A New Way to Encourage Advance Care Planning

Many of you may have already seen this video, however, from the time I first saw it, I wanted to show anyone that would sit down for a few minutes to watch it. I think we often wonder what’s the best way to disperse important information to the masses and I think ZdoggMD has found that way. Although many of his videos are funny parodies of songs to teach or just to have fun, this is one in which the tone is serious. As those of us who work in the health care field know, advance care planning is not often done. Poor unsuspecting families, unaware of what’s to come during an unplanned medical event, often get blindsided when their loved one is in the hospital. Their loved one is no longer able to make their own decisions and the hospital physicians and staff are looking to them to make difficult medical decisions. Atrocities occur daily in the ICU, especially to people with advanced chronic illnesses or age because the family who is left behind to deal with these issues is feeling an emotional roller coaster of guilt, uncertainty, anger, fear, selfishness and anxiety (to name a few) and are often paralyzed to make difficult decisions. I think the Coalition for Compassionate Care of California (link below), an organization responsible for implementing POLST in California, has done an immense job in actively taking this issue a huge step forward. With the help of the Coalition, National Healthcare Decisions Day (link below), ZdoggMD and countless other organizations and healthcare professionals we can make a change one person at a time. Please share this video with your family, friends and colleagues. A big shout out to #ZdoggMD!

Link: Video “Ain’t the Way to Die”

Link: The Coalition For Compassionate Care Of California

Link: National Healthcare Decisions Day

Trach and PEG

There I was in ICU rounds (the Palliative Care Team attends ICU rounds) shaking my head as usual. One of my nurse practioner students told me she disliked going to ICU rounds because it was like a “Nursing Home.” She was saddened to see so many geriatric patients, in the ICU, mostly with a poor overall prognosis. The words “Trach and Peg,” ran through my mind for hours after rounds because so many patients were being “Trached and Pegged.” Those words brought so many negative emotions and feelings; sadness, fear, isolation, pain and suffering to name a few. The words and images burned into my mind, that for the rest of the day it was like a song that haunted me…”Trach and Peg, Trach and Peg.” The words bothered me to the point that I had to write the following:

“Trach and PEG”

“Trach and PEG”

Those words sound horrible in my ears.

Unknowing to families an artificial prison for months or years.

The family will never know what to expect.

Bedsores, UTI’s, pneumonias, you name it, continue to occur even without neglect.

Most families doing the best they can,

thinking that this is the best plan.

While I make rounds in the ICU

will the patient suffer through another code blue?

“Trach and PEG”

“Trach and PEG”

Spirituality in Palliative Care and Other Topics

Today at the AAHPM Assembly I attended four educational sessions. The one that made the biggest impact on me was the presentation entitled “None of Your Darn Business! Taking a Spritual History While Preserving Your Professional Boundaries, Your Rapport, and Your Pride,” by Tim Ford, MA MS CT at VCU Massey Cancer Center, Richmond, VA. Before I talk a little bit more about this, I also wanted to list the other educational sessions and what I took from them.

1. “Is it Futile to Discuss Futility? A review of the Medical Literature and Legal Precedent.” Futility is a difficult word to define and means many things to different clinicians. Many advocate because it is so politically charged that we get rid of it. One physician suggested that Futility is the other “F” word. Basically, there is much evidence from previous cases and court rulings that physicians are hardly ever successfully sued for a wrongful death when non-beneficial life sustaining treatments are withdrawn. I contended that many physicians do not want to withdraw care when a family “wants everything done,” due to the fear of litigation. Many physicians would rather practice against their better judgement and subject patients to things they disagree with because this is “what the family wants,” and they do not want to anger the family or make them feel that they are not appropriately taking care of the patient. It’s much easier to continue to “do” things to the patient than to discuss this with the family in an open and honest way. Nadia Tremonti, MD, Wayne State University and Children’s Hospital of Michigan made a good point about this. She stated that as physicians we have a certain obligation to the patient and the profession despite the fear of litigation. We understand as physicians that we have a certain responsibility to the patient and by choosing the easy way out we compromise ourselves and the integrity of medicine. Overall, a great presentation and much discussion afterward.

2. Paper Sessions. I attended the paper sessions covering the Palliative Care in the ICU. The take home message from all three papers is that Palliative Care can be beneficial to patients in the ICU setting. Some crossover points in all three papers are the following. Palliative Care in the ICU:
a. Showed a decreased length of stay in the ICU
b. Increased DNR’s
c. Decreased utilization of more “aggressive” measures
d. Improved relationships between the ICU staff and the Palliative Care team
e. Increased support for the ICU staff by the Palliative Care team
f. Improved physician understanding of the role of Palliative Care in the ICU and increased utilization
g. Increased cost avoidance for the hospital showing that Palliative Care programs are beneficial, self sustaining and enforce the “Mission” of most hospitals
h. Improved patient and family satisfaction scores
i. Other…(mostly stuff I forgot)

3. “Hospice and Nonhospice Models of Palliative Care Delivery.” The bit of information that stood out to me in this session, is that some SNF’s (Skilled Nursing Facilities) are beginning to implement a “Home Grown,” palliative care service on site. Advantages and disadvantages were discussed for this type of model and I had never really thought of this as an option. I heard of the other two models in which outside Palliative Care consultants are called in to do consults or a local hospice providing non-hospice palliative care to nursing home patients, but I was not aware of the “Home Grown” model. Lots of good discussion and it will be very interesting to see how this unfolds in the coming years.

4. Last but not least, “None of Your Darn Business! Taking a Spritual History While Preserving Your Professional Boundaries, Your Rapport, and Your Pride.” This session impacted me the most because as a fellowship trained Palliative Care Physician I had always advocated for spiritual care as an important piece of patient care, but never truly appreciated the spiritual care component until this presentation. I felt like my eyes were opened and I had a deeper understanding of spirituality in palliative care. How can one presentation make such an impact. Well, he presented several points that I had not considered and he also introduced the “Transdisciplinary” (TD) approach to palliative care rather than the more traditional “Interdisciplinary” (ID) approach. In the traditional ID approach each member of the team evaluates the patient within their “nich” of practice and shares that information with the team. By contrast, the TD approach has each member providing care in all 4 domains (physical, psychological, social and spiritual) as a “generalist” but provides “specialist” care in their area of expertise. For example, in the process of doing a full consultation with a patient, I may sit down and listen to their story (presence, connection) and learn what provides “meaning” in their life while obtaining the history of the patient. In fact Tim Ford advocates that much of the spiritual history can be taken from the patient just by listening to their story and in the process of doing the consultation without having go through a checklist. In this way I am a “generalist,” for the “specialist” (chaplain) to follow up after this information is shared with the chaplain. In the same manner he stated that he would not ignore soiled linens if he went to see a patient or ignore their excruciating pain. In fact he stated that he may not be able to address their spiritual pain if the physical pain is not adequately addressed. I have often seen this on my hospice team. I will get an occasional phone call from the chaplain stating a patient he was visiting was having increased pain. He has been trained in basic pain management to a level that he can relay pertinent information that I will use for appropriate follow up care. In this manner he is being the “generalist” and I followup as the “specialist.” I feel that this model engenders the true definition of holistic medicine. And lastly he reinforced the power of “presence.” The power of “just being” present can make a significant impact on a patient or family. I am thankful I attended this session and will take a new found interest and zeal back to my practice in regards to spiritual care.