Time Stamps

  • 05:54 Laying the groundwork
  • 09:00 Asking permission, eliciting values and making a recommendation
  • 16:00 When a patient is dying
  • 16:48 Sharing the prognosis first
  • 20:35 Functional status post-CPR
  • 21:54 Headline statement
  • 23:57 Virtual and PPE Communication Challenges
  • 25:36 Separate process from outcome

Show Notes

Prior to conversation

  • Identify patient’s healthcare proxy immediately upon admission
  • Ask how patients wish to receive information (e.g. directly or via proxy)
  • Ensure patients have means to connect with families (phone chargers, iPad, etc.)

1st Type of Conversation: Laying the groundwork – similar to breaking bad news

  • Elicit patient or loved one’s understanding of illness
    • “What have you been told so far about your illness?”
    • “I know things have changed quickly.  Tell me what you’ve heard more recently.”
  • Share clinician’s hopes and concerns
    • Use language of  “hope” and “worry”
      • I hope our treatments will make you better and I worry that you might get sicker from this infection.”
    • Expect and respond to the emotion that arises
      • “I can imagine this is scary to think about. I wish things were different.”

2nd Type of Conversation: Heart of Goals of Care

  • Ask permission to explore goals
    • I wonder if we could spend a little time thinking about the possibility of you getting sicker?
  • Clarify goals with specifically framed open-ended questions
    • “If time were short, are there things you would be particularly worried about?”
    • “If you were getting sicker, what are some of the things that would be important to you?”
    • “Are there any conditions you would find unacceptable or worse than death?”
    • “What would you [or your loved one] be willing to go through for the possibility of more time?” (adapted from Serious illness Conversation guide)
    • Giving examples can be helpful if patients provide abstract responses:
      • “Some patients tell me that if they were getting sicker, they would want to make sure they weren’t struggling to breathe, etc.  Do any of these resonate with you?”
    • These questions to “map” goals and values can just feel like good doctoring but they also provide key data to ultimately make a recommendation.
  • Make a recommendation
    • Summarize what you have heard
    • First, recommend what treatment options should be continued. Then state what treatment options may not be recommended (ie. the more aggressive interventions) based on the patient’s values.
    • Refrain from language of “There’s nothing more we can do,” which sounds like giving up.  Instead focus on what we can do, for breathing, comfort, pain, etc.
    • Use contingency planning in situations where patient or family has not yet decided or if there are rapid clinical changes: “Based on what you’ve told me, it would be reasonable, if you were to get sicker, to try a breathing tube and go to the ICU.  And if it wasn’t working, if it didn’t seem like you were getting better, could we think about that?”

3rd Type of Conversation: When patient is dying

  • Give clear update: “Your mom may be dying very soon”
  • Expect emotion after that
  • Express ongoing commitment to being there with loved one, especially as patient may be alone during COVID: “We’re going to be right here with her.” 

COVID-specific Considerations

  • Consider Dr. Nakagawa’s approach of sharing the prognosis first, then exploring goals, then making recommendation, especially when time is short
    • There is a tension with too much autonomy and too much paternalism. 
    • Instead of presenting GOC as a menu for patients to choose, ideally we want shared-decision making
  • Prognosis in COVID can be framed related to functional status post-CPR
  • Give a “headline:” statement of the one message you want patient or family to remember later
  • Communication challenges
    • Virtual communication
      • Validate loved one’s distance from hospital, how hard this is
      • Pause frequently and check in to see how conversation is landing
    • PPE communication challenges
      • Maintain eye contact, consider holding hands, speak loudly through respirators
  • Separate process from outcome of goals care conversation
    • Easy to feel disheartened after the best conversation if the patient and family do not choose your recommendation.  But our job is not to convince.
    • Reflect on what went well after a conversation.  Have self-compassion!

Parting thoughts

  • Communication is a skill like any procedure that requires practice and reflection 
  • At the same time, we have to practice self-care, lean on support networks for debriefing 

Transcript

Lawton: The prep work that’s required to set up a thoughtful conversation or even to give a family an update on a given day is requiring a lot of coordination. We can imagine a whole variety of situations. The patient’s probably not cognitively aware. There are language barriers. The interpreter wasn’t available.  No family members are in the hospital. Add in when the patient can’t participate

Shreya: That’s Dr. Andy Lawton, a palliative care attending at Dana-Farber Cancer Institute and Brigham and Women’s Hospital. He is pointing to just a few ways in which having goals of care conversations have changed in the world of COVID-19. 

Dr. Lawton: All these spots where things can get mixed up, there’s a real opportunity for people to not hear information correctly or, you know, the game of telephone doesn’t get to the sister. So I think the whole virtual world with COVID has made this more challenging, and we have to be extra proactive in setting things up. 

Shreya: Families can’t be by their loved one’s sides.  Patients are terrified of dying alone. You are often having these convos in PPE where non-verbals can’t be seen. On top these new challenges that COVID has brought is just the actual challenges that come with goals of care conversation. These discussions can be tricky to navigate in and of itself. And this communication is a skill and like any procedures right? It requires that prep work up front. 

Dr. Nakagawa: When you expect the conversation, you have to think, “So, how do I explain the situation?” “How do I summarize a medical condition?” “If they ask me that question, how should I answer? How should I phrase it?” But you have to do this. 

Shreya: That is Dr. Nagawaka, a director of inpatient palliative care consult services at Columbia University Medical Center. Unfortunately I feel like a lot of times, instead of a goals of care conversations, we often have to throw in a question about code status at the end of an H&P conversation, something like “I ask all my patients this but if there were to be an emergency what would you like? Do you want chest compressions? Would you want us to try a breathing tube?”… But with COVID, doing advanced care planning is now often front and center in our conversations. 

And with that welcome to a special episode of Core IM on inpatient goals of care discussions during the time of COVID-19. I am Dr. Shreya Trivedi, an internist at NYU. And to help me tackle this topic, I am joined by:

Amrapali: Hi I am Dr. Amrapali Maitra, a second year internal medicine resident at Brigham and Women’s Hospital.

Shreya: She also has a PhD in anthropology! 

Amrapali: … that basically means I’m really interested in the culture of medicine and how people communicate. We know that goals of conversations are a huge source of moral distress for clinicians right now during COVID, where the stakes are high, there’s little time to get to know patients or build trust with families, and the possibility of rapid respiratory deterioration gives these convos an added layer of urgency.   

Shreya: Exactly, and in addition to that pace and urgency, most our list–half or more of our list nowadays–probably needs an update or reassessment on goals of care. So just the sheer volume of goals of care conversations can be quite draining. So how do we do all this and cope?  

Amrapali: Yeah It’s a lot! An important thing is to remember is that we’re not alone: we should lean on each other to debrief and consult palliative care or even ethics if needed.

Shreya: Yeah. And the other thing we need to acknowledge upfront even with the best communication skills, you still might leave a family meeting feeling ugh i really tried my best but I still don’t think we are doing what makes sense medically for this patient. And I think that’s the tough nature of this work. But at least we can be humble and improve our communication skills for these high-stakes convos with patients and families during COVID.

Amrapali: Hopefully we will leave you empowered with specific language around these time-sensitive and emotionally challenging conversations. First, we will go through the three different types of conversations you might find yourself having during COVID and from the two palliative care experts’ you just heard, we will highlight their approach to these convos.

Shreya: Then, we will jump into some of the more challenging aspects around goals of care and leave you with some tips and consideration.

Communication approach: elicit understanding, map goals/preferences, share recommendation

Amrapali: Before we get into the nitty gritty of goals of care with COVID, one unfortunate thing that is happening is that patients are coming to the hospital struggling to breathe and without their families. So if possible, we need to ask right away “Who will speak for you?”  

Shreya: Yes absolutely, ask right away about their proxy before it’s too late and for example you realize the emergency contact in the chart is inaccurate or outdated. Another good question to ask upfront is if they have their phone charger or ipad to talk to their loved ones, which give you a heads up of how much you will be conveying to the loved ones how sick the patient is — just one other big challenge in the world of COVID because families can’t be in the hospital.  Lots to think about in advance, so where do we begin some of these conversations?

Amrapali: Dr. Lawton and his colleagues describe three types of conversations–they don’t all happen at once, they may not even all happen with the same patient, but they represent the three types of discussions you may engage in.  

To lay out how he thinks about these types: Conversation 1 is a version of breaking bad news- really getting a patients understanding and then giving your hopes and concerns, Conversation 2 is the meaty part, the heart of goals of care discussion where you explore patients values, and Conversation 3 is if/when a patient is dying.

Shreya: Great. Let’s get started with conversation 1.  He begins by asking patients or families what they’ve been told about their illness. Families may be hearing from different providers each day, given new teams are being created and staffing is changing constantly, so it’s all the more important to check in. 

Dr. Lawton: I’m one of the clinicians taking care of your mom. Um, what’s your sense of, uh, what’s going on with her? I know a lot has been going on, I know a lot has changed pretty quickly. Tell me what you’ve heard most recently. Like what, bring me up to speed on how clearly we’ve been communicating with you so I can know where to start from.

Shreya: I can’t tell you the number of times I’ve gotten into trouble when I didn’t start by asking a patient’s understanding because I was worried it would take too long. Then I find myself backtracking in the middle of a talk to say “Hey, wait let’s just make sure we are on the same page about your loved ones illness.”  

Dr. Lawton: I think it can be pretty quick too. This is a step that shouldn’t take more than a minute or two. This can actually save you time. 

Shreya: After we get a sense of what the patient understands, we can then share our concerns.  And using language around “hope” and “worry” can be really helpful.

Dr. Lawton: I really hope we’re going to use our treatments here and see you get better over the next couple of days. Get you to a place where you can go home. I’m also worried that I’ve taken care of patients and things can change quickly. It is possible that you could get sicker even quickly from this infection. And I want us to be aware of that possibility and think about it together so we can provide you with the best possible care.

Shreya: I really like how he gives “best case” scenario and “worst case” scenarios  — in a way that doesn’t overwhelm the patient or family as much.  I can easily see myself falling in the trap of only talking about the worst case scenarios, especially after days in NYC where all you hear overhead is rapid response and codes every 30 mins or so. I can find myself in a conversation where all I need from the conversation is decisions on CPR, intubation and ICU transfer. It’s easy to just want to talk about the worst case.

Amrapali: Totally. It’s so easy to want to prepare for the worst. We also asked Dr. Lawton to play out the scenario where you’re inheriting a patient later in their hospitalization and picking up these conversations.

Dr. Lawton: She’s been in the ICU for about a week now and it’s helpful to understand what you’ve heard from our team so far. I want to share with you that I continued to be really worried about her and I’m in fact more worried today than I was a week ago. I’m worried she’s getting sicker more quickly and we really do have to think together about the possibility that things are getting worse and she could even have soon she could even die soon from this infection. And you may stop there and then just respond to whatever emotion is likely to come up. I can imagine that this is scary to think about. I can only imagine how difficult it is to not be able to be here with her. And I really wish that that was different. 

Amrapali: So after doing that groundwork with the first type of conversation by getting patients’ understanding and stating your concerns and sometimes you end there, or you pick up with the second conversation.  The nice thing is you can titrate these conversations depending on the patient in front of you and what else you have going on in your day. The second type of conversation is really digging deeper into the patient’s goals.

Dr. Lawton: I wonder if we could actually spend a little time about thinking together, about the possibility of you getting sicker so that I can do a good job for you… so asking for permission can actually be a really powerful way to sort of transition to conversation two. If you were getting sicker, what are some of the things that would be most important to you? If time were short, are there things you’d be particularly worried about? 

Amrapali: I’ve often fallen prey to asking super broad questions (like, Who are you? What matters to you?) which are great questions, don’t get me wrong–but sometimes I get an answer like “I want to go to the beach,” while my patient has a rising oxygen requirement and is being maxed out on a non breather: a beautiful wish to express, but doesn’t align with the medical context. So I appreciate how Dr. Lawton prefaces his questions, like “If time were short” “If you were getting sicker.” Dr. Nakwagawa actually shared similar questions for clarifying goals, especially with sicker patients. 

Dr. Nakagawa: The other key question I sometimes ask is, “Is there any condition you find unacceptable, is there any condition worse than death?”

Shreya: The hard part, though, while  asking “Are there any conditions that are worse than death? sounds great, you may get an answer like “Doc, I don’t know what you mean.” A lot of people haven’t thought about their specific goals of care before this pandemic. So how do you gently but concretely help them imagine the decisions ahead of them?

Amrapali:  I think that’s where giving examples can be helpful:

Dr. Lawton: Some patients tell me that if they were getting sicker, they would really want to be with their loved ones or they would really want to make sure they weren’t struggling to breathe… So sometimes giving people examples that they’re having a hard time, you know, other patients tell me these types of things. Do any of those resonate with you, and what else?

Amrapali: And there’s another question that comes up from the Serious illness Conversation guide developed by Ariadne Labs in Boston:

Dr. Lawton: The question I find myself teaching, talking with people that I probably use more now than I did before is the question. Especially in COVID situation where we do find a lot of patients getting more advanced intensive therapy. What do you think she’d be willing to go through for the possibility of getting more time?

Shreya: But  why spend all this time asking questions of goals, worries, etc. when it may be easier if i could just cut to the chase and just ask, “Are you okay being hooked up to a machine – would you want to go through that?”:

Dr. Lawton: It often sounds like good doctoring or just sort of nice doctoring. Like, you know, tell me what your dad values… or just nice sort of banter and rapport building with the family. But what we’re actually doing is making an assessment. What we’re actually doing is gathering data, and we may, when we’re being our more directive selves, we may actually be putting the story together and interpreting in a way that maybe the family hasn’t thought about. 

Shreya: Ok, ok beyond the fact that it’s nice to know what your patient values, this can be helpful for when it comes time to propose a plan that may be the best for the patient.  

Dr. Lawton: You know what I hear about your mom is that she was, she’s a really tough lady and she’s been through a lot in her life, and at the same time the grandkids are important to her. Not having, you know, sounds like she dealt with pain for a long time. Not living in a state of perpetual pain would be important to her. 

Amrapali: So after summarizing what you’ve heard, you then make a recommendation based on the medical severity and values that might lean against the most aggressive care from someone who wouldn’t benefit.

Dr. Lawton: I think there’s a lot we can do for your mom to try to help her breathing be comfortable, to see if we can get a little bit of time, even if it’s while she’s sleeping or while she’s not fully aware to have people on the phone, and I think we can provide her with the best care possible. At the same time, I’m worried that there are things that may not help her live longer or better and may contribute to her actually having more struggle if she really is nearing the end of her life from this infection. And I think one of them is placing a breathing tube. It sounds like that may not be something she would have wanted, and I’m worried it might cause her to struggle more.

Amrapali: My takeaway from Dr. Lawton is that when making a recommendation, start by emphasizing what treatments we can continue and then touching on what we don’t recommend. Sometimes, when we only recommend stopping aggressive measures, families may hear us as saying, “There’s nothing more we can do” and think we’re giving up on them. But this is not true. There is always something we can do–whether it’s for pain or breathing or comfort. And we can show that through our language.

Shreya: You know, this sounds effortless, especially coming from Dr. Lawton who is a palliative care attending and has been doing this for years. But I gotta be honest, I’ve been in so many situations where it’s not as clear cut from their values to get concrete recommendations that resonate with the patient and resonate with families.

Lawton: For some people can feel messy and sometimes people have, you know, conflicting hopes or worries and hopes that don’t line up. And it requires us to mine a little bit more deeply for what are the core concerns they have

Shreya: But what if your patient is desaturating on 15L of NRB and the family can’t yet decide but in the back of your mind you just know this patient is going to have a rapid response in a few hours. In these situations, Dr. Lawton points out contingency planning can be helpful.

Dr. Lawton: What, I hear that it sounds like if you, if you have a chance of more time, you’d actually be willing to go through a lot for the possibility of getting that more time. So I think it’d be reasonable if you get sicker to try up the breathing tube, try going to the ICU, acknowledging that if it doesn’t seem like it’s working, we’re going to reevaluate. And, you know, could we talk about the possibility that, what if it wasn’t working and what if it didn’t seem like you were getting better just by those machines? Could we think about that?

Amrapali: It’s a good reminder that GOC is a process: not just one conversation at one point in time, but something we can keep reassessing as we build trust with patients and families. But that’s the tension we’re feeling right now with COVID, where the pace can be relentless: these conversations that might otherwise take place over multiple family meetings over multiple days now may be taking place in a single day OR in a single conversation, and there’s a pressure to resolve everything upfront.

Shreya: So that’s the meaty conversation two–getting to the heart of goals of care. Then there’s a third type of conversation that we use more often with COVID and it’s when patients are dying.

Dr. Lawton:Could I give you an update? Yes. You know, Mrs. Jones, I’m so sorry to call you. I really think that your mom is dying and may be dying very soon… You, we expect emotion after that… And you know, this must be just surreal. This must be so overwhelming. I want you to know (usually at the end, expressing an ongoing commitment) we’re going to be right here with her.

Shreya: Expressing that ongoing commitment to being there with their loved one is more important now than ever when families can’t be at the bedsides and patients are afraid of dying alone.  

COVID-Specific Considerations

Consideration #1: Rapid Deterioration

Amrapali:  This is a great framework for the three different types of GOC conversations that you might find yourself having. Let’s jump into a few considerations specific to COVID. First, how do you have these conversations when time is short? When someone is rapidly deteriorating before your eyes? 

Shreya: For example,  Dr. Nakawaga was recently consulted in the emergency room for an 80-year-old patient with metastatic cancer found to have COVID. She was short of breath, unable to speak quickly becoming hemodynamically unstable. The ED team all agreed that this patient who was frail with metastatic cancer probably wouldn’t survive their chest compressions and wouldn’t benefit from intubation. But the family didn’t recognize how sick she was.

So Dr. Nakagawa spoke to the family over the phone. His approach actually began by sharing the prognosis first, and then went to things we talked about: exploring goals/worries in order to make a recommendation. 

Dr. Nakagawa: Basically, uh, I just made it very simple. The first stage is we need to convey the prognosis. Uh, so prognosis in that case, in the metastatic cancer with COVID and the not breathing well, basically she’s dying. So I just said, uh, to the, to the, uh, some, uh, you know what, I am going to give you a very, very bad news now and then take a deep breath. And then I told them, you know, you are, your mom needs that is dying.

Shreya: [And then, he left room for silence] 

Dr. Nakagawa: And, uh, I said, you know, no matter what we do, uh, we cannot change outcome. Just make it simple. 

Shreya: [And then, he gave another pause] 

Dr. Nakagawa: Then we asked the, I asked… what, uh, are you most worried about? 

Shreya: What I took away was that by starting out with prognosis really helps frame the conversation so that when he went to ask about goals and worries it was rooted in how she was doing poorly. And in this case, the family realized that aggressive measures would be highly unlikely to help, and the goal of not wanting their mom to suffer did resonate with them, and so Dr. Nakagawa was able to make a recommendation to focus on her comfort and help her pass away with dignity.  

Dr. Nakagawa: I think that many clinicians are so uncomfortable making recommendation. Many clinicians I think ask like, yes, no questions, uh, when making decisions about treatment. Do you want to us to do CPR? Do you want us to do chemotherapy? They’re asking the yes/no questions. I think that’s wrong. I think we should make a recommendation based on our expertise. 

Amrapali: In goals of care conversations,  there seems to be tension between autonomy and paternalism.  Has the pendulum swung so far in the direction of autonomy these days that we confuse or burden patients with a series of choices that we haven’t equipped them to understand? In an ideal world, we are partnering with families through shared decision-making to provide guidance. Which we do all the time with diabetes or hypertension meds, but here  with these personal, difficult life choices, the stakes feel higher. 

Shreya: Being more forward with making a recommendation is something I’m going to take away even beyond COVID.  I can’t think of how many patients with end-stage HF, COPD patients where I just go with whatever their wishes were to the night admitting resident, never actually voice what my recommendation is.

Consideration #2: Prognosis Related to Functional Status post-CPR

Shreya: Part of what’s so tough about these conversations is the prognosis – this is hard in and of itself and we did a whole At The Bedside Episode on it but prognosis in COVID is challenging because this disease is so new. While we’re getting more studies every other day. For example, there is one study in China where all the patients who had a cardiac arrest and survived CPR had minimal neurological status at 1 month. It was eye-opening for the medical community. This is something Dr. Nakagawa will talk with his COVID patients when discussing prognosis.  He will make sure to bring up functional status after CPR.

Dr. Nakagawa: Even if you survive, you are probably not going to be at the same functional level. When I tell the family, even if your dad survives, probably he’s not going to be the same person. Uh, he’s not going to be able to, you know, enjoy watching TV at home. Probably he will end up in the nursing home, very dependent with all the daily needs. So I think that piece also needs to be conveyed. That’s all the stage 1, sharing the prognosis.

Consideration #3: Approaches to Sharing Prognosis

Amrapali: Prognosis is tough and clinicians have such different approaches — so for Dr. Nakagawa doesn’t like to give numbers – he likes to say a headliner statement like “your loved one is doing poorly”.  In headlining, you give a short statement of what is going on now — the thing you want your patient to walk away with– and then pause to let it sink in. 

Shreya: If I reflect on what I’ve done, I do like to use numbers and like to say a little bit more in my headliner.  For example, I might say, “Most people who undergo CPR with your age and comorbidities do not survive” and maybe say a little more.  For me, it gives me mental peace that I did my best to convey the gravity of the situation. But sometimes if I’m brutally honest I ask myself: am I just scaring patients to choose the code status that I think is best for them?

Dr. Lawton: Some of us in our more fumbly code status conversations do it too, right? I don’t know if you’ve heard of this, but sometimes we break ribs and it can be very uncomfortable and the breathing tube goes in. Our intention is good because we just want to help the patients see, that’s not really what you want, right? But actually the language we’re using, it feels a little bit like helping them see how risky it is or it’s a little bit threatening language, even though we’re not trying to threaten anybody. It doesn’t actually feel for most of us like the type of doctoring we want to do. Right? Like, it would feel so much more lovely if we could help the patients, how their goals match a therapy and then we can be on the same page together. Does that make sense? So we sort of want the second one, but I think all of us end up doing something where we’re talking about risks because we so don’t want the patient to choose the bad option. And at the same time, it’s messy work.

Shreya: It is messy work! Walking someone through possibly end-of-life care and making decisions that are in line with their wishes but also realistic for their health.

Consideration #4: Challenges Related to Virtual Communication and PPE

Amrapali: On top of that difficult work are the challenges related to virtual communication right now. When having GOC convos with loved ones over the phone, it helps to begin by making sure they’re sitting down or, if driving, that they’ve pulled over. 

[Shreya: I’ve made that mistake once or twice] 

Amrapali: We can begin by validating the loved one’s distance from the patient because of this pandemic—this is such a new thing and we should acknowledge that it must be so hard for them to feel so far away. How are they coping? Then, since you can’t be face to face or observe nonverbal cues, it helps to check in deliberately: Is your patient’s loved one in tears and backing away from the phone? Or are they staying calm?

Dr. Lawton: I’m aware that this is for a lot of patients, heavy things to talk about. Um, how, how are you doing in that conversation and, and does it feel okay to move forward? Um, so just really transparently checking in and saying, how is this landing with you? Because you might not be able to know any other way. 

Amrapali: I really like how Dr. Lawton acknowledges the emotion and weight of doing this over the phone and makes space for it with families.  And if you’re with patients, then there’s a whole set of challenges related to PPE. If you can, try and be level with your patients and make good eye contact (after all, it’s the only part of you they can see!), consider holding or squeezing a patient’s hand so they know you’re not afraid of them, and most importantly, speak loudly because so much gets muffled through respirators.

Consideration #5: Separate Process from Outcome

Shreya:  Despite a whole episode trying to improve our goals of care conversations, we recognize we are still going to encounter situations where you do your best with your communication strategy, and things still don’t go as we hoped. You poured your heart and soul into that goals of care conversation and it still doesn’t resonate. It’s so easy to feel defeated. Or, on the flipside, to feel it’s a win if we did get to a code status that you feel is best for the patient. But as much as we can we need to separate ourselves from the outcome.

It’s not our job is not to convince people or feel like we are a failure if we don’t “get them to change their mind” about their goals.

Amrapali: That’s right. Easier said than done but the real win should be a thoughtful conversation, one that is direct and empathetic no matter where it ends up.  Dr. Nakagawa reminds us that the best way to get good at these conversations is to reflect on what went well and what didn’t go as well with a good dose of self-compassion.  

Dr. Nakagawa: I think communication is a skill. In order for you to get better, you have to practice, you have to continue to practice diligently. I think you have to keep practicing and you have to remain humble and you have to reflect. I think that’s the only way for you to get better.

Amrapali: Having the “perfect” GOC conversation can feel like a lot of pressure right now.  

Dr. Lawton: It’s just heavily charged and very weighty because it overlaps with people’s personhood and the sickest points in their life and a lot of emotion.

Amrapali: That intensity is causing a huge emotional toll. Maybe you’ve experienced it yourself this week or have been hearing from your colleagues.  

Dr. Lawton: This is probably the time for us to lean into that, you know, weekly team check in or going to the, the virtual debrief, whatever it is. Even if that’s not normally your thing, it might be the time to like dip your toe in that a little bit because it may actually be really helpful. You may find that there’s a shared experience that you might’ve guessed was there, but it really feels different when you hear your colleagues talking about it. And it might be that showing up is part of what offers support to your colleagues.

Amrapali: And while these GOC conversations may be quite draining and pose many challenges, hopefully we are finding meaning in them too.  And reminding ourselves why we’re showing up each day.  

Dr. Lawton: Understanding where people are coming from and making thoughtful decisions with them for most of us overlapped with why we got into this work in medicine to begin with. In my own practice, it helps me feel fulfilled at the end of the day because hard as it is, I feel like this is what I signed up for.

Shreya: And with that thats a wrap for todays episode on inpatient GOC. If you found this episode helpful, please share with your colleagues or your team. Look out for an episode on outpatient ACP. If you want resources to practice with, try the VitalTalk COVID-Ready Communication Playbook.  

Tweet us and send us a comment on our website page, on instagram or facebook page if you want to add any of your own tips or share challenges. Lets all learn from each other. Thank you to Dr Kabao Vang from University Minnesota for the accompanying graphic, to Dr. Mariah Robertson, Dr. Kimberly Bloom-Fleshbach, Dr. Jafar Al-Mondiry, Dr. Kham (“cam”) Kidia, Dr. Sunny Kishore for their input on this episode, to Dr. Nora Taranto for lending microphone equipment to Amrapali, to Harit Shah for editing this very quickly on a Sunday night and thanks to you! Let us know if there is something else you’d like us to cover. 

If you found this episode helpful, give it a rating on Apple podcasts or whatever podcast app you use! It really does help people find us! As always we love hearing feedback, email us at hello@coreimpodcast.com. Opinions expressed are our own and do not represent the opinions of any affiliated institutions. 

 

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