All right, let's go ahead and get started. I want to welcome everybody to AAP Virtual Didactics today. My name is Sterling Herring. I'm a PGY-3 here at Vanderbilt in Nashville, Tennessee. We're excited for today's lectures. But I want to start, as always, by recognizing and appreciating those of you who are shouldering more of the COVID-19 burden than the rest of us. Recognize that this pandemic has not been, the burden has not been distributed equitably. So we appreciate those of you who are kind of on the, you know, we're hearing a lot of unprecedented times and front lines and whatnot. But we appreciate those of you that are. And if there's anything that we, as your colleagues, can do anything for to support you, please let us know. Want to go through the goals of this briefly. The primary goals of this online lecture series are to augment didactic curricula that are ongoing at your home institutions, offload overstretched faculty with some of the logistical challenges that have been occurring with the pandemic, and then provide additional learning opportunities for off-schedule residents, to develop more digital learning opportunities and support. Feel free to double-click either of our names, send us a question, and we will ask those questions at appropriate times during our Dr. Kaplan's presentation. If you have any general questions about the lecture series or concerns, suggestions, anything, please feel free to reach out to Candice. Her email's there on the screen. Or find us on Twitter, and that is our Twitter handle. So without further ado, we're excited to have our presenter here with us today, Dr. Naomi Kaplan from Michigan State. Welcome, Dr. Kaplan. Hi, thank you for having me. I'm just gonna share my screen right now. Great, thank you for joining us. Okay, Sterling, can you hear everything all right? Yes, looks great, sounds great. Okay, so I would like to thank, to start with, I would like to thank AAP, also Candice, Sterling, Evan. This has been such an amazing initiative, really great content, and some really inspiring speakers so far. I'm a very early career physiatrist, so I'm really happy and really humbled to be able to contribute today. My name is Dr. Naomi Kaplan, and we're gonna talk about hospice and palliative medicine, truths and myths. We're gonna do some major myth-busting today, so I'm really looking forward to sharing with you. Currently, I'm wrapping up my hospice and palliative medicine training at Mercy Health Grand Rapids, which is affiliated with Michigan State, and then I'm gonna be joining the Mary Free Bed family in a couple of months, so I'll be staying here in Grand Rapids, Michigan, and also working in Holland, Michigan. So I have no financial disclosures. I would like to acknowledge that some of you listening in may not really have very much clinical experience with hospice or palliative medicine, but you may have had a family member or a friend with a serious and or life-threatening illness who may have needed hospice or palliative medicine. So just with regards to this lecture, if it brings up hard feelings or mixed feelings, I encourage you to let yourself feel those feelings, and if it's right for you, though, I still hope that you can be open to the content that I'm gonna share, and I hope it's of benefit to you. I do mention some educational organizations throughout the lecture. I have no financial relationship with them. They're just resources out there. You can check them out. I think they're really helpful. You can have a look and see if it works for you. Okay, so we're gonna break down this lecture into four distinct areas. My goal is to really give you a broad overview of hospice and palliative medicine, but also to give you very specific tools today that you can use going forward. Because we have these four sections, I'm gonna do a quick stop after each section and check in with Evan or Sterling and see if there's any questions coming through about that section in particular so we can kind of keep it interactive. So the four areas we're gonna cover, what is hospice and palliative medicine? What is it as a specialty? And what do we actually do? We're gonna do, secondly, try to provide you with an approach to advance symptom management, a little bit of nuance. Third, we're gonna focus on some really high-yield communication techniques to have those high-stakes, challenging, but ultimately rewarding discussions with your patients and with your families. And lastly, we're gonna really do some myth-busting about what is hospice, who is appropriate for hospice, and just some details just to, so you're more comfortable with hospice as a concept. And then, like I said, there's gonna be some educational links or resources throughout. I'm gonna actually, I have them in a slide at the end. And then if you wanna take a screenshot or take a photo of it, you can kind of explore those resources at your leisure in the future. So why is this important? Why are we talking about hospice and palliative medicine as part of these virtual didactics? Well, we have an aging population. We know that by the year 2030, all of the baby boomers are gonna be over the age of 65 years old. Hospice and palliative medicine is for people of all ages, but we know with age does come some comorbidities, chronic conditions, acute conditions. So we really need to be responsive to our population demographics. We know that there's been amazing advances in medicine and medical technology, really life-changing discoveries. But something that we say in pediatric palliative medicine that I wish that we kind of said more often in adult palliative medicine is that we wanna make sure we're doing things for our patients, not to our patients. Just because something exists doesn't mean it's particularly relevant to us. Just because something exists doesn't mean it's particularly right for that patient. So that's something to reflect on. We know that the case mix group and the case mix index in acute rehab facilities are increasing. We have very complex patients in acute rehab, and we need to really have those tools to feel comfortable to manage their symptoms and have meaningful goals of care discussions. We're living through a pandemic right now. Now more than ever, we need to be able to have those meaningful conversations and relieve our patients' suffering. And I think really as physiatrists, we are optimally placed to really provide primary palliative care to our rehab patients. And by primary palliative care, I mean that you as a specialist who's not a hospice and palliative medicine provider, but a physiatrist, should still feel like you have either a first-line or a second-line strategy to relieve your patients' suffering. So what is hospice and palliative medicine? So I think people tend to forget that it's a subspecialty, a PM&R. So there's been subspecialty board certification since 2006, which is really recent, but obviously we've had decades of hospice and palliative care before that. It's a 12-month fellowship you have to do. And then the exams are right now in a two-year cycle. So there's exams on even years. So there is an exam this fall, and then in 2022, 2024, and so on. PM&R is a sponsoring board for hospice and palliative medicine. There's actually 10 sponsoring boards. Interestingly, in my program, we have five fellows from five different sponsoring boards. I think we all bring kind of a unique approach, which is really great. That's a little bit of a link to the ABPM&R if you want to learn more about the HPM board exam. And like I said, I think people forget about HPM being a career route after doing physiatry residency, but I really consider PM&R and HPM to be sister specialties. They really fit together so well. And truly, when you do both of these specialties, you can call yourself a true expert, I think, in function and quality of life. Also worth noting that this is, HPM is also a toolkit. So if you still want to, you know, you want to pursue physiatry completely as your career, you still have these HPM tools you're going to bring back to your physiatry practice. If you're like, no, I actually want to be a full-time HPM provider going forward, just so you know, there is a gap in the workforce of about 6,000 to 18,000 HPM providers. So there are a lot of jobs all over the US that are available to new specialists. Okay, so this next slide. So whenever I tell people I'm doing HPM, they go, oh gosh, that's really sad and depressing. And that must be so hard. And it is for sure very, very challenging, but a lot of specialties are challenging. And HPM is actually very rewarding and very fulfilling. And I asked some of my colleagues to say what doing HPM really means to them. And I was actually very touched and very moved by what they said. You can read it for yourself, but you do really feel every day like you're changing lives and you're making an impact. So this is the World Health Organization definition of palliative care. It's an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness through their prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual. I really like this definition. My only pause would be the use of the term life-threatening illness. I prefer life-defining illness or serious illness. You do not have to have a terminal illness to receive palliative care. But otherwise, I think this really encompasses what we do in palliative care. If you see the background of the slide, it's a gentleman sitting on a bridge. And this comes from a YouTube video from a palliative care organization. I'm gonna link to it at the end. It's a really great video. It's only about a minute and a half. You can watch it yourself and then share it with your colleagues or your patients and their families. And it's about what palliative care is. So it describes you as a person, like you're a bridge. So when you're well, the structural supports of your bridge are intact and you can really deal with whatever comes your way. But when you have a serious illness, you don't necessarily have all those structural supports. So it's harder to deal with things. So palliative care is really that layer of support to support you as a bridge. And like I said, that video link is gonna be at the end of the lecture. So this is a bit of a busy slide, but I just really wanted to hammer home some messages that this is relief of suffering and improvement of quality of life in a life-defining illness, like not necessarily a life-threatening illness. Palliative care is not hospice. We're gonna have a whole section on hospice at the end, some more to come. Palliative care can be provided in conjunction with curative and disease-directed treatments. It can be incorporated. So just like rehab, it can be incorporated throughout the continuum of care. Preferably, we do like to get involved at the beginning of a clinical journey. We can make a greater difference. This is an added layer of support to patients, families, and the patient's whole health team. So in palliative medicine and hospice, we really break down that, excuse me, that dichotomy of just a provider and a patient. What we're really doing is trying to support the patient and everyone kind of in their realm. And just like rehab, it's a team approach. We can't do, you know, no man is an island. We can't do things without really having that supportive team approach. So we have amazing advanced practice providers. We have MDs, DOs, social workers, nurses, chaplains, volunteers, which is really great. So when would you put in a palliative medicine consult? So our consults at one of the hospitals that I work at really fall into three categories. Advanced symptom management, that includes pain management, goals of care, slash, you can say difficult conversations, and then patient education. The last one sort of varies. I do think that there is a responsibility in the primary team to do the heavy lifting for patient education, but we're obviously of course happy to support that process. Like I said, we like to get involved early. So you can call a palliative consult at the time of the diagnosis that either a life-defining serious and or life-threatening illness. We're happy to come to family meetings, bearing in mind we can make the most difference when we know a family. So if you can consult us in advance so we can get to know the patient and the family, then we can be a meaningful part of the family meeting. If there's a fork in the road about which path this patient is gonna go down, either for treatment or whatever their clinical course is gonna be, and there are decisions that need to be made, you can involve us to facilitate decision-making. Absolutely. We are experts in advanced care planning. Advanced care planning is important for all patients. It's important to do this not in a crisis, but do this actually when a patient is mostly stable and well. So we're happy to help with that. And then we do assess capacity. And I encourage you to do some reading and to have some education so that you feel comfortable assessing your patient's capacity. Just as like a little quick recap, we know that capacity is not all or nothing. It's decision-based and it's kind of a sliding scale. So more complex decisions require more capacity. Whereas being competent or not, that's a legal term, a judge's term, whether or not you're competent. But with capacity, for example, we had a patient who was very, very ill with uremia and encephalopathy and could not make complex decisions. But she was able to specifically name her son as her decision maker. So she had enough capacity to name her son to make the decisions, but she could not make the decisions herself. She did not have sufficient capacity. Okay, I think that's the end of the first section. Can I check in with Sterling and Evan to see if there's any questions so far? Yep, that was great. There's no questions at this time. And again, anyone, if you have any questions, feel free to send me a direct message. My name's Evan Berlin, or just put it in the chat for everyone and I will be able to read it out loud. So I think we can continue on at this point. Okay, great, thanks. So we said that the second topic we're gonna discuss is an approach to advanced symptom management. And what I would like to talk about first, this is my plea to wipe out opiophobia. So I'm gonna kind of talk you through the cycle of opiophobia and how we can break the cycle. So a lot of providers, trainees, anyone in healthcare is really fearful of opioids. Fear is a normal feeling. It may not necessarily be the most productive feeling, but maybe instead of fear, let's say extreme caution. Having extreme caution is absolutely normal. We have to be aware of the context that we live in. So we know that between 1999 and 2017, there were 700,000 drug overdose deaths. We know that in 2017 alone, there were 70,000 drug overdose deaths. We know that almost 70%, so that's seven zero, 70% of drug overdose deaths are either legal or illicit opioids. So exerting caution is absolutely appropriate. But when you combine fear and excessive caution with a lack of education, that's problematic. So I do think that med schools and residencies and fellowships are catching up to the need for more pain education, opioid education. But if you're not getting this, I really encourage you and I almost would say this is your responsibility to educate yourself as a specialist provider about opioids. Because we know if you are fearful and cautious and you don't understand opioids, but you still see someone in your practice who either needs opioids, for example, they have cancer pain or they have end of life pain, or they come to you and they're already on opioids, so you have to manage them maybe even just short term because you don't have the education and you have this cautious, fearful approach, you may have non-ideal prescribing practices. And when we're doing not a great job at prescribing, we have non-ideal outcomes. So patients may still have refractory symptoms or they develop pseudo addiction. So they look like they're having drug seeking behavior, but it's really because their pain is untreated. Or the prescribing really doesn't go well and we end up with abhorrent behavior as consistent with opioid use disorder. And then you have these negative outcomes that's gonna exacerbate your fear and the cycle perpetuates itself. So I do encourage you to get as much education as you can about opioids, even if you're not going into a specialty or an area that you're gonna do a lot of this prescribing, I think you owe it to yourself as a provider and you owe it to your patients and to your community. Okay. So there is Dame Cecily Saunders, who is one of the foremost pioneers of hospice care in the United Kingdom. She came up with this concept of total pain. And I think this is a really important framework to work within. So total pain is that your patient's pain really encompasses their physical, emotional, social and spiritual pain and suffering. So when you're asking a patient about their pain experience, what you're learning from them is you're learning about their visceral, somatic, neuropathic pain, their anxiety, their depression, any of their mood disorders. You have their social suffering, for example, they can no longer be a caregiver, or they're no longer the breadwinner in their family. And then also spiritual pain, so they have existential pain, or they have religious concerns about end of life. All of these things contribute to their total pain experience. Okay. So I do think that when you're considering advanced symptom management, you really have to take into account all of those factors. So when you're committing to addressing someone's pain, you're committing to their total pain experience. So I think this is an equation that I came up with, and this is an approach to consider. So you have your pain medication number one. This is your medication, probably an opioid, but maybe not, but this is doing your heavy lifting. So here we go. And then in addition to your number one medication, you're going to have your adjuvants. So a lot of people don't have just one type of physical pain. They may have visceral pain and neuropathic pain. So you're going to be considering membrane stabilizers, SSRIs, SNRIs, tricyclics. I usually don't prescribe just one pain medication. I almost always have an adjuvant on hand. We say that the hand that prescribes the opioid must also prescribe the bowel regimen. I'm going to talk about that a little bit more on the next slide, but you cannot send someone away without a bowel regimen if you're prescribing opioids and you're serious about doing a good job. I do think that even though you're like, I'm just going to address their pain, you can't do that without saying, okay, how do I manage their insomnia, their mood, their nausea, and their dyspnea? All of these things exacerbate pain and pain exacerbates all of these symptoms. So do start making, just making inroads on like kind of complete symptom management if you can. The next part of my equations is persons and therapy. So what I mean by that is who are the people that maybe your patient needs to talk to, to relieve their suffering to some degree or to deal with things that they're trying to cope with? So people that are part of their team that you could consider would be a chaplain if they're having religious or existential pain. Maybe they need to talk to their oncologist more about their cancer treatment options. Maybe they need you to help them talk to a family member or a loved one about their medical condition. Or maybe they need therapy and that can come from a psychologist, but it can also come from a social worker. And I really encourage you to lean into your social workers. One of the social workers I work with, she can do cognitive behavioral therapy. She can do dignity therapy. She can do motivational interviewing. So all of those resources are available usually. And so really I would encourage you to consider all of these aspects when you're doing advanced pain management. So some pro tips and pitfalls to avoid. Dose based on knowledge, not based on fear. So what I mean by that is patients come to me and they're on Percocet or Norco Q6 hours to Q8 hours PRN. And I believe that they come to me on that regimen because the initial prescriber who provided the Norco and the Percocet were perhaps a little bit cautious about those medications. And caution is okay, as we said, but remember we have to educate ourselves. So we know that all short-acting opioids only last four hours. So oral short-acting opioids peak at one hour and they last four hours. So we really should be dosing Q4 hours PRN. Not longer than that because the patients are not going to have pain coverage for those last two to four hours and they're going to be asking you for more meds. If you're feeling a little bit cautious, you're like, oh gosh, Q4 hours means that they might get six tablets a day. Then what you can say is the patient can get up to four tablets or up to four doses per day as needed. So you could do QID PRN. Really if a patient is needing more than four PRN doses per day, they really need a long-acting opioid because if they're taking all of those short-actings, it means their pain is yo-yoing and we don't want this. We want this. We want to manage their pain over hours and over days, not just kind of have this roller coaster effect. The next point I wanted to make is that all good opioid prescribing comes with free sides. You get patient education and bowel regimen. I touched upon bowel regimen before. So we know that our body never gets used to opioid constipation and we always have to proactively manage that with our patients. So I usually offer patients either Muralax or Senna. The Senna would be two tabs daily or Muralax in the morning in their coffee or in their orange juice. I really tell them that we have to be vigilant about preventing constipation because our body never adjusts to opioid-induced constipation. And then patient education, you can talk to them about side effects that they may expect. So itching, sedation, nausea, constipation, I tell them that the constipation never goes away or the risk for constipation never goes away, but with the other side effects, our body develops a tolerance to those side effects and they should go away. And then in Michigan, for example, for a pain contract, we do a start talking form, which is a really good form and it just takes you through a lot of the risk and safety associated with starting your patients on opioids. I often see patients have allergies to opioids listed in their electronic medical record and then it says that with morphine, they got nausea. So we know that nausea is an expected side effect or an expected toxicity of morphine that would not be considered an allergic reaction. So if you do see that in the EMR, feel free to talk that over with a patient. That's not a true allergy removed from the record if you can. If your patient is requiring a really significant pain management regimen or they're needing pain relief and they become NPO, don't panic. There's a lot of other routes available. Also a lot of medications do come in like a very concentrated sublingual form. So Roxanil is concentrated morphine, it's 20 milligrams per mil. You can do that sublingual even if somebody is NPO. You can do methadone sublingual, buprenorphine, fentanyl. You can do Dilaudid if it's not very well absorbed. You can crush oxycodone sublingual, maybe not your first line choice. Remember you also have patches available. So patches are appropriate for patients who are on a stable dose of opioids over 24 hours. So we have patches. There's IV medications certainly, rectal medications. Notice I didn't mention IM medication, intramuscular injections, HERT, and we have so many other routes. I never prescribe any intramuscular pain medication. My next point, avoid combination products, a case for Tylenol. So you will very rarely see a palliative provider prescribe a combination product like Norco or Percocet unless the patient is already on it and they're receiving benefits. So if that's the case, I'm usually happy to continue it. I wouldn't start it myself and the reason is that your combo product is always limited by your max dosing of Tylenol. So we want our patients to not get more than three grams of acetaminophen per day. We're really limiting how much of that combo product they can get. Also Tylenol is a really good pain medication. Let it do some heavy lifting. So if you change your combo product into your short-acting opioid and your Tylenol and you can dose your Tylenol around the clock, 6.50 QID, Q6 hours, and then do your appropriate safe short-acting opioid prescribing Q4 hours PRN, I think you really ultimately get more bang for your buck in terms of pain management. I believe that you'll be, you know, I'm sure you've been told that you should not use methadone or fentanyl if you're not comfortable with them. I absolutely agree with that. These are very potent opioid medications, but I would say that if you want to become more comfortable with these medications, they can be very appropriate and very helpful for the right patients at the right time. So feel free to expand your toolkit, learn more about these medications, do a palliative rotation for example. These are actually really great resources as long as you have the knowledge and the confidence to use them safely. So I think that's the end of the second section. Can I check in for any questions? Yeah, I had a question. So how quickly will you change from short-acting opioids to long-acting? I know you said if they're using like more than four times a day, then you normally switch it to long-acting. But if they're using it more like five times a day for two days in a row, then do you think about switching it or does that have to be more of a chronic issue? No. So for example, we have a palliative cancer clinic and if we're seeing a patient for the first time and we decide it's appropriate to just have a short-acting opioid PRN, we even, like either myself or maybe one of our palliative triage nurses, we'll check in with them 48 hours later, ask them to keep track of how many doses of PRN doses they're needing per day. And really, if they're, yeah, I would say even two days later, if they're needing more than four short-acting doses per day, consider switching to a long-acting plus short-acting management scheme. Awesome. Sounds good. And then someone's asking, when do you favor morphine extended release versus OxyContin or what other long-acting medications do you usually try initially? Great question. I was actually going to mention that. So thank you for reminding me. So I really favor a long-acting morphine, MSER. So actually, according to the literature, OxyContin, which is long-acting sustained release oxycodone, is more likely to be diverted to the streets. So I rarely prescribe OxyContin, unless I have a cancer patient who's already on OxyContin and are having effective pain relief, great, but I would usually prefer morphine extended release. I'm a big fan of methadone. We use a lot of methadone as our long-acting opioid in our program. That's also a great medication. You do have to get more comfortable with it. So methadone is very powerful. So if their morphine needs are low, but you still need a long-acting, start with your long-acting morphine. If they're needing pretty significant, so if they were on, let's say, 40 milligrams of morphine equivalents per day, that would be about 10 milligrams of methadone, which you could split into a Q12-hour dosing, so 5 milligrams QAM, 5 milligrams QHS. So those, my extended release morphine and methadones are my go-to. I really don't prescribe OxyContin. Awesome. I think that was very thorough. I think that's all the questions for this session right now. The third section we're going to move on to is high-stakes goals of care communication. I want to give you really specific tools and specific things that you can say to your patients and their families. I know that a lot of you are really smart physicians. You're very empathic physicians, but sometimes it's hard to know what to say. So I want to give you specific things that you can say that really work in a lot of different scenarios. So if you're going to have that difficult or challenging, meaningful discussion with your patient or their families, you have to prepare and commit to this conversation. So you need to do your homework. So these are things that I look into when I'm planning to have this conversation. So you really have to do some digging. So you can look in the patient's electronic medical records, see do they already have a living will and advance directive, any advance care planning documents, and do read through those. Find out does your patient have decision-making capacity. You might realize that actually you're going to have to have a quick discussion or maybe even a more lengthy discussion with your patient initially to figure out if they do have decision-making capacity and then have that goals of care discussion after that, depending. Have they already elected a medical durable power of attorney? Has their power of attorney already been activated? So for example, a patient with dementia, their MDPOA may have already been activated so you know it's their daughter who makes medical decisions for them. If the patient was never confident, they may have a guardian. And do know that decisions are a little bit trickier going through a guardian than going through an MDPOA. So just run things by your colleagues, by your seniors. Actually I said later in this slide that if you have any concerns about these big discussions and these big decisions, reach out for help. You can talk to your ethics team, talk to your hospital's legal or risk management team. And also know your state laws. So usually most states have a hierarchy so if a patient is not decisional, you know who to consult, you know their spouse, then children and parents. In Michigan, we don't have a hierarchy so actually we're really needing to approach all the family members to get a consensus decision and that can be challenging. Definitely look at old oncology or palliative notes. Maybe someone's already had this discussion with a patient in the past or the patient has already made their wishes or their preferences very clear. So you're not going to have to necessarily have such an in-depth conversation. Maybe you just need to confirm that their wishes and their preferences haven't changed. Like I said, if you need any help, there's people there in your institution to help you. And just remember that legally and professionally, you are not required to provide futile care. So this, just reflect on this in terms of when you're having resuscitation discussions or tube feeding discussions. As providers, professionally and legally, if we think it's futile, we do not have to do it. But obviously, you're going to have to have a really in-depth discussion with patients, family, all of your team with regards to these complex issues. Okay, so you've decided to have this discussion and you've committed and you've prepared. Another commitment you're going to have to make is time. So this may take 20 minutes or this may take two hours. So give yourself that two-hour block. And if it takes less time, that's great. You have more time for documentation or like chasing up things afterwards. But commit to the time. It may also take more than one meeting with the patient and family to really find that path forward. Find a quiet location. So right now, we're doing all of our family meetings through iPads and we've been doing that in the family room. And then what is your goal? What are you hoping to discuss with the patient and or their family? Is it code status? Is it hospice eligibility? Is it, you know, a ceiling of care, a level of care? So yeah, establishing your goals and your objectives as a provider but also being open to the patient's agenda as well. So I would say above all, your number one goal should be to get to know your patient and your family. So I don't think it's fair to you as a provider, fair to your patient or their family to have such a really meaningful, challenging discussion without knowing a little bit about them. And obviously, knowing about them, those aspects of them really contributes also to their decision making. So these are questions I pretty much ask all patients is who lives at home with you? That's a question we also ask in rehab and PM&R. I ask them, are you a spiritual person? So I actually avoid saying, do you have a religion or are you religious? Because patients will say no. But then if you say, are you spiritual, they'll say, oh, yeah, you know, I believe in God. So I think if you phrase it as are you spiritual, you're more likely to kind of find out what their spiritual beliefs are. And then what do you enjoy? What brings your life meaning? Patients really want to share this. And this really influences their decision making. And this is a way of establishing rapport and a relationship with your patients. And if they have kids, always ask about grandchildren. People love talking about their grandchildren. So just another way of really creating that connection with your patient in order to then have some very difficult but meaningful discussions with them. Okay. So these are questions I always ask my patients. And I bolded the parts of these slides that I think are most important, the greatest take-home messages. So always figure out what page they're on so that you can meet them on that page. So I say, what updates have you received so far from the team? Especially now with COVID-19, a lot of family members are not in the hospital. There's no visitors. So they may be very up-to-date because they're calling the floor every day. Or they may have no clue because they're not at the bedside. So if you're talking to family, figure out what they understand. If you're talking to your patients, still figure out what they understand. That's really crucial. I ask literally everybody, what are your concerns? And I encourage you just to say that verbatim. What are your concerns? Because I'm constantly surprised what patients' concerns are, what their families' concerns are. And you may start addressing something that's not their concern. Their concern is this 180. So sometimes people will say, I'm really worried that my loved one is suffering or in pain. Or I'll ask, what is your concern? And they'll say, oh, I want to know the prognosis of how likely my loved one is to survive this admission. So really find out what their agenda is by asking this question. So we don't really say firing a warning shot anymore. I think a lot of us learn that in medical school and communication class. But it's a little bit of a violent descriptor. So instead of saying firing a warning shot, you can say give fair warning. So I'm afraid that. I'm so sorry that. Just kind of that just that quick kind of a few seconds preparation for what's going to be really hard news for this patient and their family. And then the hardest thing after you give like bad news is to be silent. It's a completely normal feeling to want to fill that silence or fill that space. But truly be silent. It's a form of respect. It's a form of appreciation for what your patient is going through and what the family is going through. Pass them a tissue. But even just count 1-1000, 2-1000, 3-1000 in your head to give that appropriate silence and to give your patient respect and give them space. And then after you have that moment of silence, acknowledge any emotions of the patient or the family is displaying. And literally you can just reflect back verbatim what you see. I can see you're crying. This is very hard. I can see you're angry. I can see you're so sad. These are normal feelings. So literally just reflecting back what you see can be very powerful. Next section. I do encourage you to use very direct, honest language. Decide if statistics are appropriate. I think a lot of suggestions are that you use eighth grade language. I actually did a course with the University of Nebraska who really encourage you to use fifth grade language. So just as much plain English as possible. There's this concept of the fifth grade language. I think it's very applicable. There's this concept that we have of universal precautions for infection control. So we all know what those are, but that we should also have universal precautions for health communication that we start at a level that everybody can understand. And then you go from there. So you may make the language more advanced or you may make the language more basic. But kind of start at an accessible level of communication. Some lines I would use is your mom, your dad, your husband, your wife, your partner is very sick. Her heart or liver, kidneys are failing. The concept of an organ failing I think is a pretty accessible, understandable concept to most people. And they understand that that's very serious. Some families and patients really do want statistics. So if you used like a prognosticating tool, and I'm going to talk about that a little bit. But if you use a tool for prognosis, you can say there's a 70% chance your loved one will die within the next month. I think most people appreciate the meaning behind that. Your loved one is transitioning to active dying. I'm so sorry to tell you this over the phone. And especially during this time of the pandemic, it has been really hard to give bad news over iPads, over phones. It's very challenging. I know we're all doing our best. If you're not so sure about kind of what the clinical course is going to be, but maybe there's a very high morbidity, mortality, you as a provider can say, I'm worried that. I'm worried that after surgery, getting off the vent is going to be very hard. I do encourage you to use the D words, death, dying, died. These are appropriate terminology to use, appropriate to use with patients and families. And I think they need to hear those words used specifically. When we're talking about hospice, I like to say we can, especially with hospice, we know we're going to get good outcomes with hospice in terms of managing comfort and quality of life. So I tend to say we guarantee a comfortable, dignified, beautiful death. A lot of these lines on this slide are platitudes. You might say they're platitudes, and maybe they are platitudes, but I always get very positive feedback from patients and families. I say, you are in our thoughts and prayers, because I do think about my patients after I leave the bedside. And when you say that to them, they really appreciate that. Especially since a lot of families are not at the bedside because of the pandemic, I say, we're going to treat your loved one like she's our mom or he's our dad. They really appreciate that too. Thank you for allowing us to take care of your loved one. And then also making sure you have that time, you've committed that time to seeing at the end, what questions do you have for us? Not, do you have any questions, because this is a huge conversation. Of course, they have questions. So what questions do you have for us? We've got the time to sit here to review your questions. And then make sure you're going to tell them what's going to happen next. Is a hospice agency going to call them? Is a case manager going to call them? Is the patient going to call their family member from their bedside phone? So you owe it to them to tell them, what's that next step going to be? I mentioned Vital Talk here. Vital Talk is a really great organization. Like I said, no financial disclosure. But they have a free app for health care communication. And they also have an amazing COVID-19 communication toolkit. And it's translated into a lot of different languages. I would definitely recommend having a look. We talked about prognostication. So providers are notoriously bad prognosticators. But that doesn't mean we can't try. Providers tend to overestimate patients' lifespan or the duration of time they have left. Also, paradoxically, the longer a provider knows a patient, the less good they become at prognosticating. So these are some of the tools that I use and you might wish to look into. So this is our palliative performance scale. You read it from left to right. So really, their performance is very much weighted towards, can they ambulate or not? And the PPS kind of parallels the Karnofsky performance scale. These are very synonymous scales. I prefer the PPS. The Karnofsky sort of assumes that your patient is always going to stay in the hospital throughout the duration of their illness, which is maybe not necessarily true. The palliative prognostic score gives you what their survival percentage over 30 days. The FAST scale is for Alzheimer's dementia, looking at how is their Alzheimer's dementia progressing. So if you're FAST scale 7C, you are eligible for hospice. I've had a lot of patients recently on my consult service who had advanced hepatic disease. So I do use the MELD score. In terms of how you approach, doc, how long do I have to live? Patients, I find patients don't have a positive response when you say you have six months to live and then they outlive it. And they're like, oh, well, I outlived my six month prognosis. But I think patients and families are receptive to you saying, I think you have hours or days to live. I think you might have weeks or months to live. And given that window of time, I think that they still understand the impact of having that period that they're working with. And then like we said, prognostication is not a science. It's a science and an art. So usually in my notes, I say best judgment prognosis, just so other providers or specialists can see what I'm prognosticating. That's the end of the third section. Quick check-in for questions. It doesn't seem like there's any questions about that. I know this is extremely helpful. A lot of these times, a lot of these situations, it's very difficult to talk with patients and their families. And I know one thing that the palliative team here at Vanderbilt always says is that the moment of silence is really important. Because a lot of people, like you were saying, feel uncomfortable with that silence. Yeah, to remember it's about the patient. It's not about our discomfort. It's about giving them space. Absolutely. Yeah. OK. All right, so we'll move on to our last topic, which is hospice. So what is hospice anyways? So if you can see above these three things that I have discussed, so hospice is a philosophy. And what I mean by that is your patient and their family want to focus on comfort and quality of life and symptom management at the end of life. And part of the hospice philosophy really is that hospice is your new 911. So if you're not feeling well at home, you're not calling 911. You're calling your hospice triage nurse or their triage phone center. And they're going to make sure that you're comfortable and that your symptoms are managed in your home or wherever you're receiving hospice. So you want to make sure that your patient and their family are hospice-minded and the right mindset to sign on to hospice. Ultimately, hospice is a Medicare Part A benefit. So Medicare expanded to hospice coverage in 1982. So we're coming up on the 40th anniversary of the Medicare hospice benefit. So when a patient, what a patient does is they sign off of their Medicare Part A and they sign on to their Medicare hospice benefit. It's not jail. You can choose to be done with hospice at any time if that's what you want. Equally, if you're doing really, really well, you might graduate from hospice when your provider thinks that you're no longer hospice eligible because you're living so long. So ultimately, it is an insurance benefit. And this is health care delivered everywhere. So you can have hospice in your home, in a nursing home. It's in hospice homes. And then if you have unmanaged symptoms, you may have hospice care in the hospital. So we'll go into that in a little bit more depth. I wanted to show you my awesome team, but this is also a helpful photo because there's certain federal guidelines about who you have to have on your hospice team. So if you go from left to right, that is we have two nurses. We have a nurse manager and two nurses' aides. We have the hospice medical director. We have myself. We have a volunteer coordinator. We have environmental services. We have a secretary, a social worker. We have another nurse's aide, and we have a chaplain. So you have to have all these members of hospice. So hospice is a team approach. You have to have, I think, about 5% of your services provided by volunteers. So volunteers are an essential part of the hospice team. And you also have to follow families for 12 months after the patient is deceased to provide bereavement support. So when would you consider hospice? So this is the surprise question. Would you be surprised if your patient died in 12 months? Would you be surprised if your patient died within six months? If you believe your patient is going to die within six months if their disease follows a natural progression, you would strongly consider them being eligible for hospice. So there's disease-specific hospice eligibility criteria. So CMS has guidelines. So, for example, common hospice diagnoses are COPD, congestive heart failure, advanced neurological disease, dementia. These are guidelines. They're not laws. So if your patient fits those guidelines exactly, for example, with COPD, if they have shortness of breath at rest and they are maximized on their medical therapy, then they would qualify for hospice. If they do not fulfill those guidelines exactly, but you can paint a picture of someone who may die within the next six months because maybe they have COPD and they have very advanced chronic renal disease, they would also be hospice-appropriate. So you need two providers. You need two physician signatures for initial certification. And then you also have to do recertification. So you have these recertification periods. So the first periods are, there's two 90-day periods. And the reason that it's that way because once you get to two 90-day periods, six months of time has elapsed and your patient is still alive. So that's fine as long as you consider them to still be hospice-eligible. So then you're doing your face-to-face meeting and you're going to see the patient and making sure the hospice care is still appropriate. After that, you go down to 60-day period. So you have to approve a little bit more frequently that your patient is still hospice-appropriate because Medicare is providing the hospice with reimbursement for these hospice patients. So you have to make sure that they are appropriate for this type of care. This is a really great booklet that we give to families. Nature Gave Us Butterflies. It just has some really lovely descriptors of those end-of-life stages. So we share that with all of our families and you can kind of have a closer look at it on Amazon, but butterflies are a really nice analogy. So there's four different types of hospice care. Not everyone knows that. So routine care, your hospice organization is getting $150 a day. And what we're saying here is the patient is hospice-appropriate, but their symptoms are stable. They are seeing their nurse probably once a week. They may be liaising also with their social worker or their chaplain, but they're stable and they're either at home or they're in a nursing home or they're in a hospice home. And they're on routine level of care with a specific amount of reimbursement. GIP stands for general inpatient. What we're saying in this kind of situation is the patient has to either be in a hospice home or a hospital because their symptoms are uncontrolled and they can't be managed in any other setting. So you can't do GIP in a patient's home when you can't do it in a nursing home either. You have to be in a hospital or a hospice home. The hospice gets higher level of reimbursement per day. And these are patients who require close observation and frequent intervention to manage their symptoms. They may start on GIP because of uncontrolled pain and you manage their pain, but then they become dyspneic. So then you can kind of convert their GIP status to GIP for dyspnea. You are gonna start to raise red flags if your patient's on GIP for longer than seven days because you're on GIP, you're getting a higher level of reimbursement as a hospice organization. And you should be really trying to manage your patients in a shorter period of time to get them stable again. Respite has nothing to do with a patient's status, but really with a family. So if the family has burnout or the family needs to make a quick trip away, respite is for up to five days. A patient can go to a hospital or go to a hospice home and just have routine level of care. And they're just somewhere where they can be observed instead of being at home with their family because their family needs a break for whatever reason. And then the last type of hospice care is continuous. You never see this anymore. So this continuous hospice care was abused in the past by for-profit hospice organizations. So a myth you may hear from maybe older families or older patients are, oh, hospice moves in with you at the end of life. So that's not true, but some for-profit hospices would use that continuous hospice care. They'd get more reimbursement and provide a nurse at home for eight hours a day. So that's not really a good use of resources. We don't usually do that anymore. That patient would either be routine or you decide that they're appropriate for GIP care. So really you're gonna be seeing those three. I've never seen continuous. My attending with years of experience has only seen one or two cases of continuous hospice care. And really this is a take-home message that I share with families and patients and even my colleagues. Hospice is the highest level of care for patients who are not pursuing curative or disease-directed treatments. It's an amazing level of care. And it's, yeah, it's really rewarding, ultimately. This happens to be the lobby of the hospice home that we're affiliated with. So these are the educational resources that I sprinkled through this lecture. So this is our national organization, AHPM. This is vital talk for all of those helpful communication tips, especially around COVID, around any other kind of health communication. Fast Facts is this amazing resource. You can have it as a free app on your phone or on your iPad. It's all hospice and palliative information pages. There's almost 400, I think. They're actually so rigorous and they're peer-reviewed. We actually use them for board review. But if you just wanted to know a little bit more about a specific area of hospice or palliative, you yourself could access them for free. If you want to really learn more about opioids and get some free opioid education, you can do your ex-license training or your waiver training to prescribe Suboxone or Buprenorphine, even if you don't want to prescribe those medications. Like I said, it's free education about opioids to empower yourself. And this is a resource that I use for myself. CAPSEA is an organization, a Center for Advanced Palliative Care. Your institution needs to have a membership, but then there's modules for symptom management, especially for safe opioid prescribing that I would encourage you to explore. This is the video about describing palliative care like a bridge. It's a really, really great, quick video. ABPM and AHRQ, if you want to know more about the HPM board exams, board certification. And then this is the link to that booklet about describing the stages of end of life and dying with patients' families. So feel free to take a quick picture or a screenshot of that. And I think we're pretty much wrapped up. And then if you want to email me or reach out to me on Instagram, that would be great. Thank you so much. Awesome, thank you very much, Dr. Kaplan. As one, again, thank you for coming out and giving us this talk today. I think it was very useful, and especially about everything, all the difficult discussions that no matter what field you go into, you're going to be having with your patients. I think given the fact that it is time for the next lecture, I think we will defer questions at this point, if that's okay. So I know this is Dr. Kaplan's email. I'm sure if you're okay, feel free to reach out. And then also Sterling Herring and AAP's Twitter handles, you can ask or reach out with questions also to them. So thank you again for coming out. We really appreciate it. Thanks so much, bye.

hospice

palliative medicine

communication techniques

difficult discussions

patients

families

preparing for discussions

direct and honest language

patient emotions