Welcome to MedEvidence: Two Docs Talk Hospice and Palliative Care. In this 4 part podcast series, Dr. Michael Koren and Dr. Alpa Patel bring you personal stories, expert insights and valuable knowledge on the importance of Hospice and Palliative Care for patients suffering from severe chronic diseases. Part 1 focuses on cure vs. comfort.
Whether you are a patient, caregiver, or healthcare professional, this series is the perfect resource for learning about hospice and palliative care. Tune in to gain a deeper understanding of these important healthcare topics and to discover how they can help improve the lives of patients and their families.
Listen to the whole series:
Two Docs Talk: Hospice and Palliative Care Pt 2
Two Docs Talk: Hospice and Palliative Care Pt 3
Two Docs Talk: Hospice and Palliative Care Pt 4
Alpa Patel, MD, is an internal medicine expert in preventive care and patient-centered services at Millennium Physicians Group and has been practicing clinical research for 16 years at ENCORE Research Group. She received her Doctor of Medicine from, the University of Florida College of Medicine, Gainesville, FL. with her residency at the University of Florida Health Jacksonville Department of Internal Medicine, Jacksonville, FL.
Michael J. Koren, MD, is a practicing cardiologist and Chief Executive Officer at Jacksonville Center for Clinical Research, which conducts clinical trials at 7 locations in Florida. He received his medical degree cum laude at Harvard Medical School and completed his residency in internal medicine and fellowship in cardiology at New York Hospital/Memorial Sloan-Kettering Cancer Center/Cornell Medical Center.
He is a fellow of the American College of Cardiology, fellow and two-time president of the Academy of Physicians in Clinical Research, and the regional chapter of the American Heart Association.
Original Air Date: March 31, 2023
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Two Docs Talk: Hospice and Palliative Care Part 1
Welcome to MedEvidence where we help you navigate the truth behind medical research with unbiased evidence-proven facts powered by ENCORE Research Group and hosted by cardiologist and top medical researcher Dr. Michael Koren.
Dr. Koren: My name is Dr. Michael Koren. I’m a cardiologist and I'm the host of this MedEvidence educational session. I am delighted to have Dr. Alpa Patel sitting next to me who is a tremendous internist and excellent clinical trialist. I've worked with her for a number of years. She just reminded me that it’d been 16 years that we've been working together. Amazing and she's also had a recent personal family situation that she's going to talk with us about. This involves the concept of palliative care. Palliative care is something that all of us in medicine get exposed to because as hard as we try some patients have just incurable problems. It's always a little bit of a struggle for us in terms of one accepting the fact that you know maybe we don't have the answer for everything and maybe there is a less intense approach in terms of medical intervention to help people deal with end-of-life issues. So, Dr. Patel and I are going to explore the concepts of palliative care this morning. She's been kind enough to be willing to share some very personal experiences and I do appreciate that.
Dr. Patel: Thank you so much.
Dr. Koren: Let me just ask you to give us a little bit of your background and your previous exposure to the concept of palliative care. Then we'll get to the point where you can talk about what happened to you personally and why this became a very passionate concern of yours.
Dr. Patel: Sure I’m an internist as Dr. Koren mentioned I've been practicing now 22 years and have done clinical trials for almost 16 years. I've been very privileged to work with you during that time. I would say I've used palliative care in these terms for my patients for quite some time now. The main objective behind palliative care is to make the patient and the family comfortable with the next stage of managing a chronic disease. These patients are not looking for a cure at this point. Whatever treatments are given to them are not for any curative intent of the disease. We realize that the disease process may continue taking on whatever form or shape it takes. However, during this process we make the patient and the family feel comfortable. They can have objective relief from pain, and some subjective relief, providing counseling and social support to the family. During this time spiritual counseling and respite care, all of this is an essential part of helping this patient and their families. I have patients you know who are suggested to do palliative care be hesitant at first because they think that as Physicians, we're giving up on them. And that's where they have to realize that at times, we don't have all the answers. We don't have a cure for every disease. Especially as a patient ages and cannot tolerate a lot of medications or treatments. Which is what we've kind of dealt with my father and I'm willing to talk about our experience and how we even got to this.
Dr. Koren: Well before we get to your personal situation, I want to highlight this concept of cure versus comfort. So it's very interesting so in medicine, most of our training is about cure obviously. We diagnose disease and then we try to cure whatever the problem is. Some things we can't cure but we can manage well. But the other part of what we do as clinicians and particularly through medical training is learn about comfort. There are different elements to that and certainly, symptom relief is one of the reasons that we do what we do. But sometimes a cure and comfort work together quite well but at other times they may be working against each other so if you want to comment on that concept.
Dr. Patel: Yeah, and in fact when I started this journey again, I keep going back to my father because this is all I can relate to. Because even when I've made referrals for my patients after that initial palliative care referral is done, we're almost out of the picture. Until you experience it yourself the disease process that we dealt with my father was oral cancer, which is a very painful condition. His health was very frail, to begin with. He's 85 with multiple comorbid conditions that put him at very high risk—of long-term complications from any curative treatment. So, we opted not to have surgery, which was what was recommended to us.
Dr. Koren: Yes, so that's really, really interesting so that's the focal point between cure and comfort. And probably cancer patients are the patients that are most likely to be referred to palliative care. But in my space in congestive heart failure, it happens as well. So, for example, you may have somebody with a severe valvular disease problem and there's a potential cure through surgery. Still, you have to weigh what the risk of that surgery is and whether or not you're putting the patient at such a disadvantage in terms of achieving their comfort goals. The cure is not even worth it so of course in medicine we always have uncertainty. When we go about a decision-making process for example whether or not to treat oral cancer with major surgery which may or may not be successful. We have to look at the comfort side of it. That's certainly something that we do and it crosses a lot of different areas. Can you think of any other areas other than cancer and heart disease where that might come into play?
Dr. Patel: I think congestive heart failure for sure like you mentioned valvular heart disease even in severe coronary artery disease. I've had a population of patients who really didn't want to go through a cabbage, and they made significant lifestyle changes to improve their heart disease. Which can be achievable I think in the past we always pushed procedures on patients or surgeries. And I think there's a big push now for us to consider the patient as a whole and improve their lifestyle. A lot of their chronic conditions improved just from that some things that come to my mind in my space are aneurysms.
Dr. Koren: So, I've certainly had patients over the years that have large aneurysms that are in danger of rupturing and causing catastrophic consequences. Once they rupture the risk of dealing with them can sometimes be extraordinarily high. And of course, there's always a protracted post-hospital course after surgery which people may not want anything to do with. I have, you know one particular example a lovely fellow who was an Air Force colonel and he had this massive aortic aneurysm up to nine centimeters.
Dr. Patel: Wow,
Dr. Koren: It's crazy but he lived with it for about 10 years, and we had multiple discussions. I think we first discovered it when it was about six and a half centimeters, and he was high risk for a number of reasons and I remember his creatine was very very high. So he may have needed to be on dialysis and the thought process would be that if we did the surgery, he would almost certainly be committed to dialysis long-term. He hated that idea.
Dr. Patel: Yeah
Dr. Koren: So we actually watched this in a palliative care setting for many, many years. Wow and again it was this concept of cure versus comfort. Again I stuck with him and we talked about it every time that I saw him I felt the obligation to mention at least the fact that there was a potential cure. He and I were on the same page knowing that we had decided to go with the comfort approach.
Dr. Patel: Yeah and I think even as physicians we don't discuss that comfort approach as a first-line option for patients because maybe we feel like our patients may think we're giving up on them. Like even when we saw my dad's surgeon his ENT surgeon for the first time They were gung-ho oh yeah we can do this, we can operate, we'll take a graph from here we'll need the muscle this with this, he'll be on TPN for this many weeks, he'll get a tube feeds and wait a minute we don't want to do it.
Dr. Koren: Part of my job is just to define some things we say TNP that's Total Parenteral Nutrition.
Dr. Patel: Yeah,
Dr. Koren: Which means you're basically not eating and you're getting all your nutrition through IVs. Which is not exactly comfortable right?
Dr. Patel: And my dad and I interrupted him at that point and said listen he's 85 and a lot of the pleasures that he may have left at his age you're talking about taking all of those away. He's been a chef or a cook most of his life and he loves to eat. Now you're talking about putting in a feeding tube and he's like I'm not going to enjoy that. I don't want to do this. What other options do I have?
Dr. Koren: So before we get to your dad's story which we're going to get into a lot of detail very soon but I just wanted to make a couple of points. General points. So when you say palliative care sometimes that means going to a facility where everything is kind of taken care of for you and that would be typical for people who maybe have a few weeks to live or even days to live. But most palliative care is now in the outpatient setting. You might comment that?
Dr. Patel: Yeah, most of it is in the home setting, where the patients are the most comfortable. It is a lot of work from the family standpoint as far as providing caregivers but also hiring additional help that you need because everyone has to be safe in this process. Palliative care is basically allowing you to continue to live life understanding that you have a chronic condition or a terminal condition. However, this might be the last stage of your life where you still want to live it to the highest potential that you can.
Dr. Koren: When you're in practice, do you prescribe exactly the vision for palliative care? So let's say you had a cancer patient not your dad we'll get to him in a second but just a general cancer patient that's decided they want to go palliative would you comment on whether or not that person should be in an “inpatient facility” versus an outpatient? How do you go about that thinking?
Dr. Patel: I think now most of the inpatient facilities as you said are usually the last several weeks of the dying process. Unfortunately to determine a better way I don't know but the majority of care is given either in the home setting if there's enough support or in a nursing facility. You can even have hospice or hospice palliative care at a nursing home. Which was something I didn't know. I thought you would have to do that in one of their facilities but the majority of patients and families want to try to keep their loved ones at home with the care that they've received most of their life.
Dr. Koren: Well, sometimes it's actually done in a hospital. I've had the experience where there's a palliative care wards in the hospital. Or just change the status of a patient in the hospital into palliative care which reduces the nursing burden and other things and sometimes it makes it easier for families. So in my experience, the other part of this is that not all families have equal abilities to cope with the situation.
Dr. Patel: Yeah, it's true
Dr. Koren: And some families actually need the support of the hospitals as an institution or inpatient facilities as institutions to help them through these difficult times with loved ones.
Dr. Patel: Yeah, that's true and I think that during palliative care too you know if there's a sudden downturn in the patient's medical problem like say for example all of a sudden, they were able to drink but now the last two days you can't even keep down any fluids. In that condition, they still can't go to a hospital facility to get palliative fluids like you know we talk about. We always think that hospice withholds fluids and all this at the end of life. But that's not even true. That was a misconception I even had.
Dr. Koren: And that's a great point so just because somebody's in palliative care doesn't mean you don't treat the patient correctly. But we're treating for comfort not cure right. So we're going to take a break here but when we get back to this discussion I want you to walk the audience through what your experience is with your dad starting from the beginning. You know tell us a little bit about him and then perhaps let us know when he first got his diagnosis and how that all played out.
Dr. Patel: Sure.
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