The Pain and Reward of Delivering Palliative Care During COVID

Commentators

• Seth Krevat, MD, FACP

Transcript

Excellent palliative care is inherently challenging. Providers need to diagnose the need for pain management and comfort services well before and beyond end of life treatment. They must arrange the time and space for careful “goals of care” conversations with patients and families. Under-utilization of pain and comfort care by providers and patients alike has even led to calls for changing the intimidating-sounding term “Palliative,” to “Supportive Care” instead. A relatively young sub-specialty, Hospice and Palliative Medicine was officially recognized by the American Board of Medical Specialties in 2008.

The COVID-19 pandemic has only added to the complications. Over-capacity hospitals and a shortage of palliative specialists that pre-dated the crisis has led to some improvisation and innovation. A hospital in Boston embedded a palliative care specialist in the emergency department, working alongside intensivists. A New York safety net hospital put out a call for remote volunteers via social media, and recruited hundreds of specialists for a pilot telehealth program for palliative care for its patients.

Data from thousands of malpractice claims in the CRICO national Comparative Benchmarking System show that communication is a contributing factor in more than a third of all medical professional liability cases, and roughly half of those involve patient/provider communication. Overall data indicate, however, that liability cases with central allegations involving palliative care are relatively unusual. Among several reasons for that may be the heart of the specialty itself, which is listening to patient concerns and preferences. Getting to know the patient and family personally and establishing a close rapport are skills that can be transferred to other specialties.

We had a chance to discuss palliative care in the COVID era with an expert practitioner from the Metro DC area… to hear about his personal experience….and perhaps pick up some insights that might help improve communication between any specialist and their patients.

Q.) Joining us now is Dr. Seth Krevat. Dr. Krevat is the Senior Medical Director and Assistant Vice President at MedStar Health National Center for Human Factors in Health Care. He is also a palliative care physician at MedStar Georgetown University Hospital, and Assistant Professor of Clinical Medicine at Georgetown. Dr. Krevat, thank you for joining us.

A.) Thank you for having me, Tom.

Q.) Why are you attracted to palliative care in the first place?

A.) I’ll start by saying I’ve been attracted to this field for years, mostly because I enjoy helping people who are in tough spots in the health care journey. So a lot of what we’re taught in medical school is to find problems and fix them. And people get into a little bit of a jam when problems may no longer be fixable, and this happens when people have chronic illnesses and they have symptoms that aren’t controllable. It happens toward the end of life when treatments start to fail or there are no more treatments, and it’s a very important, it can be a very difficult, and sometimes it can be an exceptionally special time in people’s lives. And it feels to me like a privilege to be able to step in and help people during these tough times.

Q.) This is the kind of work that isn’t easy for clinicians who are typically trying to fix things, not accept things as they are.

A.) Exactly, yes. I watch other clinicians who are incredible at what they do, struggle when they realize that there are no more treatments to fix patients’ problems. Again, it’s what we’re taught to do in medical school. If a potassium is too low, we learn how to treat it appropriately with the right amount of potassium. If a blood pressure is too high, we figure out how to treat that with the right medication. If an appendix is inflamed, a surgeon learns how to take it out. But when a patient is in pain or struggling with a life decision because we can’t fix those problems, it becomes almost an internal struggle for a lot of clinicians to work with those patients. And there’s a select group of us who look at those moments as opportunities to alleviate suffering and to help patients and families in a different way.

Q.) What are the challenges specifically to providing palliative care during this pandemic?

A.) The pandemic was challenging. People have seen it on the news. It’s challenging for all healthcare workers. It’s been an incredibly devastating moment in time for health care providers at all levels. For palliative care doctors, there’s been a large increase in the need for our services because people would come into the hospital, they would get sick quickly, we didn’t know exactly the trajectory of their illness and it was scary. It was very scary, and people would get sick so quickly and decisions had to be made about what the next steps were in a moment.

So we started getting called frequently on our palliative care team, because there were chronically ill or older people who are now in the hospital and terribly short of breath who were on the verge of being intubated, placed on a breathing machine. And we were pretty sure at the time that once they got put on these breathing machines that they would not get better. And there was a need to have quick conversations with patients and families about whether or not they wanted us to do this. And these are conversations that normally evolve over hours, days, sometimes weeks, sometimes months, and we were in a new position where we needed to have these conversations sometimes in an hour or less. And it was really hard for us as clinicians to do this. It was terribly painful for families. It was painful and complicated for patients that they were even able to have these conversations, and I think it took a big toll on palliative care physicians who were seeing a lot of people struggle with emotional and spiritual and physical pain. And we did our best to help them through and hold their hands, either virtually or in person. But a lot of times it was very hard for us to alleviate that pain.

Q.) You have the added complication and challenge of limitations on visiting and being in the same room, patients and families and their providers. Was telehealth a way out of that or a way to address that? How does telehealth play into this?

A.) Telehealth was a great gift in many ways. Because of this huge increased need for palliative care across the MedStar Health System, we didn’t have enough resources to provide what we needed to provide to all the patients and families; one, because there was an increase in volume of need for palliative care, but two, also because we had providers who were at high risk for contracting the virus and getting terribly sick from it or maybe not able to come in and see people in person. And what telehealth did was enable us to spread our resources across the whole system and enabled people to be in safe spaces, either at home or separated physically from patients to keep them safe and that was incredible. So it allowed us to provide more care, sometimes in a safer space. Now many of us continued to go to the hospital and see patients, but it prevents us from having pulled people out of the workforce to keep them safe.

The challenges of palliative care via telehealth were mostly not being able to be physically present with patients in these really important times of life, and communication is often done through the words we use. People pick up on the tone we use. And then there are a lot of verbal cues that people pick up on when we’re with them. In gaining trust and being able to listen in person with a patient, there really still is no substitute for that.

It’s the nonverbal cues that are really, really important too. And sometimes just physical presence, so we do spend time in palliative care holding people’s hands and it’s just not possible to do that via telehealth. And again, I go back to what the other benefits are, we were able to conduct family meetings with multiple family members quickly. They were able to see their loved ones and to see us, which I think made a difference to them. The logistics of getting people into the hospital were removed by being able to send out meeting requests for video meetings. So there were significant benefits and it enabled us to continue providing care where we needed to, enabled us to continue providing care on a larger scale, and some drawbacks about the lack of physical presence.

Q.) Seth, could you share some of your personal experience providing this kind of care via telehealth during the pandemic?

A.) Sure. I think there’s the caring for patients in person, and I will say that that was scary initially when we had very little information when we were going into the hospital in March and being terribly afraid I was going to contract COVID and bring it home to my family, bring it out to the community, and to have to be with patients when their families couldn’t be. And then providing care via telehealth was in some ways a sad but an experience for which I was grateful. I was grateful that we had the tools.

So I remember one 55-year-old gentleman who became very, very sick quickly and he was intubated and on a breathing machine in our ICU, and his organs were failing, his kidneys were failing, his liver was failing. His lungs and his heart were failing, and we knew he was going to pass away and I was able to see him on a Friday in person and was able to be present with him and have a video call with his family and have the family see him via the video call. And the next day on a Saturday, his course took a turn for the worst if that’s even possible, and it was clear that our medical interventions and our options were running out. And because we had a telehealth and the telehealth platform, the primary team in the hospital, the ICU team, was able to contact me and I was able to arrange quickly a video call, a telehealth call with multiple members of the family and just spend time with them. And they were able to see me, they were able to see how much I cared about them. I was able to see them and see who was struggling. I was able to call out the people who I think maybe were struggling more and needed some attention, which I wouldn’t have been able to do on a phone call. And I’m hoping in the end that I was able to give them some comfort as they made their decision to transition him to comfort care and to stop the breathing machine and other medical interventions.

Q.) That’s an amazing service that you were able to give to them.

A.) I hope so. I always hope so. I often come home from working with people like that and, without sharing names or patient information, I talked to my children and my wife about how grateful I am that I get to be part of people’s lives in this very vulnerable time and that they let me in. I really feel like it’s a privilege.

Q.) Now we don’t typically think of palliative care as being associated with malpractice cases, end-of- life care and claims of negligence, do you see liability risks in this kind of thing?

A.) I think there are very few, and it makes sense after what I’ve read over the years and after speaking with multiple patient and family advocates who have actually had their loved ones harmed in the health care system. They often say that the reason why they sue or there’s risk is because they can’t get information and because people don’t listen to them. And palliative care is a specialty which is focused on listening to patients. For me it’s about being curious. I want to understand what’s important in a family and the patient. I don’t have an agenda when I walk in the room except for me to learn as much as I can about them. And then figuring out how do I get them the information that they want and need and to hopefully help them achieve their goals. If that’s our main focus in palliative care and if we know that patients often sue because they don’t get information or because they are treated poorly or because people don’t listen to them, it makes sense why there’s a very low risk of malpractice suits in the palliative care field.

Q.) It almost sounds like palliative care or the field of palliative medicine has something to teach other specialties, every specialty, in that regard.

A.) I’d like to think so. It’s very nice that you say that. I was a hospitalist and internist before I practiced palliative care, and as I implemented some of the tools of palliative care into my hospitalist practice it really was about listening and understanding, rather than speaking and telling people what I thought. Which seems like it would be inherent in how we all practice medicine, but it’s not. It wasn’t natural to me initially based upon my medical training. But if other people could incorporate some of these tools into their practice, not only would they find it easier to practice because communication of patients and families get, I think it actually gets better, but it’s actually more fulfilling. So I would love more people to incorporate this into their practice. It doesn’t necessarily take a lot more time, and I think it makes it more fulfilling to practice medicine.

I love to hear about patient and family stories because they’re fascinating because everybody has had a full life even at 6 years or 10 years, unfortunately, if someone dies at a young age, but think about 50, 60, 70, 80-year-old, those many years of experiences. And if people could just tune into them a little bit with a little bit of emotional intelligence and curiosity, I think they’d find their work so much more satisfying and gratifying. I think patients and families would feel so much better, and we would be doing what we’re supposed to be doing as clinicians which is healing.

Well thank you, Dr. Seth Krevat. Dr. Krevat is the Senior Medical Director and Assistant Vice President for MedStar Health National Center for Human Factors in Healthcare. He is a palliative care physician at MedStar Georgetown University Hospital and Assistant Professor of Clinical Medicine at Georgetown University Medical Center. I’m Tom Augello.