COVID-19 and the Role of Surgical Palliative Care

#006 - Recorded on March 20, 2020. Join host Dr. Red Hoffman, cohost Dr. Mac Cook and guest Dr. Katie O'Connell (acute care surgeon and director of surgical palliative care at Harborview Medical Center in Seattle, WA) as they discuss the Covid-19 pandemic and the various roles that surgical palliative care may play throughout this public health crisis.  They compare notes on the responses of their various institutions and commiserate about the shared sense of anxiety, boredom and identity distress that many surgeons throughout the country are currently feeling.  They also talk about the importance of making sure that all of patients have updated advance directives, the use of telemedicine at end of life, ethical dilemmas in the time of resource scarcity and various resources (listed below) that may help all surgeons deliver primary palliative care to our patients.  Thanks to Mac and Katie for a thoughtful, honest discussion and for the reminder that we all have an important role to play during this difficult time. 

Resources discussed in this episode:
Elective Surgery Acuity Scale by Dr Sameer Siddiiqui at St. Louis University.

Covid-Ready Communication Skills published by Vital Talk- an invaluable resource to help guide your conversations with patients and families.

Covid-19 Response Resources provided by Center to Advance Palliative Care (CAPC).  Beyond communication tips, CAPC is providing- free of charge- symptom management protocols so that all surgeons are armed with the tools needed to provide excellent primary palliative care to our patients. 

Ventilator Allocation Guidelines provided by NY State Task Force on Life and Law and NY State Department of Health.  These guidelines provide an excellent introduction to the ethical considerations necessary when resources are limited. 

Rationing Life Saving Treatments in the Setting of COVID Pandemics: A Podcast with Doug White and James Frank by GeriPal Podcast.  This discussion of public health ethics manages to be both very nuanced and very understandable.  Well worth a listen. 

Surviving Sepsis Campaign: Guidelines on the Management of Critically Ill Adults with Coronavirus Disease 2019 published on Friday, March 20, 2020 by the Society of Critical Care Medicine. 

To learn more about the surgical palliative care community, visit us on twitter @surgpallcare

Transcript

spk_0:   0:13
surgical. Palliative care may seem counterintuitive, but surgeons have a rich history of pallid both their patients and their families. I am Red Hoffman in acute care surgeon in Asheville, North Carolina, and one of 79 surgeons currently board certified in hospice and palliative medicine. Join me as I interviewed the founders and the leaders of the Surgical Palliative care movement, a diverse group of surgeons dedicated to providing a high quality pallid of medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast way hell with more than steel. Hi, everyone. This is Red Hoffman. Welcome to another episode of the surgical palliative care podcast. My host for today is Dr McKenzie Cook. Mac is an assistant professor of surgery in the Division of Trauma, Critical Care and acute care surgery at O H s U School of Medicine in Portland, Oregon. Mac, thanks so much for being with me today. Yeah. Thank you so much for having me, Of course. And today, Mac and I are so excited to be speaking with Dr Katie O'Connell. Katie is an assistant professor of surgery at University of Washington School of Medicine and is the director of surgical palliative care at Harborview Medical Center. Katie, thanks so much for being with us today.

spk_2:   1:50
Thank you both. So much for having me. I'm really excited to be on your podcast.

spk_0:   1:54
Thanks. So, Mac actually suggested to me that we should do a podcast focused on Cove it 19 how this virus is affecting the surgical community and also how we as surgical palliative care providers may be helpful in this pandemic. So I wanted to just give a little bit of background as of six o'clock this morning. According to the Johns Hopkins Corona Virus Resource Center, there are 14,250 confirmed cases of cove in 19 in the United States, with 205 confirmed deaths, 74 of which have been in Washington state. So, Katie, given that you are currently practicing in one of the epicenters of the virus, can you give us an overview of what's been going on in Washington state and in your hospital for the past several weeks?

spk_2:   2:48
Ah, yes. Oh, this is really it's been in day to day sort of process and has ramped up over the past couple weeks. Um, and I think a lot of folks are contacting people from the University of Washington for guidance now because they're in other parts of the country that are you anticipating They're gonna be in the same spot in the next coming weeks as we are now. But essentially a few weeks ago at the university, there was a group of multidisciplinary leaders, both at the university and at Harborview Medical Center, who formed what we call like the Incident Command Center. These people are essentially working tirelessly around the clock to perform like situational awareness, developed protocols and keep all the UW medicine members informed of the current status within our medical system and what they're focus has been. There's, Ah, a Central Cove ID protocol repositories that's published on our institutions. Internet that details everything from environmental service. Is cleaning protocols to Papper Hood really use protocols and, like code blue guidelines, everything. And it's available to all of us working in the medical system. It's constantly changing every day. We're getting updates from the leadership on what our status is at each of our UW medicine hospitals in terms of patients who are currently positive patients who are pending test results, resource availability and sort of they're planning process in terms of shifting resource is and rolls of certain providers. A lot of people are having to be flexible and start thinking kind of outside of the box in terms of ways to adapt to this new crisis.

spk_1:   4:56
So on about a week ago, on March 13th the American College of Surgeons issued this recommendation that hospitals, health systems and surgeons should review their schedule. Elective procedures to basically minimize, postpone and cancel scheduled operations. To try to save human resource is to try to save P. P E. And to try to save. I see you and hospital beds for this coming Serge, Red and Katie, How are your God? How your hospitals dealing with us, but we following these guidelines. So

spk_0:   5:26
I work in Asheville, North Carolina, for a for profit institution, and I will say that on this past Monday. So several days after that came out, we got a letter saying that we are going to continue elective procedures for now, and the reasoning was that we have enough room and enough equipment, and resource is so we can and you know what came up for me. Is that palliative care saying Just because we can doesn't mean we should. And I did feel in some ways that it kind of ignored that whole idea of Do we really need to be bringing people into the hospital now who may be carriers of the virus? Do we need to be exposing our workers to them? Do we need to be exposing these patients thio other people who may potentially be carrying the virus? So it really brought up a lot of ethical concerns for me and for other people. I will say I think as of this coming Monday. So when this podcast is being published, actually, ah, my hospital is going to be stopping elective procedures. I understand the financial concerns, but I think that really it's the right thing to Dio. I actually heard I was listening to the daily yesterday, Think and Governor Cuomo and New York State was just saying like and it was so true. He's like, if you if you're not alive, nothing else matters. I mean, that's the That's kind of where we are. So I feel for a lot of my colleagues who were certainly paid based on production, but I just think for right now it's the right thing to do. So I'm glad to say that where I work is getting in line with that. What about you, Katie?

spk_2:   7:17
Yeah. So we received. Noticed last the end of last week, I believe on. And so we started canceling our postponing our elective non urgent cases as of Monday. And this is Ben. Challenging, especially for me is a new attending because there's a couple of different things that have come up. There's a lot of anxiety and making these decisions to postpone a surgery first because we don't really know how long this, you know, the impact of Cove. It is gonna last and to most of these cases really have the potential for disease progression. And so some of these patients, you do worry. Are they gonna convert from an elective operation too? A more urgent or emergent surgery. So that is definitely something that I think people are dealing with now. And I know myself and and some of my junior partners air kind of bouncing ideas off of each other. Hey, what do you think about this? Do you agree that this patient can can wait. But one of the things that I found helpful was the A. C. S recommended the elective surgery Acuity scale published by Dr Siddiqui. It ST Louis University which is just a really guide surgeons and sort of making these decisions. And it's kind of like this tiered based system that looks at both the combination of the acuity of surgery and the health of the patient. It just gave me a little bit of reassurance to kind of have some sort of framework for making these decisions.

spk_0:   8:53
I think it brings up the point to what is truly elective. You know, I think in the public's mind, elective might be something say a breast augmentation, but that really in our world, it's not always black and white that it is gray that what may be considered elective right now in four weeks or in eight weeks may end up being an emergent procedure or may end up causing someone thio have, ah disease progression. And so I think it has been challenging on that level A swell

spk_1:   9:24
Yeah, you know, the unknown of how long we're gonna be at this, I think is really our hospital's designated a series of surgical triage officers who are, you know, senior level surgeons to basically provide that decision support to people, you know, like, is this actually elective? Can it be delayed? What's the implication? You know, the challenges you got general surgeons making decisions about spine surgery and urologist make, you know, like it. You started across specialties, and it gets very complicated very fast. Okay, this is probably, you know, dovetails with the parrot of how do you approach patients in that situation? How would you recommend approaching patients? You know, they been getting geared up for a big operation or an operation that they think they need it. We have to call him and tell him that. Sorry. It's not gonna happen right now or may not happen for a month or two months or six months or who knows?

spk_2:   10:15
Yeah, that's really challenging for us. Some of our patients that are strictly elective operations, such as, like inguinal hernia repairs, those I patients. I feel comfortable having our patient care coordinators reach out to them and explain the situation. For the few patients that I've had to cancel that are more complicated. I call the patients and, um, speak with them myself to kind of explain what's going on. One of the things that I have phoned helpful is vital talk. Um, has published a short document on sort of How to respond to covert related issues from a pellet of care standpoint and that's that's published on the website on. And so it addresses some of these potential responses that will get as providers. You know, maybe people are frustrated. They're anxious. They're worried and kind of go to phrases of how to best navigate these conversations.

spk_1:   11:19
You know that vital talks link has been immensely helpful. We shared it amongst our icy physicians. You're down it in Portland and it's hopeful. I mean, hopefully we don't need it, but it's been very helpful in sort of how we're gonna approach these coming mess. Yeah,

spk_0:   11:34
and I'll make sure to put that in the show notes, because I have used it as well.

spk_2:   11:38
I thought

spk_0:   11:39
between the three of us we could talk a little bit about what we feel like the role of surgical palliative care is during this pandemic. In my mind, there's several different opportunities for support that I thought we discuss, and the first I thought we could discuss is just the ongoing care of surgical patients, like our surgical patients who keep coming in to the hospital. So certainly for us, our trauma patients and our emergency general surgery patients and as the palliative care teams become overwhelmed, I think that surgeons are going to need to step up and provide Maur primary palliative care. And I certainly think as people who do palliative care, we are in a position tau help our colleagues with this. One thing that I wanted to mention and that'll certainly put in the show notes as well, is that the Center to Advance Palliative Care, which is cap see, has published some amazing free resource is on their website, too assist with all sorts of symptom management. So not just looking at end of life care, but looking at things that we would often call the palliative care team for like nausea and vomiting in the setting of a malignant small bowel obstruction. Dystonia would certainly not just covert patients, but some of our other patients could be dealing with crisis management for both the patients and the families. So that was certainly one way, I was thinking we could support our surgical colleagues and kind of helping them come up to speed with their primary palliative care skills.

spk_1:   13:14
Yeah, it's gonna be a bit of a challenge. You know, You know, this is something that we do on a regular basis is trauma, and it could care surgeons and intensive ISS And it's really gonna be a challenge to bring people who this isn't part of their daily life into the fold. Katie of you guys had to do that. You have a sort of like, real time trained people are just in time train people to provide these complex primary palliative care.

spk_2:   13:36
We haven't yet, but I will say that the palliative care the specialty pounded palliative care team at Harborview has in UW medicine, has already developed and published sort of their plan for what the current state is and how they're triaging consoles on dhe. They broke it down by both in the emergency department on the acute care floor. And also I see you and then part of that plan is sort of like the surge state that's coming. And so they carefully outlined how they're going to sort of reallocate. They're already scarce manpower. And one of the main points of that is to really help in guiding. The primary service is too be having these conversations on their own. I think one of the things that I experienced last week I was on the trauma service and we noticed that our patients and the trauma I see you were waiting for, like, three days or so to get family meeting set up with the specialty palliative care service. And so they they're already feeling this cove in impact because they're getting consulted on on all these positive patients What I proposed waas in light of the fact that we have now drastically decreased our trauma admissions, Uh, we have canceled all of our general surgery clinics, and we have postponed all of our elective surgery. So for, like, the first time ever surgeons band with is like, drastically increased, Everybody's bored, you know? It's so weird. Yeah. Uh, yeah, So I think people, you know, some people, especially the more senior people are actively involved in, um, like the incident command and all the planning process is, um but for someone like myself, who is just in second year of attending. I tried to figure out a way to help, and we came up with an idea to create this sort of temporary surgical palliative care service. My my partner, this is like a two woman team. My partner is Andrea Gall, who's one of our outstanding nurse trauma coordinators at Harbor View. But we have joined forces to provide palliative care. Service is to our surgical I seeyou patients, and that is one to kind of prioritize. They're palliative care needs during this whole crisis, but also to offload the consults from the specialty palliative care service. That is kind of getting inundated and trying to figure out how to triage appropriately.

spk_1:   16:37
You know, Katie, you said something a little earlier. That kind of raised the question in my mind. You know, one of the things we try to do in people who are admitted to the icy, completely trauma patients were admitted to the I. C. U. Is have our first family meeting or goals of care discussion within 72 hours. Given the potential severity, uh, you know that I think Evergreen just published their case, Siri's yesterday and described a 50% mortality rate for patients with covert and icy admissions is just being covered positive and getting admitted to the hospital or admitted to the E S u. Should that trigger a similar threshold? You know, given that how overwhelmed everybody is and the fact that it may take a couple of days to set things up like should being covered positive in the hospital trigger a preemptive goals of care discussion?

spk_2:   17:21
That's a really good question. I think that, um, the gold Yes, yes, to the goals of care discussion, in my opinion, because there's a potential we certainly are seeing people in their thirties and forties who are getting very sick with co bed. So despite popular belief that it's mostly impacting older people, we are experiencing younger people getting really sick. And so I would say yes to goals of care. But I think reserving the palliative care consultations for those people who are in a particularly challenging situation so that we're not like overburdening that service, which I think you know what most intensive ist have Excellent primary palliative care skills and Concertante Lee provide that service.

spk_1:   18:12
So maybe they have a different way to phrase that then is you know, we should probably take the same approach we take toward badly injured trauma patients. You know, like the primary service. The primary issue service should sit down and have a real discussion about gold in case things go the wrong way.

spk_2:   18:25
I would argue that probably the 70 72 hour mark. It might be too long if we're expecting to be short on life sustaining treatments. Um, ventilators air gonna be in demand and manpower that maybe this really does need to happen within the 1st 24 hours.

spk_0:   18:47
It's kind of just this aside note, but I was just thinking of this. Katie, have you guys talked about as faras Performing Tracheostomy is on these patients like early versus late. Like, have your practices changed at all. Or if these patients are in the medical ice is to the surgery team getting Consul Tid too. Do tricks on these patients.

spk_2:   19:08
Yeah, that's a really great question. It it actually hasn't come up yet. For us, we are People are talking about that. Like, how were we going to deal with covert positive people going to the operating room? Um, and the undoubtable impact that that's gonna create for the operating room. We haven't hit that that road, Blackie and

spk_0:   19:35
I, you know, I tend to do most of my tricks Air perk tricks in the I. C. U. If the patient's Anatomy and then settings are amenable to that. Although I'm wondering if in this population the vent settings are not gonna be amenable to a perk trick at all, that kind of thinking it through is it more dangerous to be doing a perk trick or more dangerous to be doing an open trade? And who needs to be in the room? And it's just, I haven't read anything about that yet,

spk_1:   20:02
had this conversation for the first time yesterday in the setting of a coded positive patient who was on V. V. Ecuele. And because our practice least drachma patients is early tricks to facilitate mobility and recovery and the kind of our our discussion, you know, And really, for the first time, I felt like I was making actual patient care decisions that was driven by resource limitations on specifically peopie limitations. You know, it's a very high the air civilization is a real risk, and we're very low on peppers if not out of peppers, you know, and it was gonna take. You put three people in that room, right? Me and anesthesiologist on the nurse, all in papers. And e think the other thing to think about is that the human resource is particularly of intensive ists are for real. You know, we have you start losing a bunch of intensive ISS to quarantine or illness, like you start to run out of people kind of quickly.

spk_2:   20:59
Yeah, we've been talking about that amongst our group as well, because not only are we intensive ist, but we're the trauma surgeons were the general surgeons, and we're the ECMO providers. And so if you if you start taking out our group, that's that leaves a huge gap in the service is that we provide?

spk_1:   21:20
Indeed, I think it's it's been a real interesting discussion for us and read, I'd be interested in your thoughts on this, too. We in our ECMO group is sure between the surgeons the palm critical care on the anesthesia critical care. But obviously, you know, there's 1/3 of us or trauma surgeons, and we have that same discussion. Katie, if we if you go down a couple of trauma surgeons, like all of a sudden, the trauma system for the entire state where the entire city goes down.

spk_0:   21:42
Have you all made specific ECMO protocols based on Cove? It?

spk_1:   21:48
You know, I was actually up it midnight last night, writing ours, Not meant to be a leading question about it. You know, it's really interesting. And, um, this is I'm an optimist till the end, and I I do One of the fascinating things that I think has happened very rapidly, um, is that hospital systems that have previously not wanted share, like systems level information are like actively sharing systems, little information. So this this is actually the work I think of General Badger Lock is at the UW. She's an emergency medicine doctor, a critical care doctor, and one of the leaders of their ECMO program is unequal education she's put together. It's a regional dashboard of all of the hospitals in the Pacific Northwest that that can provide ECMO. You know, it's us. It's, um it's Emmanuel. It's the UW. It's the Children's hospitals, basically to be like we've got got, like, 35 beds in the Pacific Northwest that can do this and we're trying to design and it's gonna be a resource limited setting, right? So and we want to use that resource to the people who were gonna have the greatest degree of the greatest degree of a good outcome. Greatest chance of a good outcome. And it it's gonna think, come down to some moderately arbitrary age limitations. It's gonna come down to people with significant or really, increasingly, any medical corps. More abilities are not gonna be great candidates people with other organ system failure or not gonna be great candidates. But we're trying to make that decision for all of the ECMO programs in a region so that it's not like when referring hospital calls harbor view, they get a different answer than than when they call a witch issue or that work. Not that we're gonna be competing for patients, but that, like people get shunted different patients. We want to have the same set of contra indications, which are going to be much more restrictive than we usually d'oh. But it's been fascinating. You moved within a week or two, like this group has formed and is really designed, deciding on indications of contraindications that previously nobody ever would have agreed to or shared.

spk_0:   24:03
Mac, have you looked at I was just reading earlier today. The New York State Task Force, like ventilator allocation guidelines. Have you looked at those?

spk_1:   24:12
Uh, not in any detail. Now.

spk_0:   24:14
They're just really well worth reading because they really do bring a lot of the like, ethical principles into play and really try toe make decisions based on these principles. Because, of course, one of the things that we worry about in a resource limited setting is that those of of advanced age are going to be quote unquote discriminated against. And what does that mean for us as, ah, society is just a interesting topic.

spk_1:   24:40
You know, Katie is as a intensive ists and a Pirated care doctor. These are gonna be really stressful decisions for everybody to make. It's gonna be tough on the patients on the family, and it's gonna be really tough on the physicians and the nurses. How do we support ourselves and our staff and our partners through this way, doomed to be broken?

spk_2:   25:09
You know, one of the things that I've been mindful of during this the past couple weeks, is surgeons coping strategies with sort of like the changing landscape of our roles. Eso, for instance, like in our group, there's a small number of us who are either at higher risk or are currently in a more vulnerable state such as myself. I'm expecting in September Congratulations s O. There have been changes that have been made to like our service schedule and our call schedules to reduce risk as much as possible for those few of us who are in that group. And speaking from experience, I think it is hard, especially for acute care surgeons. You know, we live every day to be a part of disaster solutions, essentially and to kind of be able to step back and allow other people to do the work right now is really, really tough. And so I think there is a component of like identity to stress about oneself and one's role in society during this time, you know, trying to be mindful of that and trying to be supportive as possible for people. Are you seeing any of that in your groups?

spk_0:   26:26
I think, uh, kind of how we were talking about before the trauma census has gone down so considerably. So I I was just on the trauma service for five days and I mean, I am never bored at work, but I was I just felt board and kind of useless. And then I was saying this to you before Mac like, Yeah, I wasn't very productive doing any other academic work. I just felt kind of anxious and in stock and and in preparing for this podcast I thought a lot about you know what can I as ah, someone has been trained in palliative care and has, ah, you know, a background is a yoga teacher and really tries to be mindful like one? What could I do for myself? But to like this part of my job and my training is to like, step up and and be supportive of other people who I'm sure are feeling the same thing and maybe just are in articulating it the same way as me. And so I was just thinking, like if nothing else, trying to maintain some sort of positivity and love and light in this space is just really important and just kind of holding space for everyone and what everyone's going through, I think is is like, at least one little thing that we can D'oh.

spk_1:   27:41
Yeah, you know, it feels I don't know if you guys feel this way, but we you know, when you're waiting in the trauma bay and you can hear the sirens, you know, and you know that they're hypertensive. You're just like, Come on, come on, come on. Like you just if this is gonna happen, I almost just wanted to I don't want people to be sick, And I don't actually want a health care system to collapse, but like, it's gonna happen, like let's just get it. Yes. You know, like a way they're awful tired of talking about it wildly unprepared. Let's just

spk_2:   28:11
go. Yes. I think that's the trauma surgeon in us. Yes, I feel so understood right now, right. Our medicine colleague may be feeling quite differently.

spk_1:   28:25
Oh, God. You know, this, um, just happened at our hospital, and I'd be really interested in your thoughts. Both of you actually are hospital. As many have have instituted very severe visitor restrictions from probably other infinity from public health perspective. But we haven't an elderly patient who is cozy, covet positive with bad air D s and he died, and this was after a transition. It was after goals of care discussion, and it was a planned transition to comfort focus measures. But at the time of his death, he had one person in there in full P p e. I was sitting there watching this, and I was like, How are we going to deal with people dying in quarantine? Because it runs contrary to everything else that we want to do around the time of death, providing comfort and normalcy and family presence. And we're just very, clearly not gonna be able to do that. Thoughts, considerations, advice.

spk_2:   29:22
Do you have a protocol mat for her back for that? Are people allowed to be at the bedside as long as they're in?

spk_1:   29:29
Yeah, Didn't our hospital has said No visitors period, except for Children and people at the end of life can have one visitor, you know, But it's a person in, you know, a face mask and a shield and gloves and gown, and otherwise you try. You try to get as many people in there at the time of death. It's just runs against everything we've been trying to do, and I worry that is the volume. If we're really going to see a surge here in the volume of deaths, is going to increase our ability as surgeons intensive inspite of care doctors to devote the time we need to these transitions is gonna rapidly fall away.

spk_2:   30:06
One of the things that I thought about Mac when you were telling that story is maybe utilizing this sounds sort of terrible, but but telemedicine capabilities for those cases, the other things that we do to help patients and families at the end of life, like playing their favorite music were potentially having spiritual care available. Those small things to help kind of ease this transition. I don't know. Do you have thoughts read?

spk_0:   30:36
I was thinking a couple of weeks ago when I was in the I C. U. I was taking care of someone and we had three. She was dying and ah, there are a lot of family members in the room. But we had three different cell phones on her chest, with people there also talking to her and just like being present. And they were definitely in the room, too. And so I think just as a society, we've become more comfortable. I've had a lot of people on cell phones at the end of life now and and just making sure that we can help facilitate that are making sure that everyone's on a group called that they could be there. I think we're just gonna have to turned to that. It's not as good, but it's something.

spk_2:   31:14
Yeah, we're certainly We have this similar policies of no visitors at Harborview. They've gone as faras like barricading our most of the entrances and exits to the hospital. What we're dealing with in the trauma I C. U is folks who are approaching end of life and their family members can't be there. And that is so unbelievably frustrating for people. And so having family meetings in having zoom or Skype er, whatever face time set up by the nurses having pictures of family members in the room, all these things are becoming more and more important. And for us, we're trying to figure out all of these like telemedicine nuances that we've never really had to deal with before, like having family meetings over Zoom, which for for palliative care providers in my experience has been extra challenging because I really rely on, like, the emotional cues of the room and that, like, nonverbal feedback that you get from people. And a lot of that is last, um and so it does feel kind of clunky. But, you know, we're doing the best we can.

spk_1:   32:30
I think that's what it's gonna have to be like we're gonna take all of these palliative care skills will be developed. Katie's reference toe, respond a non verbal and emotional cues, and we're gonna have to add them in Elektronik Communications that it's a whole, very new, challenging skill set. But

spk_0:   32:48
I think Katie used that word flexible. I think twice now. And I think that's what it's calling on all of us to be flexible. I think sometimes surgeons in general, sometimes our personalities are a little fixed, and I think that we're just gonna all have to go with the flow a little bit more and just make it work. I want to shift a little bit because I was listening to a cap. See Webinar yesterday, Think and Diane Meyer, One of the things she said is we really need to make sure that in this time of Kobe that the palliative care team does not just fall back into being the end of life team that, like palliative care, has so many other things to offer. And so one thing I've been thinking about from my palliative care world is making sure that all of my patients, when they're leaving the hospital, have good advanced directives. And so I was wondering if we could maybe talk a little bit more. Have you guys been doing that? I try to be really careful on trauma when someone's going to, ah, discharging to any place other than home that they're going if they need a d N R form, or that their most form that I've reviewed it and updated it with them. But, you know, certainly. Sometimes I let that if I'm busy, that kind of falls off my to do list. Unfortunately, and I've noticed that I've just been being really vigilant to make sure that I'm talking toe all of my patients because my concern is that if God forbid, they come back to the hospital and then their families can't visit them. That here were left with these forms that they may or may not have.

spk_2:   34:21
Yeah, I'm really thankful that you're bringing this up because I feel like it's something that I certainly need toe start prioritizing more for our group. I think you know, it's because it's a weakness that existed before this one little thing came out, and now it's just it's being elevated as such a huge priority. I think the challenge now is that for us, we've scaled back significantly in terms of like the floor manpower, right? So we don't have medical students anymore, and the residents are cut back. Time and resource is air limited to have these in depth conversations. But I know for for people who are getting discharged a skilled nursing facilities here, they do have to have a post form. But you worry about the quality of those conversations being had.

spk_0:   35:15
Mack. Have you seen any changes that away? Just you

spk_1:   35:17
think the biggest change we've been dealing with his people, patients and their families are asking really legitimate questions about going home first, going to a sniff, you know, And when we have these discussions about leaving the hospital and return to the hospital on dhe post forms you know, they rightly bring up that many of the major. You know, one of the major risk going to sniff now is contracting current virus. It's really it's been an interesting discussion universe balancing, going home with maybe some sub optimal care and knowing that there's a higher risk of returning to the hospital.

spk_0:   35:51
I've even noticed just thinking more thoughtfully, I guess, about some of these geriatric trauma patients. Like Did they really need to be admitted to the hospital? You know, there's so many people I just admit for OBS. I'm always trying to do share decision making, but really kind of asking the family to like, What is your ability to tolerate risk and which risk do you want to tolerate more, You know, because that's a very that's a very personal decision.

spk_1:   36:19
It brings up the What's the goal of this hospitalization question much earlier than we have had two previously deal with, You know, because we do the same thing, right? You admit it's two o'clock in the morning and somebody's gonna little fall like we'll admit him and deal with it in the morning, you know, And but now it's two o'clock in the morning. You got to go down there and and say, What are you trying to accomplish? How can we do this?

spk_0:   36:41
But Katie, I think it brings up what you said How you know, as a rather new attending, which we all are making these decisions, they seem like very weighty decisions. And they're sometimes a little uncomfortable to make, like there's no clear guidance.

spk_2:   36:59
Yeah, I agree. I think last week what my experience was is that the majority of our new admits are older people who fall, and then they have a bunch of rib fractures that's pretty much almost like all we're seeing now. Shelter in

spk_1:   37:17
place is working.

spk_2:   37:18
Yeah, in some aspects, I found these conversations almost a little bit easier within the context of Cove it because people do appreciate this risk. Whereas I think before some, some people are like, Well, I want to make sure everything is in tip top shape and every you know, my pains control everything is good. Where, as now, the conversations I've had with regards to you know, if things don't go the way we're hoping for, either you die in the hospital or you would need life supportive therapy. I'm finding that most people are like, Nope, I not gonna go down that route. I'm And also they're totally on board with getting out of the hospital as soon as possible. You know, after having a frank discussion with them about there, risks with within the context of Cove in.

spk_1:   38:14
As the P P E limitations become more severe and the number of patients were seeing with active code disease become more common, it seems inevitable that we're going to begin to have to take care of our colleagues. Ah, you know, another spent a couple physicians in the Seattle area that have contracted this and died. What, if anything, do we need to change about our approach for for patients who are not only just physicians and nurses but are colleagues and our friends?

spk_2:   38:47
Gosh, that's that's like

spk_1:   38:48
another is the worst question. I know you think about it. One of my one of my colleagues was in a helicopter with a covert positive patient for three hours a couple of days ago. You know, like it's I think it's gonna be coming our way. The moral distress that's gonna be associated with E mean ethically. We can't provide a different set of resource limitations to our friends and colleagues than we do to the are the rest of our patients. Which means that we're gonna have to apply the same set of resource limitation decisions. Tow them that we would everybody else arguably right.

spk_2:   39:23
These conversations, because of what's been going on in Seattle, have been taking place and and I have heard people voice arguments for being a physician should count for something. We we do give up a lot of our lives in order to do what we do and should that count for something, you know. So that's like another argument playing into this. But I think we're getting down to like at what point are re shifting from prioritizing the well being of individual people to prioritizing the well being of like, the greater good. And I think where we're at in Seattle is still we're still treating the individual patient like we always would,

spk_0:   40:13
huh? Oh, that's that's interesting to hear that you haven't shifted yet because it sounds so awful there.

spk_2:   40:20
I feel like I haven't because we're not. Besides, like the p p e issue, all of Our masks are behind the O. R desk and we can only get one per day and things like that. We still have ventilators available. Our blood supply is down because people are social distancing and people aren't donating as much. But we still have blood. So I think a lot of people are talking about it and thinking about at what point are we gonna shift to having to change this focus of prioritizing public health?

spk_0:   40:55
Then there was just a Jerry Pal podcast on this yesterday. That was incredible. I'm forgetting their two names, but they're both physician to do a lot of bioethics. And, you know, one of them was talking about the fact that when the country declares, ah, a state of emergency in the state that you're living in declares a state of emergency that the ethics really shift away from a more personal ethics. Like the way we usually think about medicine and to a more public health ethics and that those ethics are different. And I mean, they kind of went through the whole ethical framework of how we make decisions and quoted several different articles that were written in the last decade about how we allocate Resource is, but one of them made the point that the reality is is we need to be thinking and talking about this right now because we are going to be faced with these decisions. Certainly there's some frameworks that may value physicians over others, and there's frameworks that may value younger people over older people, but that we need to kind of agree on some sort of framework so that we're trying as best as we can to take the subject iveness out of it, and so that if you go to a place like, oh, it just you or you come to me in Asheville that we're making the same sort of decisions and that's certainly a wayto help decrease. The moral distress of us is physicians is that we have some sort of framework to think about this rather than Oh, this is my hunch, and this is how it's gonna be.

spk_2:   42:22
Yeah, it sounds like what they're experiencing in Italy is they're really going through this right now without having sort of like a framework to go off of. And that's just causing a lot of distress for the people making these decisions.

spk_0:   42:38
What's interesting is the Society of Critical Care Medicine just released their guidelines for the management of critically ill patients with Corona virus. You know, even in these excellent guidelines that they managed to put together in the last couple of weeks, there's nothing about resource allocation, which to me it's such an issue. So again, we're we're asked to be on the forefront of this, and there's really, unfortunately, not a lot of guidance.

spk_2:   43:03
It's true, and I think that as palliative, care minded people, a lot of other folks think that, well, you must do ethics as well. But that is not true. It's not true, right? So the assumption is that if you if you have a palliative care interest or palliative care training, that you totally are into ethics and it's not true. Well, while I do think, though, that palliative care people should be involved in these ethical discussions, for all the reasons that we've talked about and they should be at the table, yeah, I

spk_0:   43:39
don't think way are the ones making the decisions. I think where we convey best serve, everyone is supporting people through their moral distress. I mean, I think We're really good at listening and holding space and helping people to normalize whatever feelings they're feeling. But there's something I was reading either from H P M. R on some palliative care Web made it clear. Palliative care physician should not be being called to make these ethical decisions. Unless you have another year of training or some special interest in ethics, that's not really within our realm. But again, I'm thinking of my own hospital. I think we have one person on the ethics committee right now. The palate care people are the next people who are going to be called Nevin early.

spk_1:   44:22
Katie, you're I think you're a framework of switching from care of the individual. Patient to care of the population is really fascinating and important framework because it's it seems like the pilot of commission is going to switch from care of the individual patient to care of the the team, right? And how do we make sure it's sort of you mentioned like support the primary team not only in the care of their patients, but if we're really gonna be at this for weeks and months and not you're not burning ourselves out of minimizing are the matter that we're gonna be burning yourselves out.

spk_2:   44:53
Sure. And I think a lot of that has to do with what we're doing now. So, like, Mac, I can see you're at home. I'm at home, You know, I'm at home and read that Home kidneys, which which resurgence is so hard? It's like counterintuitive, Ilic everything that we do. In reality. We're trying to preserve our man four so that when people do start getting sick, there's there's reinforcements.

spk_0:   45:24
Katie, Anything else do you want to add? As someone who's more on the forefront than the rest of us right now, Any other lessons? Learned or thoughts? Anything you wish you knew a couple weeks ago that you know, now that you can pass on to us,

spk_2:   45:38
I feel like the key to this is gonna be having each group wherever you practice needs toe have, like some sort of palliative, care minded person, and that for that person to be able to step up and really focus on all of the things that we've talked about today on the podcast, a lot of my colleagues such as Mac and other fellows that have come after him have now gotten jobs all across the nation. The younger generation of surgeons tend to be the people, even if they don't have palliative care fellowships. They are the go to people in their own place for these powdered care related topics. Trainings and a lot of them have reached out to me in terms of Hey, I'm thinking about doing this journal club or we're putting together this protocol for covert like, What are you guys doing? And so I'm really encouraged by that that there are younger surgeons, that air sort of stepping into this role, and I think this is an opportunity to really ramp up. Take ownership of that role is like the the surgical palliative care person in your group.

spk_0:   46:55
Hi lot. I love that

spk_1:   46:57
Katie, you're totally right. There's a couple of these, like pillars of surgical pirate of care and the older generation of surgeons. And then there's this huge army of us who have been trained by them and really, you know, can't be more than five or six years into practice, right? You know, start time. It's our time to season a millennial hash tag. Millennials. It just reminds

spk_0:   47:19
me of why we might not have the insight yet in tow. How to be on these huge committees that are deciding upon hospital protocols. At this time, we really can be important members of our department both supporting the patients and making sure that every patient leaving has these advanced directives making sure that if these family meetings aren't getting done by the palliative care team that we're stepping in with our extra time in doing these family meetings, making sure that our colleagues feel supported so that we do bring something important to the table even if we're younger in our careers. Absolutely. Well, I appreciate so much your time, Mac. Thank you again. You're in my awesome co host. That's one word. Katie. It was so awesome. Toa finally get to meet you and to chat with you. And I'm so appreciative of your time during this busy time in your life. And I just wish all of you guys at Harborview and in Seattle just sending you all my love.

spk_2:   48:18
Thank you so much for having me. Yeah.

spk_0:   48:21
All right, You guys hang in there. Yeah, thank you very much. Stay healthy. You. Thanks. Thank you. for joining us for another episode of the surgical palliative care podcast. Be sure to subscribe to stay up to date on the latest episodes. Toe. Learn more about the surgical palliative care community. Follow us on Twitter at Serge Pal care. If you'd like to get more involved with the surgical, palliative care Social media team, please reach out on Twitter or via e mail at surgical palliative care at gmail dot com. Lastly, take good care of yourselves and take good care of each other.