02:01We have some great ones today. Next slide,
• 02:06I'm going to introduce, oh,
• 02:07I'm a medical oncologist.
• 02:09I'm going to introduce Doctor or
• 02:11Karen Brown is going to introduce
• 02:12herself and then and then start
• 02:14out with our introductions. Thanks.
• 02:17Thank you. Thank you, Ann,
• 02:18and thank you to everyone joining as well
• 02:22as to the panelists who have prepared a
• 02:26really terrific session in primary care.
• 02:29One of our greatest challenges is
• 02:31caring for patients with cancer and
• 02:34the most challenging parts of that are
• 02:36when they first present and we need
• 02:39to make a diagnosis and at the end.
• 02:41In the middle, there's a lot of
• 02:44heavy oncologic care and they kind
• 02:45of know where they're going.
• 02:47So I'm especially looking forward to
• 02:50learning more today about how we can
• 02:53help them at the the end of their
• 02:55cancer journey or as they get more
• 02:57advanced in their cancer journey.
• 03:01I want to introduce my Northeast
• 03:04Medical Group colleague, Dr.
• 03:07Ola Rosinski.
• 03:09She received her undergraduate degree in
• 03:11Physiology and Neurobiology at UConn.
• 03:14She then went on to medical school
• 03:17at Yagolonian did I get it right?
• 03:20University Medical College in Poland,
• 03:22and she completed her residency and
• 03:24internal medicine at Saint Vincent's
• 03:26Medical Center here in Bridgeport.
• 03:28She was in academic medicine and was
• 03:30the assistant and then associate
• 03:32program director for Internal
• 03:34Medicine at Saint Vincent's and she
• 03:36was also the ambulatory Education
• 03:38Coordinator and worked on developing
• 03:40the ambulatory resident curriculum.
• 03:43We were fortunate that she joined
• 03:45Northeast Medical Group in 2019.
• 03:46She sees patients full time in New Haven
• 03:49and also teaches students in her office.
• 03:53She is well regarded by her
• 03:55patients and our medical community.
• 03:57And in her spare time,
• 03:58she likes to bake,
• 04:00and she's a history buff with an
• 04:02special interest in the ancient Near East.
• 04:05I'll pass it along to you.
• 04:06And for your introductions,
• 04:10am
• 04:14I on now?
• 04:16That's helpful,
• 04:17I'd like to introduce Doctor Morgan Bain.
• 04:20He's currently the section head for
• 04:23palliative care at Greenwich Hospital
• 04:25and former Professor of Medicine at Duke.
• 04:27He studied undergraduate at Wesleyan
• 04:30and got his Med school degree at VCU
• 04:33and trained at Norwalk Hospital in
• 04:37Connecticut in affiliation with Yale,
• 04:39followed by a Geriatric Medicine fellowship
• 04:42at the at Mount Sinai in New York City.
• 04:45He's board certified internal medicine,
• 04:48Hospice and palliative medicine
• 04:49and geriatric medicine,
• 04:51and he has many years experience
• 04:53of experience caring for
• 04:55vulnerable adults with lots of.
• 04:57Complex medical needs.
• 05:00His passions are patient
• 05:02care and medical education,
• 05:04and having taught hundreds of
• 05:06medical students how staff and and
• 05:09physicians throughout his career,
• 05:11next I have doctor Kristen Edwards.
• 05:15She's a a board certified physician,
• 05:17controlled medicine,
• 05:18Hospice and palliative medicine.
• 05:20She's the medical director of
• 05:22palliative care at Bridgeport Hospital.
• 05:24She manages all aspects of
• 05:25the PAL care program there,
• 05:27including clinical care education management.
• 05:30She's the site director for the
• 05:33Yale Geriatrics Hospice and
• 05:36Palliative Medicine Fellowship.
• 05:39She's an assistant clinical
• 05:40professor of medicine at Yale.
• 05:42And in 2019,
• 05:44she was actually awarded emerging Leader
• 05:46in Hospice and palliative medicine,
• 05:49a national award given every
• 05:51five years to 40 leaders in the
• 05:53field of palliative care.
• 05:54So fantastic work, Christian.
• 05:57And then finally Doctor Liz Persich.
• 06:00She's a physician specializing in
• 06:03medical oncology and palliative care.
• 06:05She received her medical
• 06:07degree from George Washington.
• 06:09University School of Medicine and did
• 06:12her residency and fellowship at Brown.
• 06:15She is certified.
• 06:17Also in sorry,
• 06:19she had a fellowship also at Brown
• 06:22focusing on end of life and palliative care.
• 06:24So she's double fellowship, Medoc and.
• 06:28Palliative care.
• 06:29She's an assistant professor at Yale.
• 06:31She's the director of adult
• 06:33inpatient palliative care at Yale
• 06:35New Haven Hospital and firm chief
• 06:37for for the medical oncology unit
• 06:39at Smile Cancer Hospital.
• 06:41And she's dedicated to serving patients
• 06:44with serious life or life limiting
• 06:46illness with complex medical needs.
• 06:49Difficult to control symptoms
• 06:50and supporting their caregivers.
• 06:52This is a just a terrific team
• 06:54of folks I've had the pleasure
• 06:56of working with and so really,
• 06:59really excited about the panel tonight.
• 07:01I'm going to turn it over to
• 07:04Doctor Rosinski to to start off.
• 07:12Good evening everyone.
• 07:14So let's get started case one.
• 07:17Is an 82 year old female comes to the office
• 07:21for an urgent visit regarding a lump in
• 07:24her left breast that she noted yesterday.
• 07:27Her last screening mammogram
• 07:29was 15 years ago.
• 07:31She doesn't have any pain,
• 07:32although it does feel tender
• 07:34when she presses on it.
• 07:36She has no redness, skin changes,
• 07:39****** discharge or weight loss.
• 07:42The exam is notable for a
• 07:44mass in the left breast,
• 07:462 by 4 centimeters in the
• 07:4911:00 o'clock position,
• 07:5010 centimeters from the ******.
• 07:52The mass is firm,
• 07:53with no tenderness of the mass itself,
• 07:55but there is tenderness of
• 07:58the surrounding tissue.
• 07:59There is left axillary
• 08:02lymphadenopathy present.
• 08:04Diagnostic mammogram and
• 08:06ultrasound were ordered.
• 08:08The patient herself is very afraid that
• 08:10this is cancer and that she will die.
• 08:12She says that she's not ready.
• 08:18So you order the mammogram and there is
• 08:21a 3.2 centimeter irregular mass with an
• 08:24indistinct margin and the left breast
• 08:27at the 12:00 o'clock middle depth.
• 08:30And the biopsy shows invasive ductal
• 08:34carcinoma poorly differentiated.
• 08:37The patient would like to
• 08:39pursue curative treatment.
• 08:41So how would you structure your
• 08:44conversation with this patient
• 08:46and would you even mention
• 08:48palliative care at this point?
• 08:57And to help us answer those questions,
• 08:59I'd like to turn over to my
• 09:02colleague, Doctor Edwards.
• 09:04Thank you. So couple things I think let me,
• 09:08can everybody hear me,
• 09:08okay, on this patient.
• 09:10You know really we're still trying to
• 09:12find out what is her prognosis at this point.
• 09:14I'm sure she's overwhelmed with
• 09:17emotions and really just trying to
• 09:19figure out what next steps are.
• 09:20So I think the conversation would
• 09:22really be a lot of listening and and
• 09:25I we're going to get to some of those
• 09:27communication pearls in my second slide,
• 09:30I'm going to tackle the first question,
• 09:31the second question first then,
• 09:32which is what I mentioned palliative care.
• 09:35I probably wouldn't mention palliative care
• 09:37in this particular interaction because again,
• 09:40it's very early and still trying to
• 09:41figure out what exactly is going on.
• 09:43And part of that is because of what
• 09:44the definition of palliative care is.
• 09:46So if you can, go to the next slide.
• 09:49So there are a couple of models
• 09:50out there for palliative care
• 09:52that are helpful to understand.
• 09:53Palliative care used to be
• 09:55thought of as very sequential.
• 09:57So the Top Model is what's
• 09:58called an integrated model,
• 10:00which was the new and improved
• 10:02way of thinking of palliative
• 10:03care about 10 to 15 years ago.
• 10:06Before that we thought of it really
• 10:07as all of these therapies to prolong
• 10:09life then almost a flip the switch
• 10:11and then there was Hospice which was
• 10:13approximately the last six months
• 10:15and bereavement care afterwards.
• 10:16And that was when the Hospice
• 10:18benefit was introduced in the 1970s.
• 10:20The integrated model recognizes
• 10:22that palliative care includes
• 10:24the end of life portion,
• 10:26but also includes all of these therapies
• 10:28that are geared at relieving suffering or
• 10:30improving quality of life along the way.
• 10:32Palliative care is the other part of
• 10:34it's really important to understand is
• 10:36that there's primary palliative care
• 10:37and specialty level palliative care.
• 10:39And so everyone who's on this call
• 10:41already does some primary palliative care.
• 10:44That is the the basic how do
• 10:46you deliver bad news,
• 10:47how do you have a serious conversation,
• 10:50how, what symptoms are you controlling?
• 10:52And so whether or not you referred
• 10:53this patient to specialty level
• 10:55palliative care initially,
• 10:57I'm not sure that I would introduce
• 10:58it in this particular conversation.
• 11:00If it came up, I certainly would,
• 11:02but and I would have that explanation that
• 11:04palliative care is an extra layer of support,
• 11:05but I wouldn't necessarily introduce
• 11:06it as the first thing on my mind.
• 11:08The second model that I think is important
• 11:10to understand is this other model,
• 11:12which is the bow tie model.
• 11:14This one came out in about 2014
• 11:16and it's one of my favorite models
• 11:18because it shows it's the same
• 11:20diagram but it shows how they overlap.
• 11:22And whether you look at it from
• 11:23a disease manager perspective or
• 11:25a palliative care perspective,
• 11:26you see that palliative care is
• 11:28much more than just Hospice.
• 11:29So in fact palliative care can be
• 11:31done even when patients are expected
• 11:34to get better.
• 11:35This this talk is obviously focused
• 11:37about patients with oncology,
• 11:38but we do palliative care in all settings.
• 11:40So we do palliative care for other disease
• 11:42serious illnesses and even include.
• 11:44Trauma, burn, etcetera, in which patients
• 11:46are definitely expected to get better.
• 11:48So it's someone who has a serious
• 11:51illness but not necessarily terminal
• 11:53illness and needs additional symptom
• 11:57management communication and goals of
• 12:00care decision making along that process.
• 12:02Can we go to that, my next slide,
• 12:04oh, oh, sorry, let me go back,
• 12:08let me go back to that one.
• 12:09The the communication phrases I'm going to.
• 12:12I think what I would focus on
• 12:14for this particular patient would
• 12:15be setting the stage for her to
• 12:17focus on specifically next steps.
• 12:18So one would be addressing the emotions
• 12:22and empathy and then helping her focus
• 12:24on truly what are the next steps that she
• 12:27wants to know about and how would she
• 12:29focus specifically on just the next steps.
• 12:31For the moment,
• 12:32I think my communication pros will come
• 12:34in after the next part of this case.
• 12:36So I'll I'll talk about that then.
• 12:41So we're going to continue the case.
• 12:43The patient afterwards underwent
• 12:45lumpectomy with lymph node dissection.
• 12:48She had 12 or 14 Sentinel notes
• 12:51positive for metastatic disease.
• 12:54About four months later,
• 12:56the patient really begins to decline.
• 12:59The work up at that time included a
• 13:01pet CT that showed avid mediastinal
• 13:04bilateral hilar and left internal
• 13:06mammary lymph nodes that were
• 13:09highly suspicious for metastasis,
• 13:11avid multifocal liver and osseous metastasis,
• 13:14lytic metastasis involving
• 13:16the right occipital condyle.
• 13:18Her daughters at this point are
• 13:20with her in the appointment,
• 13:21and I've heard that even with Mets,
• 13:24some patients can be cured.
• 13:27Her declining functional status is noted.
• 13:30She has by this point been spending more
• 13:33than half her time in bed during the day.
• 13:37So the question that we have is
• 13:39how do you transition her goals of
• 13:42her goals of care at this juncture?
• 13:45And I think Doctor Edwards is going
• 13:47to talk a little bit more about that.
• 13:50So if we could go to, yeah, so,
• 13:51so this is the slide that I'll walk
• 13:53through some of the communication
• 13:55tools and some of these would have
• 13:56been appropriate even in the first
• 13:58conversation that I had with this patient.
• 14:00So that's really important to recognize.
• 14:03You may have seen some of
• 14:05these tools already there.
• 14:06While we do think of them
• 14:08as palliative care tools,
• 14:08they're really just communication tools
• 14:10and some of them you will have seen
• 14:12in other forms that do communication.
• 14:14So whether it's leadership
• 14:15training or education or patient
• 14:18standard relation communication,
• 14:19you may have seen similar
• 14:21phrases that are used.
• 14:23So I'm going to go through each one of these.
• 14:24Some of these are what the I wish statements,
• 14:29I'm sorry the the slide I think got.
• 14:31Change. So the first one is
• 14:32actually supposed to read, ask,
• 14:33tell, ask and then the second
• 14:35one is I wish statement.
• 14:37So bear with me.
• 14:37It's not important for the slide but it does,
• 14:39it does matter in terms of the the terms.
• 14:41So ask, tell,
• 14:41ask is a way we think of
• 14:43structuring the conversation.
• 14:44So actually if you go back to
• 14:46that first conversation with the
• 14:47patient what you when you ask,
• 14:49you ask what they know and
• 14:51what they want to know.
• 14:52You wait for their answers and
• 14:54then what based on what they say
• 14:56then you tell them what they've
• 14:58asked and what the clinical update
• 14:59is and then you ask again.
• 15:01What have they heard so that you make
• 15:03sure that you have explained it well?
• 15:06What questions do they have and
• 15:08what else do they want to know?
• 15:11And the reason to do it in this
• 15:13structure is it really helps pace the
• 15:15conversation for what somebody can absorb,
• 15:17especially when they're overwhelmed
• 15:19with emotion in a first encounter.
• 15:21So if you think about that very
• 15:23first encounter when you met her,
• 15:24to help her focus on those next steps,
• 15:27I would have used an ask,
• 15:28tell,
• 15:28ask strategy to get through
• 15:31that conversation.
• 15:31The other comments tell me more is a
• 15:34good one to use when you're not sure
• 15:37what someone is saying or what you're
• 15:39there said something but you want
• 15:40to explore a little bit more what's
• 15:42behind the statement or the question.
• 15:44So simply tell me more
• 15:47and then the the next one.
• 15:48That should be an I wish statement
• 15:51or an I worry those two things
• 15:53I wish and then I worry we use
• 15:56I wish statements there to say.
• 15:58When someone is expressing something that
• 16:00you don't think is realistically possible.
• 16:02So an example would be I wish that
• 16:04we were going to be able to cure
• 16:07this cancer with more chemotherapy,
• 16:09and I'm worried that that may not be
• 16:12possible given your functional status.
• 16:15The When you combine them that way,
• 16:17it does two things.
• 16:18One is it,
• 16:19it reinforces the reality of what's there.
• 16:22It also with the I wish it
• 16:24aligns you with
• 16:25that person. And so it's really is empathy
• 16:28building and relationship building.
• 16:29The I worry part of it allows
• 16:32you to introduce some of the
• 16:33concerns that might come up.
• 16:35It'll like again allows you to
• 16:37empathize and to align yourself
• 16:38with that person and it allows you
• 16:41to introduce a little bit of the
• 16:43humanity of you as the clinician
• 16:44interacting with that patient as well.
• 16:48The next one here is we're
• 16:49in a different place.
• 16:50This comes from vital top training.
• 16:52I know Liz will certainly recognize that one,
• 16:55and that's.
• 16:56But this patient in particular,
• 16:57she may have wanted curative intent.
• 17:00You may have had suspicions that that might
• 17:01not have been possible in the first time,
• 17:03but it wasn't entirely clear.
• 17:05But then to say,
• 17:06I know we started chemotherapy
• 17:07or I know we wanted chemotherapy,
• 17:09we're in a different place
• 17:11now than when we first met.
• 17:13Let's talk about how we can
• 17:15still meet your goals here.
• 17:16It's a way to signpost that we're
• 17:18going to be transitioning to a
• 17:20different plan than we had before
• 17:22in terms of exploring goals.
• 17:23So when you do signpost,
• 17:25then we're we can transition.
• 17:26So what are you hoping for?
• 17:27Now that you've gone through some of that?
• 17:29Here's where we are.
• 17:31This is what's realistic.
• 17:32I like to ask what are you hoping for?
• 17:34It gives an understanding of
• 17:35what their values are.
• 17:36If time were short,
• 17:38I use were in this case because sometimes.
• 17:42Well,
• 17:42actually almost always planning for
• 17:44the future and putting some distance
• 17:46between you and the future is actually
• 17:48much easier for patients to to do.
• 17:50So if if you were to get sicker,
• 17:53can we talk about what you would want?
• 17:55It's often psychologically easier
• 17:56to discuss than if you do get
• 17:59sicker or when you get sicker.
• 18:01So that's a little bit of a a nuance there.
• 18:03And then the comment of what else
• 18:05are you hoping for can be useful
• 18:07in terms of when somebody says,
• 18:08well, I'm hoping to get better.
• 18:10Well, I I'm hoping for that too.
• 18:12And I'm worried if that doesn't happen,
• 18:15is there something else that you're
• 18:16hoping for that we can aim for?
• 18:18Again,
• 18:18it just softly redirects them to
• 18:20something that might be able to be achieved,
• 18:22rather than perhaps something
• 18:23that's not realistic for them.
• 18:25One of the other key things that
• 18:26we use is silence, obviously,
• 18:28to allow people to express their emotions,
• 18:31gather their thoughts.
• 18:32Most people on the giving end of information,
• 18:36so clinicians feel much more
• 18:37uncomfortable with the silence than
• 18:39the person on the receiving end.
• 18:40They're just trying to get their heads
• 18:42around whatever news has been delivered.
• 18:44And so if you wait,
• 18:46they will usually offer what
• 18:47they need to say next.
• 18:48And then finally,
• 18:49if it goes on and on,
• 18:51you can certainly ask can you
• 18:52tell me what you're thinking?
• 18:54And that will prompt them to to
• 18:56discuss what's on their mind.
• 18:57Lastly, there is a pneumonic to help
• 19:00reinforce those empathic statements.
• 19:02So nurse emotions,
• 19:03which is stands for you, name the emotion.
• 19:05It it sounds like you're very frustrated
• 19:08or it sounds like you're very sad.
• 19:10Understand. Can you tell me a little
• 19:12bit more about what's helping?
• 19:13What's making you feel sad right now?
• 19:16I respect.
• 19:16So respect is we respect the journey,
• 19:19respect that personhood.
• 19:20I can understand how you might
• 19:22feel sad in the circumstances.
• 19:24I would certainly feel sad too.
• 19:27The support piece is really important
• 19:29for aligning yourself with that person
• 19:32for the duration of their care.
• 19:34I am going to be here and walk you
• 19:36through every step and then lastly
• 19:38is explore what else is making you
• 19:40sad or what would support you so.
• 19:42So that's just a little snippet of how
• 19:44to address emotions in an encounter.
• 19:47Lastly,
• 19:47I just wanted to leave some tools
• 19:48that we have within our system.
• 19:50So within Epic itself there are two
• 19:52places where you can find some advanced
• 19:54care planning pathway tools that
• 19:56can help guide these conversations.
• 19:58So one is the advanced care planning pathway,
• 20:01unfortunately it is only for inpatient
• 20:02right now, but it does exist.
• 20:04And then the other is advanced care
• 20:06planning tools where there is a
• 20:07serious illness guide conversation,
• 20:09it is literally you can you can
• 20:11print it out and while that sounds.
• 20:15Scripted if you say, you know,
• 20:17I'm just going to keep these questions
• 20:19here because I want to make sure I
• 20:21cover the important things for you
• 20:22many times that is actually very well
• 20:24received by patients and families.
• 20:25And then lastly if you additional
• 20:27training on how to have some of these
• 20:29conversations would be through catsy
• 20:30vital talk and then the serious illness
• 20:32conversation which is the last one there.
• 20:34So I think for this individual
• 20:36going back to the case,
• 20:37can we flip back one more slide backwards?
• 20:41So the how would I transition her from
• 20:43goals of care, from cure to treatment
• 20:45would really be that conversation.
• 20:46What's important to you?
• 20:47I do see your your functional
• 20:49status is declined.
• 20:50I'm worried that we're not going to be
• 20:51able to get more chemotherapy at this time.
• 20:54What would be important to you?
• 20:56And then I would go, I'm
• 20:59going to pass on to that.
• 21:03Okay, so now we're on Case 2.
• 21:08So case two is a 47 year old female with
• 21:11a gist tumor metastatic to the liver,
• 21:14treated with SUTININIB,
• 21:16seeks advice for fatigue,
• 21:18abdominal pain, sores in the mouth,
• 21:20nausea and insomnia.
• 21:22Her dose was actually recently increased
• 21:25and she does not think this is going well.
• 21:29Her gist tumor was first
• 21:31diagnosed five years ago.
• 21:33At that time she underwent
• 21:35surgery with splenectomy.
• 21:36Initially she was treated with imatinib
• 21:39and then transitioned to sunitinib
• 21:4150 milligrams due to recurrence.
• 21:47She's having the abdominal pain every day
• 21:50and she wants to avoid opiate medications.
• 21:53She has nausea daily.
• 21:55She has trouble eating and
• 21:57has lost about £10 so far.
• 21:59She has a sore in her mouth which
• 22:02is bothering her greatly and also
• 22:04prevents her from eating.
• 22:06Overall, she's feeling stressed,
• 22:09tired, and she can't sleep.
• 22:12So the questions are,
• 22:14how can palliative care help
• 22:16us manage her symptoms?
• 22:18How does prognosis factor
• 22:20into this discussion?
• 22:22Remember, she does have
• 22:23metastatic disease to the liver.
• 22:26And what is the role of
• 22:28primary care here now?
• 22:30She's been stable for a long time,
• 22:32even with the metastatic disease.
• 22:35So I'd like to go to my colleague and
• 22:43thank you Doctor Brzezinski.
• 22:44Actually you can go back the
• 22:45previous slide and we can tackle
• 22:47some of these questions though.
• 22:49So this is an example of a patient who is is
• 22:51not in the beginning of her cancer journey.
• 22:52She's been diagnosed and has been undergoing
• 22:55treatment for many years at this point,
• 22:57but is experiencing a lot of side effects
• 23:01and disease related issues at this point and.
• 23:05This is a typical patient we would
• 23:07kind of see in the outpatient
• 23:09pitive care arena before coming
• 23:11to you on the Haven health system.
• 23:12I was at Duke as the medical director
• 23:15outpatient pitive care and so many
• 23:17patients in the Duke Cancer Center that
• 23:19were actively going through treatment.
• 23:21We weren't at end of life scenario.
• 23:23This was trying to help them live as best
• 23:25as possible and so that's the goal of
• 23:28Pitive cares to help improve quality of life.
• 23:30Regardless of where they are
• 23:32in their treatment trajectory.
• 23:33So how can palliative care help
• 23:36manage her symptoms?
• 23:36So we'd like to think that we're experts in
• 23:39managing symptoms related to serious illness,
• 23:42in this case cancer we.
• 23:45Kind of are the ones that assess
• 23:48them frequently in our visits.
• 23:50We have some assessment tools like
• 23:52the Edmonton Symptom Assessment Scale,
• 23:54which just has 8 to 10 different
• 23:56questions about do you have fatigue,
• 23:59do you have pain, are you sleeping,
• 24:01are you anxious, are you nervous,
• 24:03are you depressed?
• 24:04So,
• 24:05so it's a regular thing that we assess
• 24:08for when we have patient encounters
• 24:11and not uncommon pain and fatigue
• 24:12are the most common symptoms that
• 24:14we find for patients with cancer.
• 24:16So we deal with it quite frequently.
• 24:20So one is just assessing how severe
• 24:22are the symptoms.
• 24:23Is it just mild and a mild nuisance to
• 24:26her or is this something that really
• 24:29is moderate to severe and so it's
• 24:32just trying to figure out where they're at.
• 24:33And those are through basic questions
• 24:35that we're all taught through
• 24:37our medical training, so.
• 24:39When we are taking care of patients,
• 24:42we will frequently see them.
• 24:43It may be every week depending upon the
• 24:46severity and if we're titrating medicine,
• 24:48sometimes it's every couple of weeks,
• 24:50but for more stable people is usually
• 24:52once every month they would come
• 24:54and visit us and we would assess
• 24:56change medications,
• 24:57change treatments and then go from there, so.
• 25:00So we certainly could help
• 25:03this patient manage her pain.
• 25:05She has a preference for not
• 25:07using opioid medication.
• 25:08I often say that when we're
• 25:10managing symptoms,
• 25:10it's best to use non
• 25:12pharmacologic therapies first.
• 25:14So that might include psychological support
• 25:17through cognitive behavioral therapy.
• 25:19It might include sort of alternative
• 25:22therapies like acupuncture,
• 25:24meditation, things of that nature.
• 25:26Certainly we could use pharmacological
• 25:29medications that don't use
• 25:31opioids right up front.
• 25:32Sometimes we can use adjuvant
• 25:34medicine such as gabapentin or other.
• 25:38You know, nonopen medications.
• 25:39But when it does get moderate
• 25:41and severe and it's not being
• 25:43controlled with the current
• 25:44regimen, then sometimes quite frequently
• 25:46we have to escalate into the stronger
• 25:49pain medicines and that it's really
• 25:51weighing the benefits and burdens of it.
• 25:53But hopefully our role is to help
• 25:55support the patient through that
• 25:57process so that they are aware,
• 25:58they know what they're getting into,
• 26:00where they're to monitor them closely.
• 26:03Nausea is certainly another chemo related
• 26:07immune related disease side effect.
• 26:10And so one other thing I'd like to say is
• 26:13that sometimes we like to pull things out
• 26:16of our sleeves like with fatigue certainly.
• 26:19Most commonly, we recommend exercise.
• 26:22Sometimes we're talking about
• 26:24energy conservation techniques,
• 26:25but sometimes we pull out medicines that
• 26:27most others don't think about or don't use,
• 26:29such as methylphenidate.
• 26:31Sometimes for severe cases,
• 26:33we'll use those kind of medications and
• 26:35it's not something that many providers
• 26:38will know how the expertise and how to use.
• 26:41Moving to the second question,
• 26:42how does prognosis factor into
• 26:45the discussion?
• 26:45It's a very good question as hopefully we
• 26:49follow these people through their journey,
• 26:51we will get a sense of what they're
• 26:54likely prognosis is.
• 26:55Certainly there are therapies that
• 26:57we wouldn't recommend if it was
• 26:59a long prognosis of many years.
• 27:01Certainly steroids we use for
• 27:03pain management as an adjuvant,
• 27:05but we don't want to put people on
• 27:07steroids for several months to years
• 27:09knowing the side effects of that.
• 27:12There's certain things that we wouldn't
• 27:14recommend if prognosis is short,
• 27:16things like total parental nutrition
• 27:18for help with nutritional support.
• 27:21If the prognosis is less than three months,
• 27:23the literature would generally
• 27:24not support that.
• 27:25So it definitely plays a factor into
• 27:28what is going to provide the most benefit
• 27:31and minimize the burdens in those situations.
• 27:34So and we we get that through
• 27:36following the patient,
• 27:37we also get it through frequent
• 27:40conversations with the oncologists.
• 27:41The goal is to work side by side with them
• 27:44and that's how my experience has been.
• 27:46And so it's a dialogue back and forth as
• 27:48to how are they doing on their regimen,
• 27:50are they progressing,
• 27:51are they improving,
• 27:52are they changing treatments?
• 27:54What does that mean for the patient?
• 27:56So it's a close collaboration to get
• 27:59a sense of what that prognosis is.
• 28:00Certainly prognosis can be talked
• 28:02about at length in another venue,
• 28:05but it's important for patients
• 28:07to know that sometimes for life
• 28:10planning and other things.
• 28:11Moving to the last question,
• 28:13what is the role of primary
• 28:15care in the care team here?
• 28:17As mentioned,
• 28:17I'm trained in geriatric medicine,
• 28:19Hospice and palliative medicine.
• 28:20And in those two disciplines
• 28:22it's very much a team sport.
• 28:24I know that I can't provide the care myself.
• 28:27It takes, you know,
• 28:28our social workers, our therapists,
• 28:30our nurses, our other volunteers.
• 28:33And so primary care is a very important
• 28:36part of that team collaboration.
• 28:39It also depends on the scenario.
• 28:40I I've seen patients where they
• 28:42just started with a new primary care
• 28:44physician and don't know them very well,
• 28:46don't you know,
• 28:47haven't had many interactions.
• 28:48So there's not a lot of trust build up yet.
• 28:51But then certainly there's patients
• 28:53who've been followed by their primary
• 28:54care physician for several years
• 28:56and they completely trust them.
• 28:57So it's good for us to know those
• 28:59things because we can go back to their
• 29:02primary care physicians and try to
• 29:04include them in the care and sort of
• 29:06again have a dialogue back and forth.
• 29:08A lot of times patients when
• 29:10they're getting cancer care,
• 29:11just want to know who do I call
• 29:13when I have a problem, you know,
• 29:16as opposed to just going to
• 29:17the emergency department.
• 29:18They want to have somebody at the at
• 29:20the ready on the phone and we kind
• 29:22of try to help sort that out with
• 29:24them and who's responsible for what.
• 29:26So including primary care is certainly
• 29:28an important part of that next slide so.
• 29:33And I was asked to talk about a
• 29:36few things related to this case
• 29:38and that the case is presented one
• 29:41about Pine to care triggers.
• 29:42When do you want to get
• 29:44pine of care involved?
• 29:45Sometimes it's readily apparent
• 29:47and sometimes not so much.
• 29:48So this is just a list of some criteria.
• 29:52Certainly there's many different lists
• 29:54in the literature about criteria,
• 29:56but quite often we're thinking
• 29:57of people that have life limiting
• 30:00or life threatening illnesses,
• 30:01what we call a serious illness.
• 30:03There's primary criteria,
• 30:05secondary criteria,
• 30:06and this was published by Dr.
• 30:07David Weissman and his colleague Dr.
• 30:10Diane Meyer several years ago.
• 30:12But we also talk in the π to Care
• 30:14World about the surprise question,
• 30:16and that is,
• 30:17when looking at a patient in any venue,
• 30:20would you be surprised that this
• 30:22patient died within the next 12 months?
• 30:25And it's used for research purposes
• 30:27and just an easy question to gauge
• 30:30whether somebody would potentially
• 30:32benefit from palliative care.
• 30:34Palliative care is more focused on
• 30:36needs and not necessarily prognosis,
• 30:38but it's a it's an entry question
• 30:40to figuring out the trigger.
• 30:42Certainly people are coming to
• 30:44the hospital frequently if they've
• 30:46had a severe decline in function,
• 30:48unintended decline in weight.
• 30:50Secondary criteria include things
• 30:52such as an elderly patient,
• 30:54metastatic or locally advanced cancer,
• 30:58cardiac arrest. So it goes on and on.
• 31:01And so they exist out there.
• 31:03We in the hospital here have a
• 31:05resource card which we carry around
• 31:07and it has a number of questions.
• 31:09Or triggers both in the Ed and
• 31:11also in the ICU.
• 31:12So.
• 31:13So we have tools in the system that
• 31:15can help people understand when they
• 31:17might want to get pit of care involved.
• 31:20I was also asked to talk about sort
• 31:21of the pit of care stigma and I I
• 31:23leave a quote from my mentor and
• 31:25national leader and pit of care, Dr.
• 31:26Diane Meyer out of Mount Sinai.
• 31:28And she told me early on when I was a
• 31:30fellow that if you're trying to sell death,
• 31:33no one is going to buy.
• 31:35And I think frequently my
• 31:36colleagues and I run into patients,
• 31:38run into staff who, you know,
• 31:41we hear the words patient is not ready
• 31:44for palliative care and that is a barrier.
• 31:46If they're not ready for palliative
• 31:48care or don't want palliative care,
• 31:50then we're not allowed to
• 31:52be involved in their care.
• 31:53And so it's trying to highlight the
• 31:58positive things about palliative care.
• 32:00You know, palliative care is there
• 32:02to help improve quality of life.
• 32:04And that's the focus talking about Hospice,
• 32:08talking about stopping treatments,
• 32:10talking about death is certainly
• 32:12very charged and very powerful
• 32:14and patients don't readily.
• 32:16Embrace that and that is often a barrier
• 32:19to getting high to care involved.
• 32:21So, so this is a what I call a Diane
• 32:23Meyerism that sticks in my head and
• 32:25it's always to try to highlight the
• 32:27positive things that high to care does.
• 32:30We certainly do help manage
• 32:31with end of life situations,
• 32:33but we don't sort of bill
• 32:35ourselves as that next slide.
• 32:39Another part of support for patients
• 32:41and especially the Cancer Center
• 32:43is about advanced care planning.
• 32:45Most patients and families don't know
• 32:48exactly what advanced care planning is,
• 32:50but really the goal of it in our
• 32:53daytoday conversations is to enhance
• 32:55patient and family education about
• 32:57their illness about likely prognosis.
• 33:00Outcomes of alternative care plans,
• 33:02we hear what treatments they're on.
• 33:04We gauge how well they're
• 33:05doing with those treatments.
• 33:06We kind of want to know what other things
• 33:09might be available if it doesn't work.
• 33:11So we take the time to talk to patients and
• 33:13families about all those different things.
• 33:16Certainly, we wanted to find key priorities
• 33:18in the end of life care and develop a
• 33:20care plan that addresses these issues.
• 33:22A lot of those conversations is something
• 33:24that Kristen already brought up and we
• 33:26use those tools in these conversations.
• 33:28And also to help shape future
• 33:29clinical care to the fit the patient's
• 33:32preferences and values, you know,
• 33:33do they want to go to the emergency room?
• 33:35If they should get sick,
• 33:36would they want to be transferred
• 33:38to the intensive care unit?
• 33:39Would they want to be resuscitated?
• 33:41These are all conversations that
• 33:42we have every day in the hospital.
• 33:44And if we can move some of these
• 33:47conversations into the nonemergent setting,
• 33:48into the primary care office or to
• 33:51the Cancer Center visit, you know,
• 33:53it's a better conversation in that sense.
• 33:56There are certainly documents in
• 33:58Connecticut that help with these things.
• 34:01Most recommended I would say is the
• 34:03healthcare representative form.
• 34:04If a patient lacks capacity to
• 34:06make decisions in the hospital,
• 34:07the providers are going to be
• 34:09looking for somebody that can
• 34:10make decisions for that person.
• 34:11And we want the patient to maintain
• 34:13control as much as possible.
• 34:15And so through this document they
• 34:17can designate who they trust to
• 34:19make medical decisions for them.
• 34:20Living Will is sort of another
• 34:23document that exists.
• 34:24It's.
• 34:27Not the greatest tool in my sense,
• 34:29but certainly helps with
• 34:31promoting the conversation.
• 34:32And then the last document is the
• 34:35medical orders for life sustaining
• 34:36treatment which is exists in Connecticut.
• 34:39We do have conversations
• 34:40but it's not most common.
• 34:42I'd say the healthcare representative
• 34:44conversation is the most common that we have.
• 34:47The next picture on the slide
• 34:49is just go back one is just
• 34:52how for all of our encounters,
• 34:54all of our patients,
• 34:55we always keep them in the
• 34:57center when we work as a team.
• 34:58We're all working around the patient.
• 35:00And so certainly primary
• 35:02care is part of those,
• 35:03one of those surrounding circles
• 35:05along with physicians and others.
• 35:07So it's just again A-Team sport and we
• 35:10just need to communicate with each other.
• 35:12Next slide.
• 35:15This is the last slide I have.
• 35:17It's just some common things that
• 35:19we are concerned about when we
• 35:22engage with patients and families,
• 35:24we sort of look at, you know,
• 35:27suffering as a total, total pain scenario.
• 35:31You know, what are they suffering from?
• 35:33Is it physiologic, is it social,
• 35:35is it spiritual, is it emotional?
• 35:37So questions that we have are
• 35:40are there distressing symptoms?
• 35:41Is there significant social concerns,
• 35:44spiritual concerns affecting
• 35:45their daily life?
• 35:47Does a patient,
• 35:48family surrogate understand
• 35:50the current illness?
• 35:51There's many a times when I speak to
• 35:53patients who have incurable disease,
• 35:55but they still think that it is
• 35:58curable and we do have to help
• 36:00with those conversations to help
• 36:02transition the goals at that point.
• 36:05We also asked what are their goals,
• 36:07what treatment options they prefer?
• 36:10Have they completed advanced care
• 36:12planning documents or conversations?
• 36:14And then lastly,
• 36:15what are the key considerations for
• 36:16a safe and sustainable transition
• 36:18from one setting to another?
• 36:19Certainly,
• 36:20we see patients that come back and
• 36:22forth from home to the hospital
• 36:24or hospital to nursing home,
• 36:25nursing home back to the hospital.
• 36:27And so we are familiar with a
• 36:29lot of transitions and we try to
• 36:31help support it as best we can.
• 36:33And I think that is it.
• 36:41Okay. So this is our last case.
• 36:44It is a 65 year old female with
• 36:47metastatic lung cancer who presents as
• 36:49a new patient due to a recent move.
• 36:52She is there with her niece
• 36:54who is her caregiver.
• 36:56She is being managed by a new oncologist and
• 36:58is not responding to the current regimen.
• 37:01She is on causing great distress to her.
• 37:04The patient had to move in with her niece
• 37:06as she lost her house due to mounting
• 37:09medical bills and inability to work.
• 37:11The patient herself has no children.
• 37:14She needs help with toileting,
• 37:15dressing meals and ambulates only with a
• 37:18Walker for short distances in your office.
• 37:21She is in a wheelchair.
• 37:25The niece has bags under her
• 37:27eyes and she looks very upset
• 37:29throughout the entire encounter.
• 37:31You ask her what is the
• 37:33matter and she begins to cry.
• 37:35The niece tells you she is under
• 37:37a lot of stress, taking care of
• 37:39her aunt and working full time.
• 37:41She feels like she is working two jobs.
• 37:44She is not taking care of her own.
• 37:46Diabetes and her blood sugars have
• 37:48been in the three hundreds recently.
• 37:51This is clearly an argument
• 37:53the Paris had in the past.
• 37:55The patient states she does not want
• 37:58anyone else in the House because she
• 38:00would not trust them and she's far
• 38:02too young to go to an old folks home.
• 38:05Also she says she has no money and if
• 38:08her niece does not take care of her,
• 38:10she will be out on the street.
• 38:13So this is a very difficult situation.
• 38:15So how can you take care of the
• 38:18patient and help the niece as well?
• 38:21And how can palliative care
• 38:23help you in this scenario?
• 38:26So I'm going to turn over to my colleague.
• 38:36Liz, you're on mute.
• 38:43I am so sorry about that.
• 38:44I was trying to make sure you
• 38:46didn't hear my kids screaming in
• 38:47the background, and here we are.
• 38:49So I'm Liz persichen.
• 38:50Thank you so much for giving me the
• 38:52opportunity to speak here today.
• 38:53I think what struck me most about that
• 38:55last slide is the comment that the niece
• 38:57felt that she was working two jobs.
• 38:59And I want to take a moment to
• 39:01acknowledge the significant
• 39:02caregiving burden that so many of our
• 39:04patients and their families face.
• 39:06And I know that many of you in the
• 39:08primary care field have seen your own
• 39:09patients be caregivers and seeing the
• 39:11significant caregiving burden that
• 39:13many of your patients require for care.
• 39:15And I think one thing just to step
• 39:17back is to define palliative care.
• 39:19And palliative care is really a
• 39:22team based interdisciplinary means
• 39:23to support patients facing serious
• 39:25illness as well as their caregivers
• 39:28and addressing the caregiver distress
• 39:29and the caregiver needs is an
• 39:31important part of what we do as well.
• 39:33So the niece is working two jobs.
• 39:36She's a caregiver.
• 39:38And our team offers a true
• 39:40interdisciplinary mechanism to
• 39:42support patients and families that
• 39:44are facing serious illness together.
• 39:46And what I wanted to highlight
• 39:48here is really the amazing team
• 39:50that we have both within SMILO and
• 39:52in the palliative care programs
• 39:54throughout the only Haven hospital,
• 39:56the only Haven health system.
• 39:58And I was going to talk through
• 39:59them one by one.
• 40:00So many times people think you know.
• 40:03Patient is very sick.
• 40:04They need certain resources.
• 40:06Let's send a referral to palliative
• 40:07care and what exactly does that mean?
• 40:09What do you get with a palliative
• 40:10care referral?
• 40:11What do you get with a palliative
• 40:13care consultation?
• 40:14And I,
• 40:14I want to make sure folks know that
• 40:16consultations are available in the
• 40:17inpatient setting for patients with all
• 40:19diagnoses and in the outpatient setting.
• 40:21Our current availability is really
• 40:23only for the patient population with
• 40:26cancer and that is a big limitation,
• 40:28I understand,
• 40:30but.
• 40:31We are working on that in the
• 40:32background today,
• 40:33we're going to talk about resources
• 40:35for patients with cancer.
• 40:36So when you do place a palliative
• 40:38care consultation or referral,
• 40:39you're getting an entire interdisciplinary
• 40:42team that's working together
• 40:44with expertise for supporting
• 40:46patients facing serious illness.
• 40:48We have a team of physicians,
• 40:50nurse practitioners.
• 40:52Social work chaplains,
• 40:54bereavement care as well as
• 40:56ancillary services within and
• 40:58without our palliative care program,
• 40:59including medical, legal support,
• 41:01psycho oncology,
• 41:03integrative medicine and also
• 41:05relationships with Hospice caregivers.
• 41:07So our social work groups offer
• 41:09individual and group programs including
• 41:11both bereavement and grief support groups,
• 41:13not just for patients but
• 41:15also their caregivers.
• 41:16So a mechanism to connect
• 41:19with other caregivers,
• 41:20connect with other people who are
• 41:21facing loss or serious illness.
• 41:23Whether you are the patient or whether you
• 41:25are the caregiver is really important.
• 41:28Our spiritual care chaplains are
• 41:30available both inpatient and outpatient.
• 41:32They help with Valuebased resources,
• 41:36spiritual resources,
• 41:37support for existential concerns,
• 41:39and also help complete some of
• 41:41the advanced care planning that.
• 41:43That Morgan had discussed earlier,
• 41:46our palliative care chaplain at Yale
• 41:47is actually one of 20 palliative care
• 41:50certified chaplains in the country,
• 41:51which he's really proud of.
• 41:53So really a dedicated and
• 41:56focused response there.
• 41:57Our Psycho Oncology team has
• 41:59support for resilience building,
• 42:01emotional support skills,
• 42:02CBT as well as expressive therapy
• 42:05and art therapy and we contract
• 42:07with the art therapist who is
• 42:09part of our services as well.
• 42:11And then we have a very well structured
• 42:14bereavement group as well for both
• 42:15telephone outreach in real time,
• 42:17monthly bereavement seminar support
• 42:19groups and also support around
• 42:21times of holidays and memorials
• 42:23for patients and families.
• 42:24So this is all clearly kind of.
• 42:27Some of this is at end of
• 42:28life and post end of life,
• 42:30but available for patients and caregivers
• 42:32throughout the disease process.
• 42:34And of course we have our physician
• 42:37and APP colleagues who work with
• 42:39primarily symptom management and
• 42:41also navigating these difficult
• 42:43conversations for goals of care,
• 42:45medical decision making, et cetera.
• 42:48So when you reach out for
• 42:49a palliative care consult,
• 42:50you're getting all of
• 42:51these different services.
• 42:52I did want to speak briefly about
• 42:54the medical legal support system.
• 42:55So within Yale we have a relationship
• 42:57with Yale Law School and they have a
• 43:00pro bono program for medical legal
• 43:02support for patients that are in need,
• 43:05whether that be related
• 43:06to financial constraints,
• 43:07social constraints or health related issues,
• 43:10so.
• 43:11Guardianship Wills financial complex
• 43:12situations that need to be dealt
• 43:15with in a time sensitive manner,
• 43:17whether that be in the hospital,
• 43:19in the patient's home, etcetera.
• 43:21We've helped navigate guardianship
• 43:22instant for instance for patients
• 43:25that are facing serious illness
• 43:26that have either minor children
• 43:28or dependent adult children,
• 43:30where times of the essence and
• 43:32these are very important things,
• 43:33not just logistically but also
• 43:35in terms of bringing peace and
• 43:38a sense of closure to families,
• 43:39knowing that their loved ones
• 43:40will be cared for and.
• 43:41Things that are important to
• 43:43them that they value are done.
• 43:46We also work with our integrative
• 43:48medicine colleagues who have both
• 43:50inpatient and outpatient services.
• 43:52For patients that are within the smilo
• 43:54system, they offer massage therapy,
• 43:58Reiki,
• 43:58aromatherapy as well to patients
• 43:59in and out of the hospital,
• 44:01which is a huge support.
• 44:04And then also we work closely with Hospice.
• 44:06So if there's any questions about
• 44:09the Hospice referral program
• 44:10resources in the community,
• 44:12we're not a Hospice agency.
• 44:13Of course, a lot of times people can
• 44:15found Hospice and highlighted care,
• 44:17but we can certainly help navigate
• 44:19what that system is,
• 44:21inform,
• 44:22educate and also be a bridge if
• 44:24and when Hospice is appropriate
• 44:27for patients and families, so.
• 44:30You know,
• 44:31I think we have a lot to offer
• 44:33besides symptom management and
• 44:34goals of care and a lot to offer
• 44:36throughout the trajectory of
• 44:37a patient's serious illness.
• 44:39I think that alludes to Kristen slides.
• 44:41You know from the time of diagnosis
• 44:43whether the intent is curative or whether
• 44:45this is a lifelong illness or some an
• 44:48illness of the very short prognosis,
• 44:50palliative care has a lot to offer in
• 44:51terms of improving quality of life,
• 44:53not just for patients but
• 44:55also for their caregivers.
• 44:56And I think we all recognize the enormous.
• 44:59Financial, social,
• 45:00psychological and medical challenges that
• 45:04so many people face with serious illness.
• 45:07I think I answered all the questions
• 45:09that I was hoping to get to.
• 45:11I'm really looking forward to Q&A.
• 45:12I hope, I hope this has been a
• 45:16helpful presentation and I look
• 45:17forward to discussing more with
• 45:19our audience and other panelists.
• 45:23Thank you so much. That was.
• 45:26Really great with a lot of very practical
• 45:29pearls in addition to kind of a nice
• 45:32theoretical concept of palliative care.
• 45:35I I love the specialty versus
• 45:38nonspecialty palliative care because
• 45:40I think in primary care we are
• 45:42doing palliative care all the time.
• 45:44And so it's it's nice to hear that,
• 45:46kind of recognize it and realize that
• 45:48some of the same tools you use are things
• 45:51we can apply across broader diagnosis.
• 45:56I think just a couple of housekeeping
• 45:58things is there will be a survey at
• 45:59the end and that's how you get the CME.
• 46:02Doctor Chang just posted that and
• 46:05we do have our upcoming talks.
• 46:08In the meantime,
• 46:09I want to make sure that we open
• 46:11up for questions.
• 46:13We've had some really,
• 46:14we have good attendance and I'm interested
• 46:17to hear questions that people have.
• 46:20And Ola,
• 46:20I don't know if you have any questions,
• 46:22additional questions on the cases
• 46:24that you presented before we
• 46:26move to those who are watching.
• 46:32I guess my just my one question is
• 46:35actually in terms of the medical
• 46:37orders for life sustaining treatment,
• 46:39I feel like that is a very useful
• 46:42tool and I'm wondering how we
• 46:44can get that in Connecticut.
• 46:48So the Department of Health actually
• 46:50will send them to you for free.
• 46:53That's how we get it here
• 46:56in Greenwich Hospital.
• 46:58It differs from state to state.
• 46:59It's based upon the.
• 47:01What was originally the pulsed
• 47:02paradigm out of Oregon?
• 47:04The physician orders for
• 47:05license taking treatment.
• 47:07My years in North Carolina.
• 47:08The document was what we called Pulsar Pink,
• 47:10very bright pink.
• 47:11Here in Connecticut,
• 47:12it's more of a neon green,
• 47:14so it was intended to stand
• 47:16out in a written chart,
• 47:19but we don't have written charts anymore.
• 47:21Some of my colleagues,
• 47:22it may not be just the
• 47:24completion of the document,
• 47:25but it serves as sort of a
• 47:27template for conversation.
• 47:29Yeah. And my understanding is
• 47:31that because it has to be green,
• 47:33it's not as easy to scan in.
• 47:35So the patient has to carry
• 47:37around the green form.
• 47:38But certainly having things well
• 47:40documented in the chart and whether
• 47:42we do it from inpatient or outpatient,
• 47:45these advanced care planning
• 47:46has a huge free text section.
• 47:48So I hope that you guys look at that
• 47:52when we do that from primary care
• 47:54for bidirectional communication.
• 47:58I'll just add a question as well
• 48:01while we wait for some in the
• 48:03audience to come up with some.
• 48:04So and we're getting that diagram
• 48:06that you gave which had that kind of
• 48:08circle and then all the caregivers
• 48:10around the patient and their family.
• 48:12Sometimes I feel like, you know,
• 48:14Smilo has such complete services
• 48:16that in primary care we're a little
• 48:18bit like in outer space around that,
• 48:20maybe not outer space,
• 48:21but in a different room.
• 48:22We're all on the same chart, right?
• 48:24But at the same time,
• 48:27sometimes that communication would be hard.
• 48:29Is it possible to initiate a palliative care,
• 48:33consult yet palliative care advice
• 48:37or or interact?
• 48:38What's the best way to kind
• 48:40of interact with you guys?
• 48:44Very good question.
• 48:46So different avenues.
• 48:47We all have main office numbers if
• 48:50people want to call and hopefully we
• 48:52can provide that to the audience.
• 48:55Epic, certainly there is messaging
• 48:57capability from provider to provider,
• 49:00so that could be another platform.
• 49:03And those are the the typical
• 49:05ways I communicate when I see
• 49:07a patient and write a note,
• 49:08I CC their primary care physician so
• 49:10that hopefully they get to see the
• 49:12notes as well and are up to speed
• 49:14with what changes may have been done.
• 49:18And then let's move.
• 49:20We do have a question that came in
• 49:23and and the question was,
• 49:25is it possible to introduce
• 49:28palliative care too late?
• 49:31And I think, Liz,
• 49:32you had answered that a little
• 49:33in writing, if you want to.
• 49:34Yeah, I I wanted to answer that.
• 49:36And you know, I, I do inpatient palliative
• 49:38care and a lot of oncology and and
• 49:40oftentimes like our consoles do come too,
• 49:42too late by some traditional metrics.
• 49:45I would argue to say that it's never too
• 49:47late to introduce palliative care, however.
• 49:50I think sometimes we're involved
• 49:52very short periods of time,
• 49:53but have an enormous impact on the patient,
• 49:56on the family, on bereavement for the
• 50:00caregivers and for a sense of closure and
• 50:02sometimes the most helpful support we give,
• 50:04just making sure I'm not muted is when we
• 50:07can help support those with complicated
• 50:09bereavement needs after a patient's death,
• 50:11let's say, you know,
• 50:12the illness was very brief and there was
• 50:14a very difficult short hospitalization.
• 50:16There's a lot of.
• 50:17Sense of regret or uncertainty or, you know,
• 50:20lack of closure for the family member.
• 50:22Our social workers will contact them
• 50:25and have bereavement support groups,
• 50:27one-on-one, counseling,
• 50:28telephone outreach,
• 50:28in addition to whatever other support
• 50:31services they may have access either
• 50:32through Hospice or other places.
• 50:34And that is a really important
• 50:35resource for many people.
• 50:37So I would argue it's never ever too
• 50:39late to introduce palliative care,
• 50:42ever.
• 50:43I'm so glad Liz asked that or answered that.
• 50:46I wanted to to piggyback on top
• 50:48of that because that was the other
• 50:49thing that I wanted to mention is
• 50:51the bereavements of part the other.
• 50:52The other thing, there's actually
• 50:54a study, and I'm sorry,
• 50:55I don't know the authors at the moment,
• 50:57but there was a study that
• 50:58looked at patients,
• 50:59families of patients who had died
• 51:01and asked them how they felt about
• 51:04when palliative care was introduced.
• 51:06And most of the researchers thought
• 51:08that they would be too late.
• 51:10And no matter when in the disease trajectory,
• 51:13palliative care was introduced,
• 51:14the family thought it was the right time.
• 51:16Which whether that's a psychological
• 51:18confirmation bias or what,
• 51:20it's just interesting to me that
• 51:22almost always families are just
• 51:23grateful for when it's offered.
• 51:25And and the one thing I will add is
• 51:27going back to that very first case.
• 51:29How early can you introduce palliative care?
• 51:31So, so that my one question was
• 51:33as as I was thinking that as this
• 51:35was coming up it it is possible
• 51:37to introduce it right early on.
• 51:38I wouldn't have referred that patient
• 51:41to palliative care at the time of
• 51:43diagnosis if it wasn't mastatic
• 51:45and she didn't have symptoms.
• 51:46But if it was either metastatic or she
• 51:49had symptoms needing to be controlled,
• 51:52then yes,
• 51:53absolutely would consider referring
• 51:54to specialty level powdered care.
• 51:55And you can introduce it the way
• 51:57I introduce it and my guess is
• 51:59that my pallet care colleagues,
• 52:01it would be pretty similar
• 52:02because we have sort of a national
• 52:04expectation of how we stand.
• 52:05I say it's a, it's a specialty of medicine,
• 52:07it's a focus on symptoms,
• 52:09communication and sometimes decision making.
• 52:11The best way to think of it
• 52:12as an extra layer of support.
• 52:14There are other versions
• 52:14of that whether it's,
• 52:15you know,
• 52:16it's a team of experts who are
• 52:17going to help partner with me to
• 52:20manage your symptoms etcetera.
• 52:21But it's it's that whole concept
• 52:22of it's a team.
• 52:24So, so yes,
• 52:24absolutely could have referred it.
• 52:26I think that my thought in that first
• 52:28case is she's just getting the diagnosis,
• 52:30she's completely overwhelming.
• 52:31So you really just want to ground
• 52:33her in next steps and and if she
• 52:34weren't actively symptomatic,
• 52:35I'm not sure I would have referred
• 52:37at that point yet.
• 52:39If I can jump in, just give talks about
• 52:41what I call fishing further upstream,
• 52:42meaning trying to get involved
• 52:44earlier from the time of
• 52:45diagnosis for palliative cure.
• 52:46Because when you're introduced as
• 52:48just another part of the team,
• 52:50you're not sort of looked at as
• 52:52the Boogeyman or boogeywoman.
• 52:55That sense you, you know,
• 52:57I worked with the brain tumor center
• 52:59at Duke and it was sort of what day
• 53:01should we put the π to care visit
• 53:03on day one or day two. You know,
• 53:05as they're seeing the radiation oncologist,
• 53:07medical oncologist, surgical oncologist,
• 53:09it's just it was baked in into the
• 53:11care as that extra layer of support.
• 53:13And when you're caring for people earlier on,
• 53:16you develop relationships with them,
• 53:18they develop trust with you and
• 53:21you get to know the team and and
• 53:22know their their desires basically.
• 53:24So it's.
• 53:25Earlier is better but at any
• 53:27time we can certainly help
• 53:31that's terrific. I I don't,
• 53:34I don't see more questions coming
• 53:36in but I I'll just make one more
• 53:38comment and and that is that all,
• 53:40all of these words matter and I know
• 53:44that and you know Ola knows that
• 53:47because we see the families afterwards
• 53:50whether it's because they're also our
• 53:53patients or because we kind of do a.
• 53:55A later follow up that's I think not
• 53:58always but often part of primary care
• 54:01after a longstanding relationship.
• 54:03And I can't tell you how much words matter.
• 54:07And people will recount entire
• 54:09conversations that happened in those,
• 54:12you know, in the end of cancer care,
• 54:14whether it was a turning point in
• 54:17management to more palliative care,
• 54:20to Hospice care or the actual death and,
• 54:23you know, words that set them.
• 54:26Help them be comfortable with what's
• 54:28happening ring especially true it helps
• 54:31them to you know not feel guilty or
• 54:33not feel bad about how things went.
• 54:35So I think it's it's great.
• 54:38We have one more question that came in.
• 54:41Can you repeat information on training
• 54:43for having tough conversations.
• 54:45I think that was one of Kristin's slides.
• 54:47Yeah.
• 54:49Are these slides made available for
• 54:50people afterwards as well because they're
• 54:52actually links on them to the specifics.
• 54:55It's, yeah, it's a recording
• 54:57on any of the slides.
• 54:59Maybe I can send those to you Karen,
• 55:02and maybe we can send them out.
• 55:03But the there there are
• 55:04three sites, so one is cap
• 55:09CW w.capcapc.org. The next
• 55:10one is vital talk, which is W
• 55:21w.vitaltalk.isitorgorcapccapc.org.
• 55:23Vitaltalk.org I believe and then if you
• 55:25Google cuz the the the link was quite
• 55:28long the serious illness conversation
• 55:30would be the one that the other one.
• 55:33All right so
• 55:36and do you wanna I think
• 55:39you had one more comment.
• 55:41I I just wanted
• 55:42to I know this is geared towards
• 55:44the primary care population and they
• 55:46just want to highlight how important
• 55:48you know you Karen was saying that
• 55:50words matter and the words that you
• 55:52share the conversations you have
• 55:53with your patients matter more than
• 55:55any advanced care planning document
• 55:56or healthcare representative.
• 55:58Those are certainly important but
• 56:00for the patients and their loved
• 56:02ones to know what their wishes are
• 56:03what they would or would not want
• 56:05is so important in the earlier you
• 56:07have those conversations and more
• 56:09honestly and openly have those
• 56:10conversations they matter and.
• 56:11Been involved in the care of
• 56:13many patients and patient who,
• 56:14you know, they want to know what
• 56:15their PCP thinks that you know,
• 56:17they've seen a million specialists,
• 56:18they've been through the wringer,
• 56:19they've had every test under the
• 56:21sun and they want to know what Dr.
• 56:23Brown thinks.
• 56:23And so when I'm able to engage
• 56:25with primary care doctors,
• 56:27it's like speaking to an old
• 56:28family friend or a loved one,
• 56:29like getting that history and
• 56:31that collaboration and also
• 56:32the medical expertise is there.
• 56:34And so I really value that work and want
• 56:36to thank everyone who's listening for that.
• 56:39And also think of us if you're
• 56:40worried about a patient with
• 56:41serious illness and you want the
• 56:43palliative care team to do a check,
• 56:44you know, I'm worried about symptoms.
• 56:46I'm worried about.
• 56:46They've had a lot of financial stressors.
• 56:48Their loved ones are really struggling.
• 56:50You know,
• 56:50ask the team or or contact us directly.
• 56:52We're happy to see your patients.
• 56:54You know,
• 56:54we're here to advocate along with you,
• 56:57and our team
• 56:57rolls deep. It's not just doctors and nurses.
• 57:00You've got a lot of great resources
• 57:02to help support your patient.
• 57:05There is a question,
• 57:07let's see from the will you from an attendee,
• 57:11will you be able to send contact
• 57:13information for scheduling to
• 57:15those that attended night tonight?
• 57:17I don't know if we can put
• 57:19something into the chat or else.
• 57:22Maybe folks can repeat that for
• 57:26scheduling. So that's for scheduling
• 57:28palliative care consultation.
• 57:30You think maybe we need to clarify that
• 57:34question or is it, I think there's
• 57:37a different way to do it inpatient
• 57:39and outpatient, right folks, I mean.
• 57:43That that's how it kind of flows to us.
• 57:45It's an ambulatory referral to palliative
• 57:47care and it lists the different sites.
• 57:49So New Haven or Greenwich that is the easiest
• 57:52for providers through the epic system.
• 57:55Yeah. And it depends the,
• 57:57the organization is based on where
• 57:59their primary oncologist resides,
• 58:01quote UN quote. So if their primary
• 58:03oncologist is at York Street,
• 58:04then they're at main campus.
• 58:05If they're at North Haven or Greenwich,
• 58:07then that's where their palliative
• 58:08care services would be rendered.
• 58:11Yes, you can do it through epic.
• 58:13I do it once several times a week.
• 58:16We're a minute over want to thank.
• 58:18I mean this is such a terrific team.
• 58:20I'm so glad that you guys are here taking
• 58:22care of our patients and helping us.
• 58:24I've learned so much from
• 58:27this presentation, Chris,
• 58:28and I've used half of those things
• 58:31today when I've talked to patients.
• 58:33Hola, Karen, thank you.
• 58:35Thank you all for your input and
• 58:38thanks for folks for showing up.
• 58:40And continuing to show up.
• 58:42Please tell your colleagues and of course,
• 58:44feel free to access this online.
• 58:47Have a great night.
• 58:48Thanks everybody
• 58:49and stay on for the questionnaire
• 58:52because that's the CME.