The Surgical Palliative Care Podcast

Dr. Karen Brasel: Surgical Palliative Care Educator

April 06, 2020 Season 1 Episode 7
The Surgical Palliative Care Podcast
Dr. Karen Brasel: Surgical Palliative Care Educator
Chapters
The Surgical Palliative Care Podcast
Dr. Karen Brasel: Surgical Palliative Care Educator
Apr 06, 2020 Season 1 Episode 7

#007 - Join host Dr. Red Hoffman and cohost Dr. Mackenzie Cook as they interview Dr. Karen Brasel, Professor of Surgery in the division of Trauma, Critical Care and Acute Care Surgery, as well as the Program Director of the general surgery residency, the Vice-Chair for Education and the Assistant Dean of Graduate Medical Education, all at OHSU School of Medicine in Portland, Oregon.   Karen is a national leader in both surgical education and surgical palliative care and has authored or co-authored over 250 papers.  Under her leadership, the general surgery residency at OHSU is the only surgical residency in the country which requires all trainees to spend one month on a palliative care service.  Join us as we discuss the benefits of being a "spork" (neither a spoon nor a fork), family presence during resuscitation and the ethics surrounding the idea of futility. 

CAPC (Center to Advance Palliative Care) features the IPAL (Integrating Palliative Care into the ICU) toolkit on their website.  Many organizations maintain CAPC memberships; to find if your organization is a member, go online and type in your email here.

Papers discussed:
Palliative care in the trauma ICU by Drs. Katie O'Connell and Ron Maier

Read about the Geriatric Trauma Outcome Score here and here.

TQIP Best Practices for Palliative Care can be found here.

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

Show Notes Transcript

#007 - Join host Dr. Red Hoffman and cohost Dr. Mackenzie Cook as they interview Dr. Karen Brasel, Professor of Surgery in the division of Trauma, Critical Care and Acute Care Surgery, as well as the Program Director of the general surgery residency, the Vice-Chair for Education and the Assistant Dean of Graduate Medical Education, all at OHSU School of Medicine in Portland, Oregon.   Karen is a national leader in both surgical education and surgical palliative care and has authored or co-authored over 250 papers.  Under her leadership, the general surgery residency at OHSU is the only surgical residency in the country which requires all trainees to spend one month on a palliative care service.  Join us as we discuss the benefits of being a "spork" (neither a spoon nor a fork), family presence during resuscitation and the ethics surrounding the idea of futility. 

CAPC (Center to Advance Palliative Care) features the IPAL (Integrating Palliative Care into the ICU) toolkit on their website.  Many organizations maintain CAPC memberships; to find if your organization is a member, go online and type in your email here.

Papers discussed:
Palliative care in the trauma ICU by Drs. Katie O'Connell and Ron Maier

Read about the Geriatric Trauma Outcome Score here and here.

TQIP Best Practices for Palliative Care can be found here.

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

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 palliative medicine to all surgical and trauma patients. Welcome to the surgical palliative care podcast. We heal with more than steel. Hi, everyone. This is Red Hoffman. Welcome to another episode of the surgical palliative care podcast. My co host 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, my alma mater. So I'm very jealous, Mack, Thanks so much for joining me again.

spk_1:   1:33
Oh, yeah. I'm glad to be here. It's an exciting time,

spk_0:   1:37
definitely. And Mac and I are so excited to be interviewing Dr Karen Brassell today carrying a professor of surgery also in the Division of trauma Critical care and acute care surgery, as well as the general surgery residency program director, the vice chair for education and the assistant dean for a graduate medical education at Oh a chest you. She is also a prolific author and a leader in surgical education. Karen. Thanks for being with us today. It's great to be with you. Thanks. So, Karen, as we're getting started, can you tell us a little bit about yourself, where you grew up, where you trained and why you decided to pursue a career in surgery? So I'm

spk_2:   2:20
a Midwesterner who now finds myself on the West Coast. I. Tate Upper Midwest starts to my life. I was born in Illinois and raised in Iowa and educated in Minnesota and Iowa. And then, after trying out and then a pediatrician and then an O. B and then an internist and my first day of my surgical clerkship, I decided I was gonna be a surgeon. I had a phenomenal team, and they had a great influence on me. And so that day there was an hernia in the basement O. R of the Iowa City v a.

spk_1:   3:04
Carrying in the Serie thing and do your the course of your career. How did you How did you come to an interest in palliative care? Surgical palliative care?

spk_2:   3:11
So probably two things really brought me to palliative care. One was my experiences as a fellow. This was a long time ago, so the rules are a little different than and I really ran the unit, not by myself. I had phenomenal faculty, but Asai said the supervision rules were different and I didn't have a co fellow. We had some really good examples of surgeons at practice, palliative care and then some examples where proactive palliative care in the outpatient setting would have made the patient's lives in the family's lives so much better and certainly alleviated a lot of moral distress that we felt in that unit. Ah, and I can remember very specific examples on both sides and nurses that I worked with really, really quite closely. So you might say I was then primed, and I can't remember if it was my first year on faculty or my second here on faculty, where David Weisman, who is one of the gurus in palliative care and palliative care education, started fast fax from the medical College of Wisconsin. He walked into my office and said, I've got this phenomenal train the trainer model, how to introduce palliative care into residency education. And we have it up and going in internal medicine, neurology and family practice. And we're moving into surgery, and I need a surgeon to sort of champion it on. And I have these two surgeons nationally, but I need a local champion and you're And it turns out that sort of told me for the role, which it's not that I was volunteered to do something that I wouldn't have chosen to do. It was a phenomenal opportunity, and I'm really grateful both to have been involved in that residency, education, national residency education program as well as the opportunities that then came from collaborating with David Weisman.

spk_1:   5:12
This is maybe a kind of a tough question to answer. But when you think about your experience in fellowship, do you think it was good examples or the bad examples that were more motivating?

spk_0:   5:22
Well, that's a great question. So I'm gonna loop in

spk_2:   5:25
my surgical education colleagues and some of their research. You have to know that I'm a preventive focus educator and So it was the bad examples and the what could we have done to make this better? Ah, and that really has informed a lot of the work that I've done with Gretchen Schwartz Z or she's done with me. It's really she's driving a lot of this. We went into this with We could just develop a tool or a checklist and have been gotten into a lot of the conversational aspects and tools to guide conversations rather than just specific checklists. But I can't even tell you what room the most impactful patient was. Who? The surgeon waas. Ah, what what? The disease process was on the bad example side.

spk_0:   6:14
I so had the same experience in residency that it was definitely the quote unquote bad examples that drove me to want to do fellowship. And I, too, can remember the exact pink shin and the exact bed they were lying in for months. Basically, while no one really took the lead in having a good goals of care discussion with the patient in their family and

spk_2:   6:38
the one good example, I actually don't even remember who the attending was. I just remember the nurse and I directing the care and the positive aspects of that and the nurse and I looking at each other in saying, Is it really okay that we're going this far and cause we were a little bit out of it out on a limb deciding that, yes, this was consistent with goals of care consistent with what the family wanted. So I do have an example on the positive side, that was also pretty impactful.

spk_0:   7:08
So before we start talking about some of the specific papers you've authored, I just want to comment on how extremely prolific you've been as both a writer and a researcher. And I'm wondering for the residents and young faculty who are listening, What do you feel have been the key to some of your success?

spk_2:   7:27
Well, some would actually say that when you look at what I have written about that it's viewed kindly. It's a little Perry pathetic, viewed unkindly. It's all over the map, which is not the advice that many give. I heard recently that the advice from some very, very prominent academic surgeons and shares that you're not supposed to be a sport. You have to decide if you're going to be a spoon or decide if you're going to be a fort. Good. I looked at that advice and I'm like, Yeah, I'm a spork. That's it. I am. I think you have toe. You have to do it because you love it. If you're doing it because you think it needs to be done to be promoted, then you probably need to figure out a different way to be in academics because it takes personal time. It takes doing it at nights that takes doing it weekends, and it takes all of that s O. That's the first thing. The second thing is make everything count twice. If you write a grant, the background of specific games should be Ah ah, white paper review paper that you turn in. And if you're doing something for class, you should. Every class assignment should be a paper that you can turn in. Then Ah, the third thing is, say yes a lot. Don't say yes to things that are going to take a ton of time with little reward. But take a lot of one hour meetings or 30 minute meetings with potential collaborators. We literally yesterday got five different projects off the ground in a 40 minute conversation that I didn't have any idea where the conversation was going to go. Then don't care where you are in an author list. Do it for the reasons of getting out the science and doing the work and being excited about the work, and the rest of it will take Take care of itself.

spk_0:   9:24
Thank you for that. So I know both of you recently authored a paper regarding surgical palliative care training in general surgery residency, and I'm wondering if both of you can discuss the findings of your needs assessment. Go. So you Mac, mostly

spk_2:   9:44
because it's It's his. This is Hiss. And so for me to comment on it is not the right thing to do. It's It's his work that I'm grateful to be ableto provide an opportunity to actually put to use and have our residents experience. But it's his work, so he needs to be the one that gets credit for talking.

spk_1:   10:02
So thank you for that. That's I appreciate the sponsorship. This this is actually no leash. A banana who's one of our now current chief residents was the first author in this paper, and you know the This kind of began with a what do our residents want to nose or need to know? And then what? Our faculty want our chief residents to know about surgical palliative care, and it's a single institution study. And it's an anonymous survey and it's got all the you know, the limitations of that study design, you know. But really, what we found is that the about 90% of our responding faculty said that the chief resident's needed additional training in surgical palliative care topics. Ah, and this is leading goals of care discussions transitioning patients that comfort focus, care, delivering bad news. Both the residents across all the training levels the Pete, the junior residents and See residents really wanted additional training in surgical part of care with a dedicated curriculum and a dedicated curriculum that was rolled into their clinical experience. And then one of the things that we show that perhaps is wasn't a terrible surprise. Is almost all of the surgical palliative care training at least the time we did this study, which was I think the data's from public a year or two ago, is that almost all of the training happens on the trauma service. It happens in the setting of the trauma surgery I see you, which is post injury, which is post complication, which is as things were going bad in the acute setting. And there's really this huge gap in, and I think this is really a needs assessment, really highlighted The captures this huge gap in the preoperative counseling in the goals of care discussions before they go to their big oncological surgery before they go to their big in general surgery operation. Now we're in the process of doing a little bit more of ah, more detailed needs assessment and really is going to drive an integrated pilot of care curriculum that'll be part of our residency, Hopefully, within the next year or two,

spk_0:   12:00
I think I r. I thought I had heard that your residents rotate on the palliative care service. Is that true?

spk_1:   12:06
That's an excellent doctor Brad's question, but yes, it is.

spk_2:   12:10
So we have a dedicated palliative care rotation for our intern. The rotation director is, ah, surgeon who practices palliative care. He has a joint appointment in the section of palliative care and in the Department of surgery. They are with him for four weeks. They go to clinic with him. He has two separate clinic. One is in concert with surgical oncology, and then one is his own clinic, where he sees his own patients. Ah, they do inpatient round. They go to all of the palliative care journal, club and educational activities. And then they see in patient ah, and do impatient rounds and participate in both patient evaluation, seeing in patients on a daily basis and doing consults they now have, as all of us have changed. Their workflow and palliative care is now virtual, and the residents resident that is on that service right now is still participating in all of those virtual experiences with the rotation site director.

spk_0:   13:12
That's awesome. I actually recently approached the palliative care team at my hospital to see if it would be possible to integrate Ah, first or second year surgical resident onto There Service, And the answer that I got is I think they're just regardless of what's happening right now, their service is just constantly overwhelmed, and they felt really unwilling at the time to take on another Lerner. And so I think this kind of points to the fact that if we have surgeons integrated into the palliative care teams, we might be able to have a better experience with surgical residents on that team.

spk_1:   13:48
Karen, I know it's early in the experience, but sort of remained a Redd's point like what has been the experience of the residents on the palate of care rotation so far? I don't really listen. You're into it.

spk_2:   13:59
So we have plans again. You make everything count twice, right? So this is a great educational experience, but we're also gonna be assessing it. Ah, and we have not done that yet because that's an end of the year activity. But the anecdotal experience is that it is extremely positive for really a variety of different reasons and some of which I think we anticipated in some of which we didn't. It's totally precept er based, and it is the only intern experience that is precept er based, and the receptor is also ah, one of our three faculty who lead our ethics skills laps, and so they have the one month intensive experience with him. But then they also have an ongoing relationship with him and that for interns who change every four weeks, some of whom come from all over the country. That aspect. I don't think any of us, at least on the education team except for maybe Mac was smart enough to figure that out. That wasn't really the the reason we did it, but I think that's turned out to be very valuable the time in the space to think about these things and tow emotionally. Process has been huge, and there are times that, you know, just going home at two o'clock to decompress and think about the difficult family dynamics or the young patient who's dying of cancer, that that has been huge when they don't have that opportunity, where when they're on the primary service to be able to do that. And then, from a skill standpoint, I have actually seen the skills the interns use the skills in subsequent rotations, most specifically actually on the trauma rotation. Ah, and they will take the lead in doing this on our trauma wards. Ah, it's interesting, they have the skills, but it all it is also, and again this relates to some of our surgical education work. They have the confidence to be able to do it. And I think that's huge

spk_1:   16:13
well, in minutes, and it's really amazing to watch me. They're obviously very capable young physicians, and this is what amazing to be able to wash them, gain the skills and the confidence of the confidence to use them. Karen and you're sort of like putting together your tide of care and your education hats when you think of a graduating general surgeon. Um, now, this is not somebody who's going to seek additional training and surgical pad of care, searchable critical care, surgical oncology or some of those heels were maybe pied of Castle, but more prominent. But what are the skills that a graduating general surgeon should

spk_2:   16:45
have? I think that the end of life skills, the knowing how to make the transition to hospice, not all of the hospice rules, not all of the you know what you have to do and how you have to document to make sure it's Medicare compliance so that you don't disadvantage the families. That, to me, is specialize palliative care, and I think it is actually unreasonable or a general surgery resident to know that, but to know when it needs to happen and if you wantto make that more broad, a more broad brush when specialty palliative care is necessary. So when palliative care should be consulted. That goes to entrustment when you, you know when you need help and call when you need help. But knowing when the difficult conversation is the right thing to Dio rather than to offer an operation that you know is not going thio achieve those goals just because the patient wants to do everything that I think is probably the hardest and that I think should be within the realm of all general surgeons to know when that decision needs to occur and to be ableto have the skills to move a patient and family through that decision, and to be with them to know how to capture their time on the pre upside when they have those discussions so that they don't financially disadvantaged themselves and make decisions that air financially or time based, that air, the wrong decisions. And then? And I hope this is what they're starting to learn as interns now. But the importance of presence and the importance of presence when complications happen and presence at the end of life, the last one I think I would put on that list is how to medically manage some of the diseases we commonly take care off. So medical management of a battle instruction at the end of life, which is absolutely counter to how we usually manage it when we use a lot of fluid using minimal fluids, ways to get n g tubes out for a patient comfort. So there are some specific symptom management things that air really specific toe diseases that we managed primarily kind

spk_1:   19:11
of

spk_0:   19:11
along those same lines. You co authored a study a couple years ago that looked at the care of geriatric patients who suffered a burn. And that study surveyed both palliative care physicians and burn surgeons and found that each specialty felt they were better suited to conduct goals of care discussions. And I found this interesting because there wasn't he study as well that looked at palliative care physicians and trauma surgeons. And again, both groups felt that they were best suited to conduct goals of care discussions. And I'm wondering if you could talk a little bit about these results, because my concern is that having witnessed some of my surgical colleagues have these discussions. Sometimes they actually think they are more skill than they really are, which I feel leaves patients and families at a disadvantage.

spk_2:   20:03
I think you're right. And I think there are problems with both of those studies, and I think they highlight probably the wrong thing, the wrong message, and or you can take it as they show the opportunity that what is important is the discussion. What we really need to do is identify what needs to come out of the discussion rather than who holds the discussion. Unfortunately, I think the measures we have right now are just provider confidence and comfort. And so if you ask me, I will tell you I think we're just fine doing it now. If you asked me to get a group of 20 trauma surgeons, many of whom I've practiced with over the last 10 years, there is a range of their skills and abilities in terms of how they provide palliative care. And the same thing would be true of the palliative care physicians that I have worked with. And so what I think, the both of those studies point out, is the need to define the elements of good discussions and outcome measures that we contract to ensure that they are being provided in the best manner possible, regardless of who provides them

spk_1:   21:38
raises an interesting question. Which is, what are the outcome? Measures that we should be looking at because, you know, if obviously, if you're having end of life discussions, everybody will die. Everybody family, your family, happiness, family acceptance, 12 month feel. I mean, it's It's a fascinating question. What we should actually be using as our outcome measure,

spk_2:   21:59
right? Well, it turns out, actually that goals of care discussion not everybody dies. At least they don't always die imminently. But your point is well taken. There are ways to survey both patients and fame, probably more important families and to measure moral distress among care providers, most specifically nurses ah, who participate in the discussions Social workers, many of the family meeting type aspects. If you're doing this on a more large scale, which wouldn't be true in clinic, you can get that asked. Ah, from a training perspective, you certainly can use standardized patients, and we do use standardized, patient, standard dyas patients in our intern curriculum. We've done that for quite a long time, and that could be a measure to see if residents, um at the bar at the time of graduation, which, you know you don't know what they're gonna do five years down the line, but you certainly could measure it at graduation. The outcome measure is really, really tricky, and it has been a big stumbling block but difficult nut to crack as we have been designing trials to investigate different communication tools to provide to both surgeons, be the elective surgeons are trauma surgeons and families. Ah, the outcome measures have been really, really tricky. Number of questions, types of questions. Patient of family agency, moral distress. We have used a number of them, and we don't have the best one yet

spk_0:   23:33
in Oregon. Is it true that you all have a statewide repositories for your post forms and that those are available to the providers in the trauma bay so that you can see if someone has already filled out what their advanced directives might be?

spk_2:   23:50
Yep, we have ah pulsed registry, which Susan told would be embarrassed that I don't know how long it's been going on, but it's been going on for a long time and through the efforts of a variety of people, including Mac. If there is a patient who is over the age of 80 think it's a tea set, right, man? Ah, we get the information about whether they have a pulsed form on our pagers. If a patient comes in and we're like, we should have the post information on this patient because they were there a ground level fall and they have a lot of co morbidity ease. And they came from a memory care and with seem as though they should. Then we can call the police registry and they get us the information within 45 seconds.

spk_0:   24:36
Wow, that's incredible. I know Miss Oregon,

spk_2:   24:40
and if they're an established patient, we have it in an epic.

spk_0:   24:44
So Karen will switch gears a little bit again. But can you talk to us about your work on the improving palliative care in the I. C. U advisory board? I know that several landmark papers were published through this advisory board, but I'm wondering if you can share some of the big take home messages that came out over the years.

spk_2:   25:05
Yeah, so again, this is something that happened because of David Weissman. And he worked with Diane Meyer and got groups of people that we didn't do any any groundbreaking research. That was not the purpose. The purpose was really toe. Try to provide some tools and resource is guidance, for I see you providers across a variety of settings. That's another place that ah burn paper came out. Pediatric I, C u paper trauma and, ah, neurologic injury as well. A neurologic injury that might or might not be trauma and then some resource is that are available on the Web site and was all done through conference call. And a Sze Yu said. I put out a variety of papers that were really recommendations on anything from how, when I see you should be set up toe optimally deliver palliative care, whether that's an open unit, a close unit, whether triggers were useful palliative care triggers for consultation, tools that were useful both from, ah, how to incorporate palliative care in two rounds, prognostic tools. And so that was really the reason for the group to get together and it the group is not active. At this point, I think I would stand behind the recommendations in any of the papers in any other tools, even though many of them are five or more years old.

spk_0:   26:36
Well, I'm grateful you're talking about them cause I did reach out to Dr Weissman and he said, I'm retired and you can ask people who are still active. So I'm so happy you're mentioning him. I told him I feel so grateful to him for all the work that he's done and how much support he offered Thio the surgical community. But I certainly respected his opinion to want to step back.

spk_1:   27:03
Yeah, I know. The W A S T I C u ah Committee just highlighted addressing goals of care in the queue care setting as one of the leading research priorities. You talk a little bit about the process about how you all came to that recommendation and then maybe a little bit about ideas for how they incorporate this. Specifically, I'm thinking about your involvement in the Palley eight consortium of the nine hospitals across the country and the jury trial Malcolm scores. And if those two kind of link up together,

spk_2:   27:31
I was excited that palliative care did come up. I did not set the methodology of the paper up, so my biases didn't drive the conclusions. But the primary goal of that critical care research agenda was to try to look at the articles in palliative care that have come out and have had the greatest impact and to see how much our surgical patients had contributed to that body of knowledge. And there's there's a separate discussion about if the literature about how we take care of a R. D s didn't include surgical patients. How much of that is then translatable from medical patients to surgical patients? So we took all of the highly cited critical care articles, and that was done by working with the medical library in the ones that had the largest number of citations over the last 10 years. And we stopped it, I think, two years ago. So it doesn't include the evidence based within the last two years and then looked at primary source the number of surgical patients that had contributed to the trials and then after that was done, we've ended a Delphi process with the Critical Care committee toe, identify where the gaps were and palliative care came up as a top gap. And it was, I think, that combined with Ron Mayor's fits oration about palliative care being the fourth leg of the four legged stool for acute care surgeons drove the creation of the ad hoc palliative care Committee of the W S T. And then the two working together. I think we'll be able to drive some actual research that comes out of the double U. S. T related to palliative care on. We are collaborating with the geriatric committee, and then the multi institutional trials commit.

spk_1:   29:33
I mean, I'm still relatively new in this, and it's even been a significant change over the past couple of years. You've been involved in the Palli eight consortium, specifically looking at geriatric trauma patients in the use of the geriatric trauma outcomes scorer in the intensive care unit setting. Can you talk a little bit about the consortium? Um, and then the geriatric try. Malcolm's scored. How you how we can or should. I might be able to use that in the inpatient setting.

spk_2:   29:57
Yes. Ah, howya consortium was the brainchild of her Phalen and was really just a group of trauma centers that were interested. Ah, and he has a statistician from UT Southwestern that has helped with some of the statistics. The group has worked on the geriatric trauma outcome. Stork Score. Validation. A swell Cem frailty work that's been champion Bible all Joseph. The geriatric Trauma outcomes scores. I think like many other scores, it's not perfect. I mean, you, we've got tress, We've got some other models. It was a a reaction, really to tress and the fact that it doesn't work particularly well in the elderly. I don't know how everybody uses it. I'm not in in my pipe of care, practice and philosophy. I'm not a numbers person. It gives you an idea whether patients are more likely or less likely tohave ah, home discharge and or to survive. And I think it helps you answer the surprise question. And because it helps you answer the surprise question, I think it drives you. If you're screening people for palliative care, it helps drive how important it is to have a goals of care discussion early. So if you look at the T quit best practices for palliative care, the surprise question is part of that early screen, and GTOs can help you answer the surprise

spk_1:   31:30
question You've written and talked and taught me in particular about family presence during recess stations. Well, a C l s for son stations in the S U and then also increasingly, a t l s for so stations in the trauma bay. Can you talk a little bit about your thoughts? Opinion research on family presence during these really high intervention, The high acuity times, Good thing, Bad thing. Beneficial for the both from the patient of family and also from a provider

spk_2:   32:02
perspective, There's actually quite a bit of research. And we were really set up Well, to do this in in Milwaukee, in the trauma bay. Ah, we're not set up well to do it here, just from a space perspective. Here it'll be just you, which isn't to say we don't do it, but it's space wise. It's It's not as easy to d'oh our work and others. Work has shown that it is actually quite beneficial for the families and that they see teams working together and they see sort of globally, that things are working or things are not working and that the fears of providers the family's gonna want them to continue longer. No, it actually, in my experience and experience of others, it's actually shorter that they are going to see when we do things wrong. No, they don't see that. They just again. They see the team working and they see the team working together. It actually does make providers behave better a little bit from what things are things that are said sort of the Hawthorne effect. But you forget that they're there. And when they are surveyed a year later, there is less psychological distress. There's less. There's less need for medication for psychiatric side effects, psychologic side effects. There's less suicide in the family members. Ah, when they have been able to be present. There's no instances of litigation that have occurred. Having taught procedures through, ah, family presence culture residents intubated residents put chest tubes and residents put lines in residents open chests. That's whether the family was there or not. The absolute mandatory thing that has to happen in order to make this work successfully is when you have to have policies around it, there has to be provider discretion, and then there has to be somebody that attends to the family. So you have to have an extra team member, whether that's registration or an extra physician who's had some training or a nurse that's had some training. But you can't assume that the nurses are gonna want to do it or chaplain or a social worker or and then you have to have a training process for all of the people that are going to be the family support people.

spk_0:   34:28
I recently had an issue where I was taking care of someone and their family member was across the country, and this patient went to surgery with. It was kind of understood that this probably wasn't going to end well, and I brought him back up to the unit and he subsequently coded and I called the family member. I was very lucky that I had a colleague there who ran the code for me while I was on the phone with a family member in the room. You know, I really wanted her just knowing a little bit about her. I think she would have wanted to be there, and so I really wanted to include her. It was just really interesting what it brought up for me. It was the first time after a code that I got off the phone with her and I burst into tears, and I think part of it was I felt so awful about did I do the right thing in calling this woman? And she did text me a couple weeks later and just said, Thank you, but I really struggled with it. And so hearing you talk and I actually went back and read these papers, it really did remind me that it is good for closure and it's very funny because when people are president, I always bring them into the room. I want them to be there. I had just never done it over the phone before, and I didn't know if I had tortured her where if I had given her closure, it was very interesting for me as a provider.

spk_2:   35:43
That's really interesting. Brings out something we're struggling with right now, right? How are we able to connect when we are socially distancing and with our families are palliative care team Ms Struggling with that and our front line providers are actually struggling with that palliative care team has been doing it for three or four days now, and they are comfortable with it. But our front line providers really are, I think, struggling with not having them there in person. And so it brings up that with the family. And then it also brings up a different legal question, right, cause it could be recording it.

spk_0:   36:22
Yeah, for me, it was just I just told her, I'm like, I'm holding your dad's hand the whole time like he's not alone because I know you'd be right here and I'm here for you. Just a very was a very human moment for me talking about what's going on with Cove in 19 right now. I took out my book, The Ethical Issues in Surgical Care, that was published by American College of Surgeons a couple years ago. And I was re reading your chapter on end of life issues. And in it you write about one how to respect patient's wishes but to how to prevent futility, which I think is a conversation that we may all be called upon to have more and more and then coming weeks and months, and I'm wondering if you can talk a little bit about futility, how to define it and really how to discuss thes really difficult sticky issues with both our colleagues and then with patients and their families. So

spk_2:   37:17
the first thing is futility in a disaster and futility in a pandemic, which is a disaster is, is a different question. And that actually does come up in the triage scenarios. And 80 l s and the American College of Surgeons Committee on Ethics is we'll be coming out with a statement shortly with some guiding principles. I know Sharmila Justice Naki is working on that actively today, so I think that's different, and we may be and likely will be called to make some decisions based on triage decision and the burn example. Burn HLs example when you have five patients and you have to sequentially take care of them or you only have resources to take care of three of them. The elderly patient with a huge burn is the one that you provide comfort care for, and that's that's triage, its resource related futility, maybe different story than than futility and are sort of normal daily operations. The community has backed a little bit away from futility and tried to phrase it more. Ah, what we would call it really focusing on goals of care. And Soto have the discussion that is a little more patient centric than physician centric, so really focusing more on futility, being the inability for any of our interventions or treatment to enable the patient to achieve their goals of care. And so that would really be the the definition of qualitative futility. Physiologic futility. I have the discussion, and I don't really call it futility anymore, right? Trying not to use that term cause that term can mean all sorts of things to tell all sorts of people. But to say, you know, we're already on maximum presser management in the event that a cardiac arrest occurs, CPR will not achieve any meaningful results, so that's that is physiologic futility. I've no phrase it in a little bit different way. And then in that discussion with and make the recommendation that the patient B D N r. Same thing will happen with traumatic brain injury. Put the non survival brain injury toe having a discussion that when the patient's heart stops, ah, CPR will not result in recovery of cardiac function because of the devastating brain injury and so my recommendation is, or we will not be providing CPR. So that's a physiologic futility angle phrase slightly differently, I guess

spk_0:   40:12
I saw on Twitter, maybe, like a year ago, but I loved it. That and I've used this a lot with my patients and their families, is that CPR is for when the heart stops first, not for when the heart stops last. I don't really seem to get that when they see the ventilator and the c R R T and whatever other thing they have going on, they like, can really wrap their minds around

spk_2:   40:37
that. Yeah, that's that's a really good

spk_1:   40:39
That's great for me to thank

spk_0:   40:42
you, Twitter and you

spk_2:   40:44
didn't see it. I

spk_1:   40:45
know before my before I was fallen, told to be the social media representative. Here it is. We wrap up here, and in light of we're all doing this socially distanced and the world is collapsing. There's gonna be a lot of people, presumably in the coming weeks and months, who are gonna be called upon to do these type of conversations that you just highlighted goals of care, inability to achieve those goals in light of the resource limitations or physiologic limitations of this of the pandemic. They who have no experience this beforehand, you know residents non intensive ISS. What resources can you suggest for some, just in time training to kind of get people up to at least a minimum threshold.

spk_2:   41:29
So I know that for the magical aspect of carrying for ah code 19 patients, there's a one pager that the that s e c m has come out with as well a CE We've got one locally. I actually don't know what age PM is putting out. I do know because I'm old and I get on Facebook Ah ah that there is a Facebook group of paleo care physicians code 19 pitted care physicians and they have actually been coming up with Cem. Really good suggestions. I think the things tow avoid are to say we don't have the resources to care for your loved one or we don't have the resources to care for you. I think to say, just like we normally do, this is how sick you are. We want to make sure that we are able to take care of you to the best of our ability while still understanding what your goals of care are so from the goals of care discussion, I don't mean there are, you know, the spike resource and or the or the Spike pneumonic about howto do Ah, family meeting our goals of care discussion. But I don't know, it's sort of a one page or but I do know there is that group and

spk_1:   42:45
this wasn't exactly designed to be leading question, but it kind of turned into the D. M. But I know

spk_2:   42:51
you know the answer vented at ideo I reckon you

spk_1:   42:54
teach I'm not directly involved with them, but the vital the vital talk. Oh yeah. Seattle. Yeah, if they have put out actually really great is on Twitter. Um, they put out a really great water words you can use to say we don't have enough ventilators, but not exactly like that. You know, the how do you support patients through these times of resource limitation and then also there, you know, the spike pneumonic and the nurse demonic. All those things are actually in their app or pretty well described. It may be a resource, particularly as we have orthopedist running ventilators and things like that

spk_0:   43:32
on times. Well Karen, Thank you so much. This has been such a great conversation. And it's been so nice toe connect because I, too, have been feeling lonely. So this has been lovely.

spk_2:   43:47
Thanks you. Thanks to you both.

spk_1:   43:48
Yeah. Thank you for taking the time. Current's really wonderful. Inbred. Thank you for organizing this. It's absolutely

spk_0:   43:55
Of course. Thanks. You guys talk soon

spk_2:   43:58
and we get to. Now we get to get off and congratulate all of our new Oh, because we got that. We got the official news. We could be here an hour and eight minutes ago.

spk_0:   44:08
It's match day. Great news in all of this. So thank God for the next generation of surgeons. All righty. Thanks. You're okay. Thank you. 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 email at surgical palliative care at gmail dot com. Lastly, take good care of yourselves and take good care of each other, huh?